Robert A. Hart

Oregon Health and Science University, Portland, Oregon, United States

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Publications (201)421.13 Total impact

  • 05/2015; 05(S 01). DOI:10.1055/s-0035-1554556
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    ABSTRACT: Study Design. Recall of the informed consent process in patients undergoing adult spinal deformity surgery and their family members was investigated prospectively. Objective. To quantify the percentage recall of the most common complications discussed during the informed consent process in adult spinal deformity (ASD) surgery, assess for differences between patients and family members, and correlate with mental status. Summary of Background Data. Given high rates of complications in ASD surgery, it is critical to shared decision making that patients are adequately informed about risks and are able to recall pre-operative discussion of possible complications to mitigate medical legal risk. Methods. Patients undergoing ASD surgery underwent an augmented informed consent process involving both verbal and video explanations. Recall of the 11 most common complications was scored. Mental status was assessed with the mini-mental status examination (MMSE-BV). Patients subjectively scored the informed consent process and video. After surgery, the recall test and MMSE-BV were re-administered at 5 additional time points: hospital discharge, six-eight weeks, three months, six months, and one year post-operatively. Family members were assessed at the first three time points for comparison. Results. 56 patients enrolled. Despite ranking the consent process as important (median overall score 10/10; video score 9/10), median patient recall was only 45% immediately after discussion and video re-enforcement, and subsequently declined to 18% at 6-8 weeks and 1 year post-operatively. Median family recall trended higher, at 55% immediately and 36% at 6-8 weeks post-op. The perception of the severity of complications significantly differs between patient and surgeon. Mental status scores showed a transient, significant decrease from pre-op to discharge, but were significantly higher at one year. Conclusions. Despite being well-informed in an optimized informed consent process, patients cannot recall most surgical risks discussed and recall declines over time. Significant progress remains to improve informed consent retention.
    Spine 05/2015; 13(9). DOI:10.1097/BRS.0000000000000964 · 2.45 Impact Factor
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    ABSTRACT: Study Design. Retrospective review of a multicenter, prospective adult spinal deformity (ASD) databaseObjective. The objective was to evaluate the impact of stiffness on activities of daily living (ADL) following instrumented total lumbar fusions to the pelvis; specifically between patients with the upper-most instrumented vertebra (UIV) within the upper thoracic (UT) versus the thoracolumbar (TL) region. The Lumbar Stiffness Disability Index (LSDI) has been validated and used in clinical studies as a self-reported outcomes tool, however, the impact of stiffness on the 10 specific ADLs comprising the LSDI have not been evaluated. A retrospective comparison of prospectively collected pre- and 2-year minimum post-operative answers to the 10 questions comprising the LSDI among ASD patients was conducted. Cohorts were defined based on the UIV as UT (T1-T6) or TL (T9-L1). 134 patients were included (UT:64, TL:70). Both groups had statistically similar changes in all individual LSDI scores at 2 years versus pre-operative values (p>0.05l) with the exception of questions #2 (Bend through your waist to put socks and shoes on) and #8 (bathe lower half of body) in which UT reported increased difficulty (p<0.05). Both groups had statistically similar individual LSDI question scores with the exception of 2-year question #4 (hygiene after toileting) in which UT had a significantly worse score (p<0.05). ASD patients undergoing instrumented total lumbar fusions to the ilium report limited changes from baseline in the ability to perform the 10 ADL functions of the LSDI and had limited differences in final scores regardless of whether the UIV was in the UT or TL region. Domains showing the greatest change from baseline involved dressing or bathing the lower half of the body among UT patients. The only domain for which UT had greater impairment was in performing personal hygiene functions after toileting.
    Spine 04/2015; Publish Ahead of Print. DOI:10.1097/BRS.0000000000000968 · 2.45 Impact Factor
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    ABSTRACT: Cervical Deformity (CD) is prevalent among patients with adult spinal deformity (ASD). The effect of baseline cervical alignment on achieving optimal thoracolumbar alignment in ASD surgery is unclear. This study assesses the relationship between pre-operative cervical spinal parameters and global alignment following thoracolumbar ASD surgery at 2-year follow up. A retrospective review of a multi-center, prospective database. Surgical ASD patients with 2-year follow-up and cervical x-rays. The outcome measure was radiographic parameters and self-reported HRQL measures (SF-36, ODI and SRS-22). Surgical ASD patients over the age of 18 with scoliosis ≥20° and one of the following radiographic parameters were included: SVA ≥5cm, pelvic tilt ≥25° or thoracic kyphosis >60°. SRS-Schwab sagittal modifiers (PT, GA, PI-LL) were assessed at 2-year post-op as either normal ("0") or abnormal ("+" or "++"). Patients were classified in the Aligned Group (AG) or Malaligned Group (MG) at 2-year follow-up if all 3 sagittal modifiers were normal or abnormal, respectively. Patients were assessed for CD based on the following criteria: C2-C7 SVA >4cm, C2-C7 SVA <4cm, cervical kyphosis (CL >0), cervical lordosis (CL <0), any deformity (C2-C7 SVA >4cm OR CL >0), and both CD (C2-C7 SVA >4cm AND CL >0). Univariate testing was performed using t-tests or chi square, looking at the following pre-op parameters: CD, C2-C7 SVA, C2-T3 SVA, CL, T1S, T1S-CL, C2-T3 angle, LL, TK, PT, C7-S1 SVA, and PI-LL. No study funding sources are related to this clinical study. The International Spine Study Group (ISSG) is funded through research grants from DePuy-Synthes and individual donations. 104 patients met initial inclusion criteria with 70 in the AG group and 34 in MG. Pre-op, patients in the MG group had a higher cervical lordosis (11.7 vs 4.9, p=0.03), higher C2-T3 angle (13.59 vs 4.9 p=0.01), higher PT (p<0.0001), higher SVA (p<0.0001), and higher PI-LL (p<0.0001) compared to the AG group. Interestingly, the prevalence of CD at baseline was similar for both groups. There was no statistically significant difference among groups in the amount of improvement over 2 years on the ODI or the SF-36 PCS. Patients with sagittal spinal mal-alignment associated with significant cervical compensatory lordosis are at increased risk of realignment failure at 2 year follow up. Assessment of the degree of cervical compensation may be helpful in preoperative evaluation to assist in realignment outcome prediction. Copyright © 2015 Elsevier Inc. All rights reserved.
    The spine journal: official journal of the North American Spine Society 04/2015; DOI:10.1016/j.spinee.2015.04.007 · 2.80 Impact Factor
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    ABSTRACT: An electronic survey administered to SRS membership. To characterize surgeon views regarding proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) management providing the frame-work in which a PJK/PJF classification system and treatment guidelines could be established. PJK/PJF are common complications of adult spinal deformity (ASD) surgery. To date, there is no consensus on PJK/PJF definitions, classification, and indications for revision surgery. There is a paucity of data on deformity surgeon practice pattern variations and consensus opinion on treatment and prevention. An electronic 19-question survey regarding PJK/PJF was administered to members of the Scoliosis Research Society (SRS) that treat ASD. Determinants included the surgeons' type of practice, number of years in practice, agreement with given PJK/PJF definitions, importance of key factors influencing prevention and revision, prevention methods currently used, and the importance of developing a classification system. 226 surgeons responded (38.8% response rate). 44.4% selected "extremely important" and 40.8% selected "very important" that PJK in ASD surgery is a very important issue and that an SRS PJK/PJF classification system and guidelines for detection and prevention of PJK/PJF is a "must have" (18.1%) and "very likely helpful" (31.9%). 86.2% and 90.7% agreed with the provided definitions of PJK and PJF, respectively. Top 5 revision indications included: neurologic deficit, severe focal pain, translation or subluxation fracture, a change in kyphosis angle >30º, chance fracture, spondylolisthesis >6mm, and instrumentation prominence. The majority of respondents employ a PJK/PJF prevention strategy ≥60% of the time, the most common were: terminal rod contour, preoperative BMD testing, frequent x-rays during first 3 months post-operative, pre-operative BMD medication for low BMD. The results of this study provide insight from the practicing surgeons' perspective of the management of PJK and PJF that may aid in the validation of current definitions and consensus based treatment decisions and prevention guidelines.
    Spine 03/2015; 40(11). DOI:10.1097/BRS.0000000000000897 · 2.45 Impact Factor
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    ABSTRACT: Instrumentation failure is a recognized complication following complex spinal reconstruction and deformity correction. Rod fracture is the most frequent mode of hardware failure in long-segment spinal fusion surgery. This complication can negatively impact clinical outcome by producing spinal pain, functional compromise, instability and loss of deformity correction. To describe the outrigger rod surgical technique. Review of literature, case review, and surgical technique description. Two clinical cases are presented. Rod fracture. Outrigger rod placement in posterior spinal arthrodesis is performed by supplementing primary spinal rods with outrigger rods attached with cranial and caudal side-by-side connectors providing a more robust construct. This technique may be beneficial for preventing rod fracture in patients undergoing surgery for three-column osteotomy for sagittal imbalance; pseudarthrosis surgery with previous hardware failure; transforaminal-lumbar interbody cage placement at multiple levels in realignment procedures, long segment spinal arthrodesis with impaired host fusion potential; long segment instrumented fusions that span the cervicothoracic, thoracolumbar or lumbosacral junction; and across spinal segments at high risk for rod fracture (e.g. following extensive resection of vertebral elements in the management of metastatic malignancy). The risk of rod failure is substantial in the setting of long segment spinal arthrodesis and corrective osteotomy. Efforts to increase the mechanical strength of posterior constructs may reduce the occurrence of this complication. The outrigger rod technique increases spinal construct stiffness and may improve longevity of the construct. This technique should reduce the rate of device failure during maturation of the posterior fusion mass and limit the need for supplemental anterior column support. Copyright © 2015 Elsevier Inc. All rights reserved.
    The spine journal: official journal of the North American Spine Society 03/2015; 15(6). DOI:10.1016/j.spinee.2015.03.004 · 2.80 Impact Factor
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    ABSTRACT: OBJECT Back and leg pain are the primary outcomes of adult spinal deformity (ASD) and predict patients' seeking of surgical management. The authors sought to characterize changes in back and leg pain after operative or nonoperative management of ASD. Outcomes were assessed according to pain severity, type of surgical procedure, Scoliosis Research Society (SRS)-Schwab spine deformity class, and patient satisfaction. METHODS This study retrospectively reviewed data in a prospective multicenter database of ASD patients. Inclusion criteria were the following: age > 18 years and presence of spinal deformity as defined by a scoliosis Cobb angle ≥ 20°, sagittal vertical axis length ≥ 5 cm, pelvic tilt angle ≥ 25°, or thoracic kyphosis angle ≥ 60°. Patients were grouped into nonoperated and operated subcohorts and by the type of surgical procedure, spine SRS-Schwab deformity class, preoperative pain severity, and patient satisfaction. Numerical rating scale (NRS) scores of back and leg pain, Oswestry Disability Index (ODI) scores, physical component summary (PCS) scores of the 36-Item Short Form Health Survey, minimum clinically important differences (MCIDs), and substantial clinical benefits (SCBs) were assessed. RESULTS Patients in whom ASD had been operatively managed were 6 times more likely to have an improvement in back pain and 3 times more likely to have an improvement in leg pain than patients in whom ASD had been nonoperatively managed. Patients whose ASD had been managed nonoperatively were more likely to have their back or leg pain remain the same or worsen. The incidence of postoperative leg pain was 37.0% at 6 weeks postoperatively and 33.3% at the 2-year follow-up (FU). At the 2-year FU, among patients with any preoperative back or leg pain, 24.3% and 37.8% were free of back and leg pain, respectively, and among patients with severe (NRS scores of 7-10) preoperative back or leg pain, 21.0% and 32.8% were free of back and leg pain, respectively. Decompression resulted in more patients having an improvement in leg pain and their pain scores reaching MCID. Although osteotomies improved back pain, they were associated with a higher incidence of leg pain. Patients whose spine had an SRS-Schwab coronal curve Type N deformity (sagittal malalignment only) were least likely to report improvements in back pain. Patients with a Type L deformity were most likely to report improved back or leg pain and to have reductions in pain severity scores reaching MCID and SCB. Patients with a Type D deformity were least likely to report improved leg pain and were more likely to experience a worsening of leg pain. Preoperative pain severity affected pain improvement over 2 years because patients who had higher preoperative pain severity experienced larger improvements, and their changes in pain severity were more likely to reach MCID/SCB than for those reporting lower preoperative pain. Reductions in back pain contributed to improvements in ODI and PCS scores and to patient satisfaction more than reductions in leg pain did. CONCLUSIONS The authors' results provide a valuable reference for counseling patients preoperatively about what improvements or worsening in back or leg pain they may experience after surgical intervention for ASD.
    Journal of Neurosurgery Spine 02/2015; 22(5):1-14. DOI:10.3171/2014.10.SPINE14475 · 2.36 Impact Factor
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    ABSTRACT: To identify the effect of complications and reoperation on the recovery process following adult spinal deformity (ASD) surgery by examining health-related quality of life (HRQOL) measures over time via an integrated health state analysis (IHS). A retrospective review of a multicenter, prospective ASD database was conducted. Complication number, type, and need for reoperation (REOP) or not (NOREOP) were recorded. Patients were stratified as having no complication (NOCOMP), any complication (COMP), only minor complications (MINOR) and any major complications (MAJOR). HRQOL measures included Oswestry Disability Index (ODI), Short Form-36 (SF-36), and Scoliosis Research Society-22 (SRS22) at baseline, 6 weeks, 1 and 2 years postoperatively. All HRQOL scores were normalized to each patient's baseline scores and an IHS was then calculated. 149 patients were included. COMP, MINOR, and MAJOR had significantly lower normalized SRS mental scores at 1 and 2 years than NOCOMP (p < 0.05). REOP had significantly worse normalized 1 and 2 year mental component score (MCS), SRS mental, and total score than NOCOMP (p < 0.05). COMP, MINOR, and MAJOR all had significantly lower SRS mental IHSs than NOCOMP (p < 0.05). REOP had significantly lower IHSs for MCS and SRS satisfaction than NOREOP (p < 0.05). REOP had a significantly lower MCS and SRS mental IHS than NOCOMP (p < 0.05). An IHS analysis suggests there was a significantly protracted mental recovery phase associated with patients that had at least one complication, as well as either a minor and major complication. The addition of a reoperation also adversely affected the mental recovery as well as overall satisfaction.
    European Spine Journal 02/2015; DOI:10.1007/s00586-015-3787-3 · 2.47 Impact Factor
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    ABSTRACT: The goal of the present study was to compare the outcomes of operative and non-operative patients with adult spinal deformity (ASD) over 75 years of age. A retrospective review of a multicenter prospective adult spinal deformity database was conducted examining patients with ASD over the age of 75 years. Demographics, comorbidities, operation-related variables, complications, radiographs, and Health-related quality of life (HRQOL) measures collected included Oswestry Disability Index, Short Form-36, and Scoliosis Research Society-22 preoperatively, and at 1 and 2 years later. Minimum clinically important difference (MCID) was calculated and also compared. 27 patients (12 operative, 15 non-operative) were studied. There were no significant differences (p > 0.05) between operative and non-operative patients for age, body mass-index, and comorbidities, but operative patients had worse baseline HRQOL than non-operative patients. Operative patients had a significant improvement in radiographic parameters in 2-year HRQOL, whereas non-operative patients did not (p > 0.05). Operative patients were significantly more likely to reach MCID (range 41.7-81.8 vs. 0-33.3 %, p < 0.05). In the surgical group, 9 (75 %) patients had at least 1 complication (24 total complications). In the largest series to date comparing operative and non-operative management of adult spinal deformity in elderly patients greater than 75 years of age, reconstructive surgery provides significant improvements in pain and disability over a 2-year period. Furthermore, operative patients were more likely to reach MCID than non-operative patients. When counseling elderly patients with ASD, such data may be helpful in the decision-making process regarding treatment.
    European Spine Journal 02/2015; DOI:10.1007/s00586-015-3759-7 · 2.47 Impact Factor
  • Satoshi Kawaguchi · Robert A Hart
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    ABSTRACT: Because of their osteoconductive properties, structural bone allografts retain a theoretic advantage in biologic performance compared with artificial interbody fusion devices and endoprostheses. Present regulations have addressed the risks of disease transmission and tissue contamination, but comparatively few guidelines exist regarding donor eligibility and bone processing issues with a potential effect on the mechanical integrity of structural allograft bone. The lack of guidelines appears to have led to variation among allograft providers in terms of processing and donor screening regarding issues with recognized mechanical effects. Given the relative lack of data on which to base reasonable screening standards, we undertook basic biomechanical evaluation of one source of structural bone allograft, the femoral ring. Of our tested parameters, the minimum and maximum cortical wall thicknesses of femoral ring allograft were most strongly correlated with the axial compressive load to failure of the graft, suggesting that cortical wall thickness may be a useful screening tool for compressive resistance expected from fresh cortical bone allograft. Development of further biomechanical and clinical data to direct standard development appears warranted. Copyright 2015 by the American Academy of Orthopaedic Surgeons.
    The Journal of the American Academy of Orthopaedic Surgeons 02/2015; 23(2):119-25. DOI:10.5435/JAAOS-D-14-00263 · 2.40 Impact Factor
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    ABSTRACT: Current spine surgeon training in the United States consists of either an orthopaedic or neurological surgery residency, followed by an optional spine surgery fellowship. Resident spine surgery procedure volume may vary between and within specialties. The Accreditation Council for Graduate Medical Education surgical case logs for graduating orthopaedic surgery and neurosurgery residents from 2009 to 2012 were examined and were compared for spine surgery resident experience. The average number of reported spine surgery procedures performed during residency was 160.2 spine surgery procedures performed by orthopaedic surgery residents and 375.0 procedures performed by neurosurgery residents; the mean difference of 214.8 procedures (95% confidence interval, 196.3 to 231.7 procedures) was significant (p = 0.002). From 2009 to 2012, the average total spinal surgery procedures logged by orthopaedic surgery residents increased 24.3% from 141.1 to 175.4 procedures, and those logged by neurosurgery residents increased 6.5% from 367.9 to 391.8 procedures. There was a significant difference (p < 0.002) in the average number of spinal deformity procedures between graduating orthopaedic surgery residents (9.5 procedures) and graduating neurosurgery residents (2.0 procedures). There was substantial variability in spine surgery exposure within both specialties; when comparing the top 10% and bottom 10% of 2012 graduates for spinal instrumentation or arthrodesis procedures, there was a 13.1-fold difference for orthopaedic surgery residents and an 8.3-fold difference for neurosurgery residents. Spine surgery procedure volumes in orthopaedic and neurosurgery residency training programs vary greatly both within and between specialties. Although orthopaedic surgery residents had an increase in the number of spine procedures that they performed from 2009 to 2012, they averaged less than half of the number of spine procedures performed by neurological surgery residents. However, orthopaedic surgery residents appear to have greater exposure to spinal deformity than neurosurgery residents. Furthermore, orthopaedic spine fellowship training provides additional spine surgery case exposure of approximately 300 to 500 procedures; thus, before entering independent practice, when compared with neurosurgery residents, most orthopaedic spine surgeons complete as many spinal procedures or more. Although case volume is not the sole determinant of surgical skills or clinical decision making, variability in spine surgery procedure volume does exist among residency programs in the United States. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.
    The Journal of Bone and Joint Surgery 12/2014; 96(23):e196. DOI:10.2106/JBJS.M.01562 · 4.31 Impact Factor
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    ABSTRACT: Object Improved understanding of rod fracture (RF) following adult spinal deformity (ASD) surgery could prove valuable for surgical planning, patient counseling, and implant design. The objective of this study was to prospectively assess the rates of and risk factors for RF following surgery for ASD. Methods This was a prospective, multicenter, consecutive series. Inclusion criteria were ASD, age > 18 years, ≥5 levels posterior instrumented fusion, baseline full-length standing spine radiographs, and either development of RF or full-length standing spine radiographs obtained at least 1 year after surgery that demonstrated lack of RF. ASD was defined as presence of at least one of the following: coronal Cobb angle ≥20°, sagittal vertical axis (SVA) ≥5 cm, pelvic tilt (PT) ≥25°, and thoracic kyphosis ≥60°. Results Of 287 patients who otherwise met inclusion criteria, 200 (70%) either demonstrated RF or had radiographic imaging obtained at a minimum of 1 year after surgery showing lack of RF. The patients' mean age was 54.8 ± 15.8 years; 81% were women; 10% were smokers; the mean body mass index (BMI) was 27.1 ± 6.5; the mean number of levels fused was 12.0 ± 3.8; and 50 patients (25%) had a pedicle subtraction osteotomy (PSO). The rod material was cobalt chromium (CC) in 53%, stainless steel (SS), in 26%, or titanium alloy (TA) in 21% of cases; the rod diameters were 5.5 mm (in 68% of cases), 6.0 mm (in 13%), or 6.35 mm (in 19%). RF occurred in 18 cases (9.0%) at a mean of 14.7 months (range 3-27 months); patients without RF had a mean follow-up of 19 months (range 12-24 months). Patients with RF were older (62.3 vs 54.1 years, p = 0.036), had greater BMI (30.6 vs 26.7, p = 0.019), had greater baseline sagittal malalignment (SVA 11.8 vs 5.0 cm, p = 0.001; PT 29.1° vs 21.9°, p = 0.016; and pelvic incidence [PI]-lumbar lordosis [LL] mismatch 29.6° vs 12.0°, p = 0.002), and had greater sagittal alignment correction following surgery (SVA reduction by 9.6 vs 2.8 cm, p < 0.001; and PI-LL mismatch reduction by 26.3° vs 10.9°, p = 0.003). RF occurred in 22.0% of patients with PSO (10 of the 11 fractures occurred adjacent to the PSO level), with rates ranging from 10.0% to 31.6% across centers. CC rods were used in 68% of PSO cases, including all with RF. Smoking, levels fused, and rod diameter did not differ significantly between patients with and without RF (p > 0.05). In cases including a PSO, the rate of RF was significantly higher with CC rods than with TA or SS rods (33% vs 0%, p = 0.010). On multivariate analysis, only PSO was associated with RF (p = 0.001, OR 5.76, 95% CI 2.01-15.8). Conclusions Rod fracture occurred in 9.0% of ASD patients and in 22.0% of PSO patients with a minimum of 1-year follow-up. With further follow-up these rates would likely be even higher. There was a substantial range in the rate of RF with PSO across centers, suggesting potential variations in technique that warrant future investigation. Due to higher rates of RF with PSO, alternative instrumentation strategies should be considered for these cases.
    Journal of neurosurgery. Spine 12/2014; 21(6):994-1003. DOI:10.3171/2014.9.SPINE131176 · 2.36 Impact Factor
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    North American Spine Society (NASS) 29th annual meeting, nternational Meeting on Advanced Spine Techniques (IMAST) 21st annual meeting, San Francisco, California, USA | Valencia, Spain; 11/2014
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    ABSTRACT: BACKGROUND CONTEXT: Patients with a spinal epidural abscess (SEA) may present gravely ill and with significant neurologic compromise. Management of these patients requires prompt recognition and often emergent surgical intervention. Appropriate care is effective in preventing both the mortality and morbidity associated with this condition. PURPOSE: To evaluate the clinical outcome of patients who underwent emergent surgical management for sepsis and neurologic deterioration due to a SEA Further, to identify significant risk factors for clinical and neurologic improvement following surgery. STUDY DESIGN/SETTING: A retrospective review of all consecutive patients with sepsis and neurologic deterioration due to a SEA treated at single, academic medical center over a 9-year period. PATIENT SAMPLE: 42 patients. OUTCOME MEASURES: Survival, neurologic improvement (ASIA Grade), occurrence of medical and surgical complications. METHODS: All patients were clinically septic and had a history of worsening neurologic status. No patient had undergone prior spine surgery at the site of the abscess. Surgery was performed emergently (! 6 hours) from the time of notification of the orthopedic spine service. Surgical approach was determined on location of the abscess in relation to the thecal sac. Eight occurred within the cervical spine (all anterior), 12 within the thoracic spine (6 anterior, 6 posterior), and 22 occurred in the lumbar spine (7 anterior, 15 posterior). All cervical SEA underwent an anterior decom-pression and structural grafting with plating, while anterior SEA within the thoracic and lumbar spines underwent anterior decompression and structural allograft followed by a staged, posterior instrumented fusion. Posterior SEA in the thoracic and lumbar spines underwent decompression and evacuation only. Preoperative neurologic function was ASIA Grade B in 16, C in 16, and D in 10. Neurologic deterioration was documented in the medical record for each patient. The mean time of neurologic deterioration was 24 hours (range: 6 hours-5 days). The identified bacteria was MSSA in 19 patients, MRSA in 11, Gram negative rod in 6, TB in 4, and Pseudomonas in 2. Step-wise multivariate regression analysis was employed to identify significant risk factors for survival and neurologic improvement, RESULTS: All patients survived surgery, although 6 patients (14%) died within one month of surgery. Significant risk factors for mortality were age O 70 years (p5.02), hospitalization O 5 days prior to surgery (p5.04), ASIA D (p5.01), diabetes (p5.01), MRSA sepsis (p5.03), and end-stage renal disease (p5.02). Of the surviving patients, the average improvement was 2.4 ASIA grades. Thirty-four of the 36 surviving patients (94%) regained the ability to ambulate. Significant factors for neurologic improvement included age ! 70 years (p5.01), neurologic deterioration documented to shorter than 24 hours (p5.01), a lumbar abscess not requiring fusion (p5.02), preoperative ASIA B or C (p5.01), and non-diabetics (p5.02). Major medical complications (prolonged mechanical ventilation or ICU stay O 72 hours, any major organ system failure) were more likely to occur in diabetics and those hospitalized greater than 48 hours prior to surgery, ASIA Grade D or E, and MRSA sepsis. Surgical complications requiring additional procedures occurred in 9 patients (21%), including: displaced thoracic strut graft in 2 patients, failed posterior thoracolumbar instrumentation in 4 patients, and epidural hematomas in 3 patients. CONCLUSIONS: Despite emergent surgical management, in our series, there was a 14% mortality rate in patients with sepsis and neurologic deterioration due to an SEA. However, in those who survived, there was a high likelihood of neurologic improvement and regaining the ability to ambulate. Older patients, diabetics, and those with a longer duration of preoperative neurologic deterioration and hospitalization had higher mortality rates and even with survival, were less likely to improve neuro-logically and more prone to complications. Prompt recognition and immediate surgical intervention is essential to maximize the outcome in these critically-ill patients FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
    29th Annual Meeting of the North American Spine Society, San Francisco, CA; 11/2014
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    ABSTRACT: Current spine surgeon training in the United States consists of either an orthopedic surgery or a neurological surgery residency followed by an optional spine surgery fellowship. In recent years, spine surgery has matured into a complex medical and surgical specialty, with a large number of procedures and techniques for spinal surgeons to understand and learn before entering independent practice. The current training system with two parallel paths to spine surgery may not be the optimal model to train tomorrow's spine surgeons. To propose a spinal surgery training pathway of categorical spine surgery residency which would complement (rather than replace) the existing training pathways. Review of literature and proposal of novel training pathway. Integration of the orthopedic spine and neurosurgical spine surgery educational programs offers one option to enhance spine surgeon training in an effort to improve patient outcomes and advance scientific knowledge. The development of categorical spine surgery residency programs would provide a focused and pertinent spine training experience aimed at training the next generation of spine surgeons. Potential benefits of unifying spine training appear substantial, although several barriers to a unified approach exist. Discussion regarding the future of spine surgery training and the possibility of creating dedicated categorical spine surgery residency training for the benefit of patients, spine surgeons, and society as a whole appears appropriate. Copyright © 2014 Elsevier Inc. All rights reserved.
    The spine journal: official journal of the North American Spine Society 11/2014; 15(7). DOI:10.1016/j.spinee.2014.08.452 · 2.80 Impact Factor

Publication Stats

1k Citations
421.13 Total Impact Points


  • 2000–2015
    • Oregon Health and Science University
      • • Department of Orthopaedics & Rehabilitation
      • • Department of Surgery
      Portland, Oregon, United States
  • 2014
    • Otto-von-Guericke-Universität Magdeburg
      Magdeburg, Saxony-Anhalt, Germany
    • University of Oregon
      Eugene, Oregon, United States
    • University of California, San Francisco
      • Department of Neurological Surgery
      San Francisco, California, United States
    • Hospital for Special Surgery
      • Department of Orthopaedic Surgery
      New York, New York, United States
  • 2013
    • University of California, San Diego
      • Department of Medicine
      San Diego, California, United States
    • University of Virginia
      • Department of Neurosurgery
      Charlottesville, VA, United States
  • 2012
    • Southern Methodist University
      Dallas, Texas, United States
  • 2010
    • Clemenceau Medical Center
      Beyrouth, Beyrouth, Lebanon
  • 2009
    • Rhode Island Hospital
      Providence, Rhode Island, United States
  • 2007
    • Oregon State University
      Corvallis, Oregon, United States
    • Portland State University
      Portland, Oregon, United States
  • 2005
    • University of Michigan
      • Department of Orthopaedic Surgery
      Ann Arbor, MI, United States