Published by Lippincott, Williams & Wilkins
Online ISSN: 1528-1159
Print ISSN: 0362-2436
Since its formation 20 years ago, the International Society for Study of the Lumbar Spine has stimulated basic and clinical research. Because few disorders of the lumbar spine are lethal, our usual goal is to improve the quality of life of our patients by relieving pain and improving function. To do so, we must continuously improve the quality of the preventive, diagnostic, and treatment methods we employ. If quality is our goal, we need to be precise in our definition, understand how we measure it, and most importantly, be explicit in how we will improve it. Also, we must understand that our work is being conducted in a shrinking world, where all industrialized nations are profoundly concerned about the costs of health care.
In order to determine the applicability of school screening techniques for scoliosis, a methodologic survey was carried out within the framework of a school screening project. The accuracy of the measurements of rib hump height, angle of trunk rotation, and of moiré topography was investigated by assessing the intraobserver and interobserver variation. The validity of these techniques was tested by comparing their outcome to the Cobb angle. Intraobserver variation was measured over both short and long time intervals. The interobserver variation was determined among two orthopaedic surgeons and among a group of six doctors. Results are expressed in a Spearman correlation coefficient and a standard deviation. The Spearman correlation ranges from 0.46 (moiré) to 0.75 (rib hump height) in intraobserver variation, and from 0.60 (rib hump height) to 0.70 (angle of trunk rotation) in interobserver variation. The standard deviations illustrate the interobserver range of the measurements, for rib hump height, 3.7 mm, for rotation, 2.3 degrees, and for moiré, 0.7 lines. The validity of the three methods varied from 0.40 to 0.53 as correlated with the angle of Cobb. The conclusion is that these methods can be applied in school screening techniques, but that they do not allow a sharp distinction between normal and pathologic cases. Instead, it is preferable to define the borderline in terms of a danger zone rather than a strict single value. The danger zone for the rib hump height should be 5-10 mm, for the rotation 3-7 degrees, and for the moiré topography 1-3 lines. Recordings in these zones should be repeated within a few months.
Retrospective clinical magnetic resonance imaging study and prospective magnetic resonance imaging volunteer study of the appearance of the ligamentum flavum. To demonstrate the effect of chemical shift artifact on the apparent thickness of the ligamentum flavum on axial magnetic resonance images. The ligamentum flavum is a symmetric structure clearly seen on magnetic resonance images. Apparent unilateral thickening may be interpreted as indicating a pathologic process, and the influence of chemical shift artifact on the apparent thickness of the ligamentum flavum has not been emphasized. Ligamenta flava thicknesses were measured from axial T1-weighted gradient echo magnetic resonance scans of 12 consecutive patients and various axial sequences in seven volunteers. The ligamentum flavum appeared consistently thicker on the lower side of the readout gradient field. This chemical shift effect could be manipulated by swapping phase and frequency or patient orientation in the magnet. Caution should be applied in attributing apparent asymmetry of the ligamenta flava to disease; the influence of chemical shift artifact should be considered.
An anatomic, epidemiologic study of facet arthrosis in cadaveric lumbar spines. To define the prevalence of lumbar facet arthrosis in a large population sample and to examine its association with age, sex, and race. Arthrosis of lumbar facet joints is a common radiographic finding and has been linked to low back pain. However, no population studies have specifically defined the prevalence of facet arthrosis in the lumbar spine in relation to age, sex, and race. A total of 647 cadaveric lumbar spines were examined by a single examiner for evidence of lumbar facet arthrosis. Information on race, age, and sex were collected. Arthrosis at each facet was graded from 0 to 4 on a continuum from no arthritis to complete ankylosis. Facet arthrosis was present in 53% (L1-L2), 66% (L2-L3), 72% (L3-L4), 79% (L4-L5), and 59% (L5-S1). By decade, facet arthrosis was present in 57% of 20- to 29-year-olds, 82% of 30- to 39-year-olds, 93% of 40- to 49-year-olds, 97% in 50- to 59-year-olds, and 100% in those >60 years old. Fisher exact test and t test demonstrated that men had a greater prevalence and degree of facet arthrosis than women at all lumbar levels (P < 0.001). The lumbar level with the highest prevalence and degree of arthrosis was the L4-L5 level, as compared with each of the other levels (P < 0.001). There was no difference in arthrosis between right versus left facet joints (P > 0.5). Facet arthrosis is a universal finding in the human lumbar spine. Evidence of arthrosis begins early, with more than one half of adults younger than 30 years demonstrating arthritic changes in the facets. The most common arthritic level appears to be L4-L5. Men have a higher prevalence and degree of facet arthrosis than women.
Human lumbar anulus tissue and cultured human lumbar anulus cells were used in retrospective studies of the immunocytochemical localization of the vitamin D receptor (VDR) in disc tissue, and of the in vitro effects of the active metabolite of vitamin D, 1,25(OH)2D3, on anulus cell proliferation, cytokine, and proteoglycan (PG) production. 24,25-D3 was also analyzed. Studies were approved by the authors' Human Subjects Institutional Review Board. Discs were obtained from surgical specimens and from control donors. To determine if human anulus cells express the VDR in vivo, and to test the effect of in vitro exposure to 1,25(OH)2D3 and 24,25-D3 on anulus cell proteoglycan and cytokine production in 3-dimensional culture. Intragenic polymorphisms in the VDR gene have been associated with disc degeneration. 1,25(OH)2D3 has well-recognized effects on calcium homeostasis and bone mineralization, and is a negative growth regulator of a variety of normal and tumor cells. Its effects on human disc cells, however, are unexplored. Immunocytochemistry was performed on human lumbar disc anulus tissue from 19 subjects; human disc cells were cultured to test the effect of 1,25(OH)2D3 on proliferation of anulus cells from 5 subjects. A paired experimental design was used to determine proteoglycan production in control or 1,25(OH)2D3-treated cells, or in control or 24,25-D3-treated cells using the dimethylmethylene blue assay. A paired experimental design was also used to identify differences in cytokine production in conditioned media from control or 1,25(OH)2D3-treated cells, or in control or 24,25-D3-treated cells using ELISA assays. Immunocytochemistry documented expression of the VDR in anulus cells. Young donor discs (aged newborn, 15 years) showed positive localization in all cells of the outer anulus, and some inner anulus cells. In adults (mean age, 38.9 years), some, but not all anulus cells, showed positive localization. Exposure to 10M 1,25(OH)2D3 in monolayer significantly reduced cell proliferation in vitro (P = 0.03). PG production in 3-dimensional was unchanged from control in both 1,25(OH)2D3- and 24,25-D3-treated cells. Cytokine production differed, however. 1,25(OH)2D3-treated cells showed significantly decreased production of vascular endothelial growth factor (VEGF) (P = 0.01), monocyte chemoattractant protein-1 (MCP-1) (P = 0.0006), angiogenin (P = 0.002), and thrombopoietin (P = 0.03) compared with controls. 24,25-D3-treated cells showed significantly elevated vascular endothelial growth factor-D (P = 0.01), beta-fibroblast growth factor (0.03), and significantly decreased interleukin-8, interferon-gamma, leptin, MCP-1, and TIMP-2 (tissue inhibitor of metalloproteinases-2) compared with controls (P <or= 0.01). Data suggest that 1,25(OH)2D3 and 24,25-D3 may play roles as regulators of cell proliferation and production of specific cytokines in the lumbar anulus.
Randomized, double-blinded, placebo controlled animal study. To evaluate the effect of teriparatide and calcitonin after an intertransverse process spinal fusion in a rabbit model. It is widely recognized that some osteoporosis medications, including bisphosphonates, can interfere with bone healing. Although prescribed frequently in the treatment of osteoporosis, the effect of teriparatide and calcitonin on spinal fusion has not been fully elucidated. We hypothesized that teriparatide, being the only anabolic medication for osteoporosis treatment, would have a beneficial effect on spine fusion. Fifty-one New Zealand white rabbits underwent a posterolateral L5-L6 intertransverse process arthrodesis using autogenous iliac crest bone graft. The rabbits were randomly divided into 3 groups. All animals received daily subcutaneous injections of group I (n = 17) 1 mL of saline placebo; group II (n = 17) 10 microg/kg/day of teriparatide; group III (n = 17) 14 IU/animal of calcitonin during the 8-week postoperative period. Postmortem analyses included manual palpation, radiographic, biomechanical, and histologic assessment. Three random 10x fields were examined/graded within the cephalad, middle, and caudal regions of each section (810 fields). Fusion quality was graded using the Emery histologic scale (0-7 based on fibrous/bone content of the fusion mass). Histologic fusion rates for teriparatide averaged 86.7% and was significantly greater than the autograft control group (50%) (P = 0.033). Radiographically, there was a strong trend towards teriparatide being superior to the calcitonin group (85.7% vs. 56.3%, respectively; P = 0.07). The average Emery grading score was 5.99 +/- 1.46 SD for the autologous group and 6.26 +/- 0.93 SD for the teriparatide group (P = 0.031). Although not significant, the teriparatide group showed less motion in flexion/extension, lateral bending, and axial rotation. Our results suggest that teriparatide enhances spinal fusion while calcitonin has a neutral effect. The teriparatide group had the best histologic fusion rate and Emery scores, while the calcitonin group was similar to the saline controls. Although not significant, the teriparatide group had a strong trend towards superior radiographic fusion over the calcitonin group.
There currently is a clinical need for an objective technique to assess muscle dysfunction associated with chronic lower back pain. A Back Analysis System for objectively measuring local fatigue in the back extensor muscles is presented. The reliability and validity of this technique was evaluated by testing chronic low-back pain patients and control subjects without back pain. Concurrent surface electromyograms (EMG) were detected from multiple back muscles during sustained isometric contractions at different force levels of trunk extension. Median frequency parameters of the EMG power density spectrum were monitored to quantify localized muscle fatigue. Results indicated: 1) high reliability estimates for repeated trials; 2) significant differences (P less than 0.05) in median frequency parameters between lower back pain patients and control subjects for specific combinations of contractile force level and muscle site tested; 3) Median Frequency parameters correctly classified lower back pain and control subjects using a two-group discriminant analysis procedure. The applicability of this technique as a treatment outcome measure and diagnostic screening method for lower back pain patients is discussed.
A study correlating protein S-100b serum levels with postoperative functional outcome in patients with spinal cord compression resulting from epidural empyema. To evaluate the potential value of protein S-100b for prediction of individual functional outcome in medullary lesions resulting from spinal epidural empyema. Despite modern medical advances, a reliable individual prediction of functional outcome in case of spinal epidural empyema is still not possible. Forming two outcome groups, clinical outcome following surgery was considered to be favorable in case of neurologic improvement with preservation or retrieval of walking ability, whereas nonimprovement without restoration of gait function was regarded to be unfavorable. Venous blood samples for protein S-100b were taken from all patients immediately after admission and regularly after operative decompression. Initial levels of S-100b were correlated with preoperative degree and duration of paresis, and the individual time course of S-100b measurements was correlated with clinical outcome. The initial level of protein S-100b is not correlated with preoperative degree and duration of paresis or with functional outcome. The individual time course of S-100b measurements, however, is different in both outcome groups. Levels of protein S-100b that were either always normal or that were initially increased but normalized rapidly within 3 days were invariably associated with retrieval of gait function, whereas none of those patients recovered in whom increased levels of S-100b persisted beyond the third postoperative day (P < 0.003). Protein S-100b might be a promising serum marker with prognostic significance in the event of spinal cord compression resulting from epidural empyema.
Study Design. Retrospective case series. Objective. To analyze the efficacy and safety of posterior vertebral column resection (PVCR) performed to a consecutive series of patients with severe spinal deformity and managed by PVCR. Summary of Background Data. The treatment of severe spinal deformities is a demanding and difficult surgical challenge. Conventional procedures such as posterior and anterior instrumentation or combined anteroposterior instrumentation afford limited correction in rigid neglected or maltreated (fused) deformities. Methods. A total of 102 consecutive patients with severe deformity and managed by PVCR between years 1996 and 2007 having more than 2 years follow-up were included. Mean age was 37.6 (range = 2-84 years) years at the time of operation. The hospital charts were reviewed for demographic data and etiology of deformity. Measurements of curve magnitude and balance were made on 36-inch standing anteroposterior and lateral radiographs taken before surgery and at most recent follow-up to assess deformity correction, spinal balance, complications related to the instrumentation, and any evidence of pseudarthrosis. Results. Preoperative coronal plane major curve of 102 degrees (range = 80 degrees-29 degrees) with flexibility of less than 30% was corrected to 38.3 degrees (range = 20 degrees-72 degrees) showing a 62% scoliosis correction at the final follow-up. Coronal imbalance was improved 72% at the most recent follow-up assessment. Preoperative thoracic kyphosis of 83 degrees (range = 65 degrees-104 degrees) in patients with kyphosis was corrected to 36 degrees (range = 25 degrees-48 degrees) at the most recent follow-up evaluation. Lumbar lordosis of 25 degrees (range = 8 degrees-35 degrees) in patients with hypolordotic deformity was corrected to 42 degrees. Two patients had nerve root palsies not identified during the surgery and healed completely in 6 months after surgery. Conclusion. PVCR is an effective technique because it is a spinal column shortening procedure and it allows to do correction in same session. However, it is a technically demanding procedure with possible risks for major complications.
Cross-sectional and longitudinal analysis of data comprising 4486 Danish twins 70-102 years of age. To describe the 1-month prevalence of back pain, neck pain, and concurrent back and neck pain and the development of these over time, associations with other health problems, education, smoking, and physical, and mental functioning. Back pain and neck pain are prevalent symptoms in the population; however, there is little research addressing these conditions in older age groups. Extensive interview data on health, lifestyle, social, and educational factors were collected in a nationwide cohort-sequential study of 70+-year-old Danish twins. Data for back pain, neck pain, lifetime prevalence of a comprehensive list of diseases, education, and self-rated health were based on self-report. Physical and mental functioning were measured using validated performance tests. Data including associated factors were analyzed in a cross-sectional analysis for answers given at entry into the study, and longitudinal analysis was performed for participants in all four surveys. The overall 1-month prevalence for back pain only was 15%, for neck pain only 11%, and for concurrent back and neck pain 11%. The prevalence varied negligibly over time and between the age groups, and 63% of participants in all surveys had no episodes or only one episode of back or neck pain. Back pain and neck pain were associated with a number of other diseases and with poorer self-rated health. Back and neck pain sufferers had significantly lower scores on physical but not cognitive functioning. Back pain and neck pain are common, intermittent symptoms in old age. Back pain and neck pain are associated with general poor physical health in old age.
A retrospective study of 103 computed tomography-guided biopsies of the spine. These represent a consecutive series of patients with spinal lesions or disorders observed over a 32-month period. To determine the diagnostic accuracy and clinical usefulness of computed tomography-guided biopsies with respect to major influencing variables. Computer tomographic-guided biopsy of the spine is considered a safe, accurate, and relatively inexpensive examination technique. A study comparing its diagnostic accuracy with respect to all the variables of age, gender, radiographic appearance, spinal level, tissue type, or pathologic diagnosis has not been done. Biopsy specimens were sent for cytologic and histologic analysis. Bacteriologic studies were performed when clinically indicated. The biopsy results were analyzed for adequacy and diagnostic accuracy, i.e., the ability to generate a tissue sample adequate for pathologic examination and one that yields diagnostic information. The mean age of patients was 60 years, with a range of 4-91 years. The spines of 52 males and 51 females were studied. There were eight cervical, 28 thoracic, 53 lumbar, and 14 sacral lesions used as biopsy sites. The radiographic appearance of spinal lesions were lytic in 74 cases, blastic in four cases, and mixed in two cases. Tissues undergoing biopsy included bone (63 cases), soft tissue (35 cases), and mixed specimens (five cases). The pathologic examinations revealed 18 infections, 23 primary neoplasms, 34 metastases, and 19 normal tissues. An adequate specimen for pathologic examination was obtained in 90 biopsies (87%). A diagnosis was achieved in 67 of 94 patients (71%). Diagnostic rates obtained in thoracic level biopsies were lower than those from biopsies of other spinal levels (P = .007). Computed tomography-guided biopsy is an important tool in the evaluation of spinal lesions. A positive biopsy result may preclude the need for open surgical intervention. This study included one of the largest series of patients in the medical literature. In addition, it determined the diagnostic rates of this procedure with respect to the major influencing variables. Thoracic-level biopsies have a diagnostic rate that is significantly lower than that of other spinal levels. No significant correlation was found between diagnostic accuracy and age, gender, radiographic appearance, tissue type, or eventual diagnosis.
A retrospective review. To characterize the risk factors for the development of major complications in 3-column osteotomies and determine whether the presence of a major complication affects ultimate clinical outcomes. Three-column spinal osteotomies, including pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR), are common techniques to correct severe and/or rigid spinal deformities. Two hundred forty consecutive PSO (n = 156) and VCR (n = 84) procedures in 237 patients were performed at a single institution between 1995 and 2008. Of these, 105 patients (87 PSOs, 18 VCRs) had complete preoperative and minimum 2-year postoperative clinical outcomes data available for analysis. Using established criteria, we reported complications as major or minor and further stratified complications as surgical versus medical and permanent versus transient. Risk factors for complications and their effect on Scoliosis Research Society (SRS) clinical outcomes at baseline and at 2 years or more were assessed. Major medical and surgical complications occurred at similar rates in both PSOs and VCRs (38%, 33 of 87 vs. 22%, 4 of 18; P = 0.28). Overall, 24.8% (26 of 105) experienced major surgical complications (3 permanent) and 15.2% (16 of 105) experienced major medical complications (4 permanent). Patients with PSO were older (53 vs. 29 yr; P < 0.001), had greater estimated blood loss (1867 vs. 1278 mL; P = 0.02), and showed a trend toward fewer fused levels (10.1 vs. 12.2; P = 0.06). Risk factors for major complications included preoperative sagittal imbalance of 40 mm or more (P = 0.01), age 60 years and older (P = 0.01), and the presence of 3 or more medical comorbidities (P = 0.04). Both groups improved significantly from baseline in SRS subscores; however, patients with PSO started off worse but improved more than VCRs in both the pain (+1.0 vs. +0.1; P < 0.001) and function (+0.6 vs. +0.2; P = 0.01) domains, with no differences in final satisfaction (4.1 vs. 4.3; P = 0.54). PSO and VCR patients with no complications had slightly higher satisfaction scores than patients with minor-only complications, major transient complications, and major permanent complications. There were no significant differences among the groups with respect to change in SRS subscores from baseline, and all complication groups improved significantly from baseline (P = 0.04). Major complications occurred in 35% of 3-column osteotomies and at similar rates for both PSO (38%) and VCR (22%) procedures. The presence of a major complication did not affect the ultimate clinical outcomes at 2 years or more.
Study design: A retrospective review of data collected prospectively on patients who underwent microendoscopy-assisted muscle-preserving interlaminar decompression (MILD) for lumbar spinal stenosis. Objective: To evaluate the clinical results including surgical invasiveness and reduction rate of facet joint with a follow-up of more than 3 years. Summary of background data: Hatta et al reported microscopic posterior decompression procedure, MILD for lumbar spinal stenosis with reference to the cervical central approach put forth by Shiraishi. Mikami et al applied spinal microendoscopy to MILD procedure (microendoscopy-assisted MILD). Methods: One hundred five consecutive patients, who underwent microendoscopy-assisted MILD, participated in this study. Operative time, blood loss, visual analogue scale (VAS), serum creatine kinase and C-reactive protein, surgical complications, reduction rate of the facet joint, Japanese Orthopaedic Association score, and Short-Form 36 were evaluated. Results: The operative time was 99.3 minutes and the intraoperative bleeding was 15.7 mL on average. The mean VAS score to assess surgical site pain was 20.6 mm on postoperative day 1. The mean serum creatine kinase on postoperative day 1 and C-reactive protein on postoperative day 3 were 145.4 IU/L and 2.7 mg/dL, respectively. Surgical complications were identified in 2 cases, cauda equina injury and dural tear. The mean reduction rate of the facet joint was 3%. The follow-up rate was 83.3% and the mean follow-up period was 52.7 months. The Japanese Orthopaedic Association score improved significantly from 14.8 to 23.7 points on average. Significant improvements in Short-Form 36 were observed in all subscales except in General Health. Revision surgical procedures were performed in 8 cases at the operated level including 4 of juxtafacet cyst, 3 of disc herniation, and 1 of insufficient decompression. Conclusion: Microendoscopy-assisted MILD is a minimally invasive procedure and favorable clinical results can be expected for lumbar spinal stenosis. Level of evidence: 4.
An Institutional Review Board-approved retrospective review of 3400 sequential CT scans of the thorax obtained at a single institution over a 3-year period from 2000 to 2003 was performed. We determined values for the volume of the right lung, left lung, and total lung volume and plot these data as a function of age and sex. To our knowledge, no normative data on CT determined lung volume as a function of age have been published. All examinations with a report of a normal CT scan of the chest (1050 examinations) were identified. The volume of lung parenchyma in each normal examination was determined by performing a three-dimensional reconstruction of the pulmonary system. Predicted increases in pulmonary volume with age for the third to 97th percentiles of male and female children were calculated. Normal values for the volume of lung parenchyma as a function of age and sex increase the clinical utility of a standard CT scan of the thorax in evaluating children with complex spinal deformities. They are a useful adjunct to pulmonary function testing. These data can be used in the pre- and postoperative evaluation of patients who are at risk of thoracic insufficiency syndrome, particularly in patients younger than 5 years of age, when standard pulmonary function testing cannot be accomplished. The effects of nonoperative treatment, early spinal fusion, and new techniques for the fusionless management of spinal deformity on lung volume can be quantified and compared to normal values.
A retrospective chart and radiographic review. To determine the long-term clinical results, radiographic results, and incidence of complications in a large patient cohort with one-level lumbar total disc replacement (TDR). Prior authors have described short-term, mid-term, and long-term clinical and radiographic results in patients with lumbar TDR with highly variable results. From January 1989 to November 1995, 108 patients, with a mean age of 36.4 years, underwent lumbar TDR with the CHARITE Artificial Disc, with 106 available for follow-up. A modified Stauffer-Coventry scale was used to determine clinical outcome. Return to work, work level, and the incidence of complications were assessed. Dynamic lateral flexion-extension and lateral bending radiographs were performed and segmental range of motion (ROM) was measured using the Cobb method. Mean follow-up time was 13.2 years (range, 10-16.8 years). Of the 106 patients, 87 (82.1%) had either an excellent or good clinical outcome. Of the 96 patients working before surgery, 86 returned to work (89.6%), including 77.8% of patients with hard labor level employment (28 of 36) returning to the same level of work. The mean ROM in flexion-extension was 10.1 degrees , in lateral bending it was 4.4 degrees , and 90.6% of implanted prostheses were still mobile. Eight patients (7.5%) required posterior instrumented fusion. There were 5 cases (4.6%) of postoperative facet arthrosis, 3 cases (2.8%) of subsidence, 3 cases (2.8%) of adjacent-level disease, and 2 cases (1.9%) of core subluxation. This retrospective study demonstrates the safety and efficacy of the CHARITE Artificial Disc at one level, either L4-L5 or L5-S1, in the long-term. Clinical outcomes and the rate of return to work were excellent overall. The rate of adjacent-level disease requiring surgical intervention was considerably lower (2.8%) compared with reports in the literature for lumbar fusion. As with any surgical procedure, proper indications play a pivotal role in clinical success.
Study design: Multicenter case-control study. Objective: To investigate the prevalence of back problems in adults with idiopathic scoliosis. Summary of background data: Information on the prevalence of back problems in adults with idiopathic scoliosis is scarce, especially in untreated individuals, males, and individuals with an age at the onset of scoliosis of less than 10 years. Methods: A total of 1069 individuals with idiopathic scoliosis and 158 individuals without scoliosis, all aged 20 to 65 years, answered a questionnaire on back problems. Individuals with scoliosis were diagnosed between ages 4 and 20 years and any treatment was terminated before the age of 20 years. Logistic regression or analysis of variance was used for group comparisons. Results: Mean (SD) age at the time of investigation in individuals with scoliosis (123 males and 946 females) was 41 (9) years, and in individuals without scoliosis (75 males and 83 females) 45 (13) years. Three hundred seventy-four individuals with scoliosis were untreated, 451 had been brace treated, and 244 were surgically treated. The mean prevalence of back problems was 64% in the individuals with scoliosis and 29% in the individuals without scoliosis (P < 0.001). Among the untreated individuals with scoliosis, 69% reported back problems; among the brace treated, 61%; and among the surgically treated, 64% (P = 0.06). When comparing females and males with scoliosis, and individuals with juvenile and adolescent scoliosis, there were no statistically significant differences in the prevalence of back problems (P = 0.10 and P = 0.23, respectively). Conclusion: Adults with idiopathic scoliosis have a higher prevalence of back problems than individuals without scoliosis. Treatment, sex, and juvenile or adolescent onset of diagnosis was not related to the prevalence of back problems in adulthood. Level of evidence: 2.
To reduce the incidence of neurologic complications following spinal surgery, somatosensory evoked potentials (SEPs) were monitored in 108 patients. An electrode with four in-line contacts was used to record spinal SEPs in the epidural space in 33 patients at locations both rostral and caudal to the surgical site. Cortical SEPs were successfully monitored in 107/108 patients and spinal SEPs in all 33 attempted epidurally. Spinal conduction velocities were found to range from 43.9 to 110.5 m/s depending on vertebral level and the time location of the measured peak in the response waveform. Frequency power spectra of the SEP waveforms were found to be a reliable adjunct to peak latency amplitude analysis in the time domain. Use of caudal and rostral epidural, subcortical, and cortical electrode sites were found to be the most reliable technique for the maximum patient safety.
Retrospective review of a prospectively collected, multicenter database. To assess rates of new neurologic deficit (NND) associated with spine surgery. NND is a potential complication of spine surgery, but previously reported rates are often limited by small sample size and single-surgeon experiences. The Scoliosis Research Society morbidity and mortality database was queried for spinal surgery cases complicated by NND from 2004 to 2007, including nerve root deficit (NRD), cauda equina deficit (CED), and spinal cord deficit (SCD). Use of neuromonitoring was assessed. Recovery was stratified as complete, partial, or none. Rates of NND were stratified based on diagnosis, age (pediatric < 21; adult ≥ 21), and surgical parameters. Of the 108,419 cases reported, NND was documented for 1064 (1.0%), including 662 NRDs, 74 CEDs, and 293 SCDs (deficit not specified for 35 cases). Rates of NND were calculated on the basis of diagnosis. Revision cases had a 41% higher rate of NND (1.25%) compared with primary cases (0.89%; P < 0.001). Pediatric cases had a 59% higher rate of NND (1.32%) compared with adult cases (0.83%; P < 0.001). The rate of NND for cases with implants was more than twice that for cases without implants (1.15% vs. 0.52%, P < 0.001). Neuromonitoring was used for 65% of cases, and for cases with new NRD, CED, and SCD, changes in neuromonitoring were reported in 11%, 8%, and 40%, respectively. The respective percentages of no recovery, partial, and complete recovery for NRD were 4.7%, 46.8%, and 47.1%, respectively; for CED were 9.6%, 45.2%, and 45.2%, respectively; and for SCD were 10.6%, 43%, and 45.7%, respectively. Our data demonstrate that, even among skilled spinal deformity surgeons, new neurologic deficits are inherent potential complications of spine surgery. These data provide general benchmark rates for NND with spine surgery as a basis for patient counseling and for ongoing efforts to improve safety of care.
STUDY DESIGN.: A retrospective review of a prospectively collected database. OBJECTIVE.: To assess rates and causes of mortality associated with spine surgery. SUMMARY OF BACKGROUND DATA.: Despite the best of care, all surgical procedures have inherent risks of complications, including mortality. Defining these risks is important for patient counseling and quality improvement. METHODS.: The Scoliosis Research Society Morbidity and Mortality database was queried for spinal surgery cases complicated by death from 2004 to 2007, including pediatric (younger than 21 yr) and adult (21 yr or older) patients. Deaths occurring within 60 days and complications within 60 days of surgery that resulted in death were assessed. RESULTS.: A total of 197 mortalities were reported among 108,419 patients (1.8 deaths per 1000 patients). Based on age, rates of death per 1000 patients for adult and pediatric patients were 2.0 and 1.3, respectively. Based on primary diagnosis (available for 107,996 patients), rates of death per 1000 patients were as follows: 0.9 for degenerative (n = 47,393), 1.8 for scoliosis (n = 26,421), 0.9 for spondylolisthesis (n = 11,421), 5.7 for fracture (n = 6706), 4.4 for kyphosis (n = 3600), and 3.3 for other (n = 12,455). The most common causes of mortality included: respiratory/pulmonary causes (n = 83), cardiac causes (n = 41), sepsis (n = 35), stroke (n = 15), and intraoperative blood loss (n = 8). Death occurred prior to hospital discharge for 109 (79%) of 138 deaths for which this information was reported. The specific postoperative day (POD) of death was reported for 94 (48%) patients and included POD 0 (n = 23), POD 1-3 (n = 17), POD 4-14 (n = 30), and POD >14 (n = 24). Increased mortality rates were associated with higher American Society of Anesthesiologists score, spinal fusion, and implants (P < 0.001). Mortality rates increased with age, ranging from 0.9 per 1000 to 34.3 per 1000 for patients aged 20 to 39 years and 90 years or older, respectively. CONCLUSION.: This study provides rates and causes of mortality associated with spine surgery for a broad range of diagnoses and includes assessments for adult and pediatric patients. These findings may prove valuable for patient counseling and efforts to improve the safety of patient care.
Retrospective review of a prospectively collected database. The Scoliosis Research Society (SRS) collects morbidity and mortality (M and M) data from its members. Our objectives were to assess complication rates for 3 common spine procedures, compare these results with prior literature as a means of validating the database, and to assess rates of pulmonary embolism (PE) and deep venous thrombosis (DVT) in all cases reported to the SRS over 4 years. Few modern series document complication rates of spinal surgery as routinely practiced across academic and community settings. Those available are typically based on relatively low numbers of procedures or confined to single-surgeon experiences. The SRS M and M database was queried for lumbar microdiscectomy (LD), anterior cervical discectomy and fusion (ACDF), and lumbar stenosis decompression (LSD) cases from 2004 to 2007. Revisions were excluded. The database was also queried for occurrence of clinically evident PE and DVT in all cases from 2004 to 2007. A total of 9692 LDs, 6735 ACDFs, and 10,329 LSDs were identified, with overall complication rates of 3.6%, 2.4%, and 7.0%, respectively. These rates are comparable to previously published smaller series. For assessment of PE and DVT, 108,419 cases were identified and rates were calculated per 1000 cases based on diagnosis, age group, and implant use. Overall rates of PE, death due to PE, and DVT were 1.38, 0.34, and 1.18, respectively. Among 82,082 adults, the rate of PE ranged from 0.47 for LD to 12.4 for metastatic tumor. Similar variations were noted for DVT and deaths due to PE. Overall major complication rates for LD, ACDF, and LSD based on the SRS M and M database are comparable to those in previously reported smaller series, supporting the validity of this database for study of other less common spinal disorders. In addition, our data provide general benchmarks of clinically evident PE and DVT rates as a basis for ongoing efforts to improve care.
Retrospective review of a prospectively collected database. Our objective was to assess the rates of postoperative wound infection associated with spine surgery. Although wound infection after spine surgery remains a common source of morbidity, estimates of its rates of occurrence remain relatively limited. The Scoliosis Research Society prospectively collects morbidity and mortality data from its members, including the occurrence of wound infection. The Scoliosis Research Society morbidity and mortality database was queried for all reported spine surgery cases from 2004 to 2007. Cases were stratified based on factors including diagnosis, adult (≥ 21 years) versus pediatric (<21 years), primary versus revision, use of implants, and whether a minimally invasive approach was used. Superficial, deep, and total infection rates were calculated. RESULTS.: In total, 108,419 cases were identified, with an overall total infection rate of 2.1% (superficial = 0.8%, deep = 1.3%). Based on primary diagnosis, total postoperative wound infection rate for adults ranged from 1.4% for degenerative disease to 4.2% for kyphosis. Postoperative wound infection rates for pediatric patients ranged from 0.9% for degenerative disease to 5.4% for kyphosis. Rate of infection was further stratified based on subtype of degenerative disease, type of scoliosis, and type of kyphosis for both adult and pediatric patients. Factors associated with increased rate of infection included revision surgery (P < 0.001), performance of spinal fusion (P < 0.001), and use of implants (P < 0.001). Compared with a traditional open approach, use of a minimally invasive approach was associated with a lower rate of infection for lumbar discectomy (0.4% vs. 1.1%; P < 0.001) and for transforaminal lumbar interbody fusion (1.3% vs. 2.9%; P = 0.005). Our data suggest that postsurgical infection, even among skilled spine surgeons, is an inherent potential complication. These data provide general benchmarks of infection rates as a basis for ongoing efforts to improve safety of care.
Retrospective clinical study. To determine characteristics, treatment methods, and outcome in an institutional series of patients with spinal hematoma not related to previous surgery. The charts of all patients with spinal hematoma treated in our institution between January 1993 and December 2002 were reviewed and analyzed with regard to location and extension of the hematoma, duration of symptoms, neurologic status, diagnostic measures, therapy, and outcome. Fifteen patients were identified with spinal hematomas not caused by previous spine surgery. There were 11 women and 4 men. One hematoma was located subdurally and another intramedullary. All other hematomas were extradural, with 10 spontaneous bleedings. Eight hematomas were located in the cervical, two in the cervicothoracic, and three in the thoracic region. Two others were situated in the lumbar spine. Mean extension was 4.7 segments (range, 2-8 segments). Mean interval between onset of symptoms and surgery was 18 hours (range, 8-48 hours) for 12 patients; in 2 cases, diagnosis was made after 17 and 36 days, respectively, and then treated by surgery. One patient was treated without operation. Operative treatment was accomplished in all cases by hemilaminectomy and/or interlaminar fenestration and hematoma evacuation, in those cases with a larger extension of extradural hematoma by an alternating hemilaminectomy, thus reducing the risk of postoperative instability. There was no recurrence. No correlation between time to surgery and outcome was found in this study group, but there was a strong correlation between initial neurologic status and outcome after surgery. Nonsurgical derived spinal hematomas are rare. In this series, most cases were spontaneous and located in the cervical or cervicothoracic region producing severe neurologic deficit and pain. Treatment should be surgical evacuation in the majority. As most hematomas are of great extension, alternating hemilaminectomy suffices for evacuation of extradural hematomas and supports the stability of the spinal segments. Outcome is highly dependent from initial neurologic status.
Retrospective study. To evaluate the clinical and functional outcomes in patients with spinal cord injury (SCI) and preexisting ankylosing spondylitis (AS). AS alters the strength and biomechanical properties of the spine that renders it susceptible to fracture with minimal trauma. Neurologic involvement is common and outcomes largely depend on the early recognition and appropriate management. A 10-year review (1996-2005) was carried out to identify all patients admitted with SCI associated with AS. The cause of injury, prehospital and emergency management, definitive treatment of fracture, final neurology, and functional outcomes were ascertained. Reasons for neurologic deterioration were determined. Eighteen patients were identified. In 15 patients, the injury resulted from trauma (fall 14, road accident 1) and in 3 the SCI followed spinal surgical interventions. Twelve of the 15 patients with traumatic injuries were able to walk immediately after the fall but subsequently deteriorated for various reasons. Spinal epidural hematomas developed in 3 patients (2 traumatic, 1 spinal intervention). The fractures were managed surgically in 3 patients, halo jacket was used in 2, and the remainder were managed expectantly on traction. Four patients died before discharge, 4 were able to walk with an aid at discharge, and the others were wheel chair dependent. Neurologic deficits were often subtle on initial presentation, resulting in many injuries being missed because of a low index of suspicion and poor visualization of lower cervical fractures on conventional radiographs. Extension of the ankylosed kyphotic cervical spine during conventional immobilization or for radiologic procedures resulted in neurologic deficits. Patients with an ankylosed cervical spine are normally unable to see the ceiling lying supine because of cervicothoracic kyphosis and use pillows to support their head. Cervical spine alignment in a similar flexed position is essential during immobilization or imaging. Medical alert cards as for patients with diabetes would be a way forward in correctly identifying patients with AS so that appropriate precautions can be instituted by emergency services.
Eleven patients diagnosed as having muscular dystrophy and who underwent posterior spinal fusion were reviewed: Becker dystrophy in one, limb girdle in two, facioscapulohumeral in one, myopathia unspecified in one, myotonia dystrophica in two, myotonia congenita in one, and hypotonia congenita in three. There were eight females and three males. The curve pattern was thoracic in four, thoracolumbar in three, double thoracic and thoracolumbar in three, and thoracolumbar lordosis in one. Scoliosis was associated with kyphosis in two, with lumbar lordosis in one, and thoracic lordosis in four patients associated with poor vital capacity and shortness of breath. Seven patients had nonoperative treatment, five showing increase of the curve, and two having control of the curve. All patients had posterior spinal fusion with instrumentation with a follow-up of 9-89 months (average, 41 months). Postoperative support was used in all but one. Major complications occurred in four patients: a symptom of vascular obstruction of the duodenum in two, extubation delayed until the 7th day postoperatively in one and pseudarthrosis in one resulting in an increasing curve and refusion. One patient (limb girdle), 6 years after surgery at 21 years died from cardiomyopathy. The second (limb girdle) lost ambulation at age 22 years, 6.6 years after spinal surgery. In conclusion, patients with muscular dystrophies other than Duchenne generally have slowly evolving curves, and the use of an orthosis in the juvenile years controlled the curve until the pubertal growth spurt, when progression occurred. Surgical treatment was successful in stabilizing the deformities.
A case report with an 11-year follow-up assessment after resection and reconstruction for lumbar chordoma is given. The literature relevant to this topic is reviewed. To report the long-term outcome in a case of lumbar chordoma, to review the literature on vertebral chordoma, and to outline the rationale for surgical resection in such cases. Chordoma is a malignant bone tumor that grows slowly, often recurs locally, and metastasizes late. Although different treatment approaches exist, including radiation and surgery, the only curative treatment is early and complete surgical excision of the tumor. Immediate spinal stability must be achieved with appropriate replacement or bone graft with rigid fixation. The 11-year follow-up evaluation of a 42-year-old woman with L3 and L4 vertebral body chordoma treated with complete removal, femoral shaft allograft replacement, fusion, and rigid metal fixation is reported. The patient was observed with serial physical examinations, radiographs, and laboratory studies over 11 years. At this writing, 11 years after the resection of the L3 and L4 chordoma, the patient is asymptomatic without evidence of recurrence or metastasis. As reported, vertebral chordomas are not curable, but the authors' experience contradicts this. The surgeon should aim at a wide, or at least a marginal, excision followed by a stable reconstruction.
Posttraumatic syringomyelia is an uncommon late complication of spinal cord injury. This study identified nine patients with posttraumatic syringomyelia and examined initial presentation, neurologic status, ability to perform functional activities, and results of treatment. Pain and numbness were the most common presenting symptoms. Motor impairment occurred later but was more disabling. Functional abilities depended mainly on the level of the original spinal cord injury. Three patients were managed conservatively and have had no significant progression of their neurologic deficit. Six patients were managed with syringoperitoneal or syringosubarachnoid shunts. Pain improved most consistently after surgery. Motor power improved less and sensation least. Ability to perform activities of daily living did not significantly change after surgery. Posttraumatic syringomyelia remains a difficult therapeutic problem in the spinal cord-injured population.
A retrospective analysis was performed. To analyze the characteristics of aneurysmal bone cyst arising from giant cell tumor of the mobile spine and to discuss the outcome of corresponding surgical and nonsurgical treatment. Giant cell tumors are generally benign neoplasms that exhibit aggressive behavior with a tendency to recur locally. Aneurysmal bone cysts are benign, highly vascular osseous lesions. Although both of them have been described separately in previous literatures, few reports have described aneurysmal bone cyst secondary to giant cell tumor of the mobile spine. Between January 2004 and December 2009, 11 patients were identified with an aneurysmal bone cyst arising from giant cell tumor of the mobile spine. Four patients underwent subtotal tumor resection followed by radiotherapy, and the other 7 patients underwent total tumor resection. Patients with lesions located below T6 were treated with selective arterial embolization before surgery. Clinical data and the efficacy of surgery were analyzed via chart review Of the eleven patients identified for inclusion in this study, the average age was 33 months (range ∇ 14-65 months). The mean length of follow-up was 31 months. Seven patients kept disease-free during the follow-ups. The remaining four patients recurred and one died of local re-recurrence and lung metastasis. Unlike primary aneurysmal bone cyst, secondary aneurysmal bone cyst arising from giant cell tumor of the mobile spine has a more aggressive tendency to recurrence locally. Complete resection with systematic radiotherapy should be undertaken for the treatment of aneurysmal bone cyst secondary to giant cell tumor of the mobile spine, which is associated with a good prognosis for local tumor control. As complete or as radical an operation as possible should be performed at first presentation. The best chance for the patient is the first chance. Selective preoperative embolization is advised to minimize intraoperative blood loss.
A cohort study with a follow-up period of 11 years. To study the growth of the spine with a focus on the development of trunk asymmetry and scoliosis. Trunk asymmetry, a common phenomenon at adolescence, can be considered the clinical expression of scoliosis. The importance of the pubertal growth spurt has been stressed in the natural history of scoliosis. However, no cohort studies have focused on the ascending and descending phase of the spine's peak growth and the development of trunk asymmetry. The cohort consisted of all the fourth-grade school children in the Western school district of Helsinki, Finland, in the spring of 1986. These 1060 children (515 girls and 545 boys), from the average age of 11 to 14 years, were invited to undergo annual examinations. The 855 children (80.7%) who had participated in the study at the age of 14 years were invited to a reexamination at the age of 22 years. This invitation was accepted by 430 (208 women and 222 men; 54%) of those invited. The forward bending test, the spinal pantography, and the anthropometric measurements were carried out by the same author (M.N.) throughout this study. At 22 years of age, 30% of the adults were found to be symmetric, with a hump less than 4 mm in the forward bending test, whereas 51% had a hump of 4 to 9 mm, and 19% had a hump 10 mm or larger (major asymmetry). The directional asymmetry of trunk surface, a skew to the right at the thoracic level and to the left at the lumbar level at puberty, remained constant at adult age. The prevalence of major trunk asymmetry at adult age was the same in both women and men, in contrast to the female predominance at puberty in this cohort. There were close correlations in the degrees of thoracic and lumbar asymmetry between puberty and adult ages. The shape of the back develops mainly during the pubertal growth spurt at ages 12 to 14 years in girls and boys. Trunk asymmetry (and mild scoliosis) seems as prevalent in young adult women as in men, although at puberty idiopathic scoliosis was twice as prevalent among girls as among boys in this cohort.
Report of an 11-year-old girl with a left atlantoaxial rotatory subluxation and ankylosis found 20 months after she sustained a cervical injury. To describe the radiographic characteristics of this rare deformity assessed with a combination of spiral CT scan with multiplanar three-dimensional reformations and functional CT scan. Atlantoaxial rotatory subluxation is a well-known condition, but its association with lateral C1-C2 ankylosis has not been reported to our knowledge. For a complete assessment of the dislocation, a combined morphologic volumetric and functional CT study was performed. Spiral CT showed an atlantoaxial rotatory subluxation with lateral C1-C2 ankylosis. CT study also demonstrated a lateral C1-C2 subluxation and an ipsilateral occipitoatlantal subluxation. Cervical MRI showed no spinal cord compression despite the seriousness of the dislocation process. Whereas "classic" spiral study with multiplanar and three-dimensional reformations allows precise assessment of relationships between the upper cervical vertebrae, as well as bony changes, a functional CT study is essential for cervical biomechanic assessment of rotational instabilities of the craniovertebral junction and upper cervical spine.
C ook et al 1 developed further insight into relative motion between vertebral bodies by describing interpedicular displacement (ID) and travel (IPT) for design assessment and refi nement of pedicle screw-based dynamic stabilizers. However, by expressing the magnitude of IPT vector alone, vital information on travel trajectory is lost, thereby undermining the quality of motion description that ID and IPT intended. Hence, we propose the following amendments to the methodology. The coordinate axes of the motion sensor and the biome-chanical testing machine should be aligned prior to testing. Data should be recorded/expressed in cylindrical coordinate system (r , θ , z); where r , θ represents the bending plane and z the bending axis. This system of measurement will help separate bending-plane translations from out-plane translations and will also allow for capture of any in-plane angular shift in the IPT vector. Assuming left-right symmetry, IPT vectors on one side may be mirrored about the midsagittal plane to double the sample size. Also, IPT and ID were calculated between different time points (IPT: peak-peak loading, ID: maximum-minimum r i). Wales to fi rst author (UC); and an internal research grant from Spine Service funds were received to support this work. No relevant fi nancial activities outside the submitted work. tandem with ID, as stand-alone IPT reveals no information on the degree of translational defl ection of the implant. We recommend that both IPT and ID should be calculated between the same time points, preferably maximum-minimum r i. Reference 1. Cook DJ , Yeager MS , Cheng BC. Interpedicular travel in the evaluation of spinal implants: an application in posterior dynamic stabilization . Spine 2012 ; 37 : 923 – 31 .
Kinetic MRIs of cervical spines were obtained and analyzed according to the amount of motion and the degenerative grade of the intervertebral disc. To define the relationship between the grade of disc degeneration and the motion unit of the cervical spine and elucidate changes in the role of each cervical spine unit during flexion-extension motion caused by degeneration. Degenerative changes in the cervical disc occur with age. The correlation between the degree of cervical disc degeneration and extent of cervical spine mobility has not yet been determined. The effect of degeneration on the overall motion of the functional spinal unit also remains undefined. We studied 164 patients with symptomatic neck pain. The cervical intervertebral discs were graded by spine surgeons according to the degenerative grading system (Grades I to V). All radiologic data from kinetic MRIs were recorded on a computer for subsequent measurements. All measurements and calculations for translational motion and angular variation of each segment were automatically performed by a computer analyzer. The translational motion in discs with Grade II degeneration (mild degeneration) increased to Grade III degeneration (higher degeneration). However, the translational motion and angular variation significantly decreased for the Grade V (severe degeneration). For patients with relatively low grades of degeneration, Grades I and II discs, the C4-C5 and C5-C6 segmental units contributed the majority of total angular mobility of the spine. However, for the severely degenerated segments, Grade V discs, the contributions of the C4-C5 and C5-C6 U significantly decreased. The changes that occur with disc degeneration progress from the normal state to an unstable phase with higher mobility and subsequently to an ankylosed stage. This study evaluated the contribution of different levels to the changes in overall motion that occur with degeneration.
Early diagnosis of vertebral infection (hematogenous or postsurgical) is necessary to choose a correct therapy and to minimize dramatic complications. All patients suspected to have vertebral infection underwent radiologic imaging and In-Biotin scintigraphy. Biotin is a growth factor used by many bacteria. The aim of our study is to use In-Biotin to diagnose vertebral infections. Magnetic resonance imaging, even if endowed with fairly good sensitivity and specificity, shows some limitations in the study of the onset of pathology and in postsurgical conditions. Conventional scintigraphic imaging, like bone scintigraphy with Tc-MDP, Ga-citrate scintigraphy, or Positron Emission Tomography with [F]FDG, are limited by relatively low specificity; the use of Streptavidin/In-Biotin scintigraphy, based on aspecific uptake of tracer in the site of infection, shows good results in term of sensibility and specificity but the use of heterologous protein might engender immunogenic reactions. All patients (pts) (n = 110) of the study underwent In-biotin scintigraphy 2 hours after intravenous injection of the tracer, 71 pts were suspected to have hematogenous vertebral infection (Group I) and 39 pts were suspected to have postsurgical infection (Group II). The reference for final diagnosis was either bacterial cultures, histopathologic analysis, and/or clinical/imaging follow-up for at least 1 year. In-biotin scintigraphy showed a sensitivity of 84% and specificity of 98% in Group I and a sensitivity of 100% and specificity of 84% in Group II. Our results showed that In-Biotin scintigraphy possess high diagnostic accuracy. This technique is easy to perform and requires short imaging time-point after intravenous tracer injection. Moreover if In-Biotin uptake is due only to high proliferation rate of bacteria presents in site of infection, it will be further investigated to discriminate definitely bacterial from sterile inflammation.
A retrospective review of a single surgeon consecutive series of video-assisted thoracoscopic anterior release and fusion. To examine radiographic fusion rates and standard radiographic parameters of spinal deformity correction, as well as to identify possible complications of thoracoscopic anterior release and fusion in patients with a minimum of 2-year follow-up treated for spinal deformity. Anterior release and fusion of the thoracic spine is indicated in the treatment of rigid scoliosis and kyphosis, the treatment or prevention of crankshaft growth, and in patients at increased risk for pseudarthrosis. Although early postoperative outcomes of video-assisted thoracoscopic anterior release/fusion exist in the literature, few data are available with follow-up greater than 2 years. A retrospective chart and radiograph review of 112 consecutive cases of thoracoscopic anterior release/fusion with open posterior instrumentation/fusion was performed. The diagnosis, indications, perioperative data, as well as early and delayed complications, were evaluated. Deformity correction and intervertebral fusion rates were assessed at latest follow-up (> or =2 years). The diagnoses included 50 patients with neuromuscular deformity, 42 with idiopathic deformity, 10 congenital, and 10 miscellaneous etiologies. The average operative time was 160 +/- 41 minutes to excise and bone graft an average of 7 +/- 2 discs, with an average blood loss of 285 +/- 303 cc. The average hospital stay was 9 +/- 5 days. Fourteen percent of the patients had perioperative respiratory complications that varied from atelectasis to chylothorax. There were no long-term complications associated with the anterior surgery. Scoliosis improved from 80 +/- 12 degrees to 36 +/- 17 degrees, and kyphosis from 88 +/- 15 degrees to 60 +/- 20 degrees at latest evaluation (P < or = 0.001). Evidence of a "solid" anterior arthrodesis (with >50% filling of the disc space) was present radiographically in 75% of the disc spaces with moderate interobserver reliability of the grading system (kappa = 0.49). Thoracoscopic anterior release and fusion of the thoracic spine is a safe and effective procedure when combined with posterior instrumentation and fusion. The primary goal of increasing the flexibility of a rigid spine and achieving a solid arthrodesis occurred in the vast majority of cases.
Study Design. Prospective cohort. Objectives. The purpose of this study is to examine the relationship between radiographic fusion and patient-reported health-related quality of life (HRQOL) measures in patients undergoing instrumented posterolateral lumbar fusion. Summary of Background Data. Previous studies have shown that a solid fusion does not always produce clinical success. However, these studies did not use validated patient-reported HRQOL measures. Methods. One hundred ninety-three patients who underwent instrumented posterolateral fusion with complete preoperative and 2-year HRQOL measures and a fine-cut computed tomographic (CT) scan with reconstructions done at 2 years after surgery specifically done to assess fusion status were identified. HRQOL measures included the Oswestry Disability Index (ODI), the Short Form-36 and back and leg pain numerical rating scales. The percentage of patients reaching the minimum clinically important difference and substantial clinical benefit for ODI and Short Form-36 were also calculated. CT scans were graded as fused or not by three independent reviewers. Comparisons were made in outcomes measures between the patients with solid fusions and those judged not to have a solid radiographic fusion. Results. There were 124 women and 69 men with an average age of 63 years. Patients judged to have a solid fusion demonstrated a better ODI score at 2 years than those who were not solidly fused (P = 0.023). There was a trend toward greater improvement in mean ODI score in those with a solid fusion (P = 0.074). A statistically greater number of patients who had a solid fusion (111 of 171, 65%) achieved the minimum clinically important difference for ODI than those who did not achieve a solid fusion (7 of 22, 32%) (P = 0.004). Conclusion. A greater proportion of patients achieved clinically relevant improvements in low back specific quality-of-life measures when they had achieved a solid fusion than patients who did not have a solid fusion. Although radiographic fusion may not be the true measure of clinical success, this study suggests that solid arthrodesis contributes to clinical outcome and is an important goal of fusion surgery.
One-hundred-fourteen patients with metastatic melanoma of the spine were retrospectively reviewed. The goal was to define the demographics, risk factors, and prognosis for this population. The incidence of melanoma is increasing faster than any other cancer. Therefore, orthopedic and neurologic surgeons will be increasingly confronted by patients with spinal metastases from melanoma. However, the demographics, risk factors, and prognosis remain unclear. From 7010 consecutive patients with melanoma, 114 were identified with clinically or radiographically evident spinal metastases. A comparison was made between these patients and the remainder of the population with melanoma seen at our institution using contingency table analysis with statistical significance determined by a chi-squared test. Survival data were represented by Kaplan-Meier curves, and log-rank testing was used for statistical comparisons. Risk factors associated with the development of these metastases included primary lesions that were ulcerated, deeper than 0.76 mm, or of Clark level II, or located on the trunk or mucosal surfaces. The median survival time for all patients was 86 days, but this was reduced in patients with more than one metastatic site in addition to the spine. The prognosis for most patients with spinal metastases from melanoma is dismal. However, patients with metastatic disease limited to the spine and one other organ may survive for a relatively prolonged time and may be candidates for surgical intervention directed toward symptomatic relief.
Top-cited authors
Lawrence Lenke
  • Washington University in St. Louis
Frank J Schwab
Steven Glassman
  • University of Louisville
Christopher I Shaffrey
  • Duke University
Maurits van Tulder
  • Vrije Universiteit Amsterdam