Evid Based Spine Care J
· 2012 Aug · PMID 23532182
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STUDY DESIGN: Retrospective case series. OBJECTIVE: To assess fusion rates in patients with sacroiliac joint (SIJ) pain following a minimally invasive technique using fibular dowel allograft. METHODS: Thirty-seven con...STUDY DESIGN: Retrospective case series. OBJECTIVE: To assess fusion rates in patients with sacroiliac joint (SIJ) pain following a minimally invasive technique using fibular dowel allograft. METHODS: Thirty-seven consecutive patients (mean age: 42.5 years [range, 23-63 years]) with SIJ pain treated with 38 minimally invasive elective SIJ arthrodeses were retrospectively reviewed using chart and x-ray data. The fusion procedure consisted of minimal muscle stripping over the posterior SIJ and insertion of a cranial and caudal fibular dowel graft across the joint following placement of Steinmann pins. Fusion was deemed to be present when bone bridging trabeculae could be seen crossing the SIJ on either oblique x-rays or by computed tomographic scan. Patients were followed-up for a mean of 52 months (range, 24-62 months). Visual Analog Scale (VAS) was used to monitor clinical pain improvement. RESULTS: Thirty-four patients with SIJ arthrodeses (89.5%) healed and led to substantial improvement in VAS pain scores (preoperative 9.1, postoperative 3.4) (P < .001). This improvement in VAS occurred over a 6-month period and was sustained through subsequent follow-up. Nonunion occurred in four patients with SIJ (10.5%). Each SIJ nonunion was successfully treated by secondary autogenous bone grafting and compression screw fixation. CONCLUSIONS: In patients with primary low back pain attributable to the SIJ, a minimally invasive, dual fibular dowel graft provided high rates of fusion and improved pain scores. [Table: see text].
Dhoke P, Goss B, Mehta S
… +2 more, Stanojevic S, Williams R
Evid Based Spine Care J
· 2012 Nov · PMID 23531776
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STUDY DESIGN: Retrospective cohort study. Clinical question or objective: Is there a benefit to additional transforaminal lumbar interbody fusion (TLIF) if a solid posterolateral (PL) fusion can be achieved with routine...STUDY DESIGN: Retrospective cohort study. Clinical question or objective: Is there a benefit to additional transforaminal lumbar interbody fusion (TLIF) if a solid posterolateral (PL) fusion can be achieved with routine bone morphogenetic protein (BMP) use in low-grade spondylolisthesis? METHODS: We performed a retrospective review of patients who had undergone surgery for grade I or II lumbar spondylolisthesis stratified into two groups. Group 1 had 46 patients who underwent TLIF along with PL instrumented fusion. Group 2 had 40 patients who underwent PL instrumented fusion alone. In both groups, adequate posterior decompression with pedicle screw instrumentation was performed and rhBMP-7 was used. All patients were evaluated clinically using the Oswestry Disability Index (ODI) and by independent radiological examination at 3 and 12 months. RESULTS: At a minimum follow-up of 12 months, there was no statistically significant difference in the rate of fusion. In addition, there were no differences in the proportion of patients who had a minimal clinically significant difference in their ODI. There was a similar rate of complications between each cohort. CONCLUSIONS: The use of BMP was associated with a high rate of PL lumbar fusion. In the presence of a PL fusion, there appears to be little clinical benefit to additional anterior TLIF in degenerative spondylolisthesis. [Table: see text].
Daubs MD, Lenke LG, Bridwell KH
… +3 more, Cheh G, Kim YJ, Stobbs G
Evid Based Spine Care J
· 2012 Nov · PMID 23531707
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STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To analyze the surgical results of a group of patients older than 65 years treated for mild degenerative lumbar scoliosis (<30°) with stenosis, treated with decompre...STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To analyze the surgical results of a group of patients older than 65 years treated for mild degenerative lumbar scoliosis (<30°) with stenosis, treated with decompression alone or decompression and limited fusion. METHODS: We evaluated 55 patients, all older than 65 years from our prospectively collected database with mild degenerative scoliosis (<30°) and stenosis who underwent surgery. Laminectomy alone was performed in 16 patients, and laminectomy and limited fusion in 39 patients. Mean follow-up was 4.6 years in the decompression group and 5.0 years in the fusion group. Clinical results were graded by patients' self-reported satisfaction and length of symptom-free period to recurrence. RESULTS: In the decompression alone group, 6 (37%) of 16 patients developed recurrent stenosis at the previously decompressed level and five developed recurrence within 6 months postoperatively versus the decompression and fusion group where 3 (8%) of 39 (P = .0476) developed symptomatic stenosis supra adjacent to the fusion. Of 16 patients in the decompression alone group, 12 (75%) had recurrence of symptoms by the 5-year follow-up period versus only 14 (36%) patients in the decompression and fusion group (P = .016). Adjacent segment degenerative changes were common in the fusion group, but only 7% developed symptomatic stenosis. CONCLUSIONS: Decompression with limited fusion prevents early return of stenotic symptoms compared with decompression alone in the setting of mild degenerative scoliosis (<30°) and symptomatic stenosis in patients 65 years and older. [Table: see text] The definiton of the different classes of evidence is available on page 67.
Evid Based Spine Care J
· 2012 Nov · PMID 23531640
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STUDY DESIGN: A prospective case series of patients undergoing lumbar spine surgery. OBJECTIVE: Is there a correlation between patients' expectations before lumbar surgery, postoperative outcomes, and satisfaction leve...STUDY DESIGN: A prospective case series of patients undergoing lumbar spine surgery. OBJECTIVE: Is there a correlation between patients' expectations before lumbar surgery, postoperative outcomes, and satisfaction levels? METHODS: A prospective study of 145 patients undergoing primary, single-level surgery for degenerative lumbar conditions was conducted. Oswestry Disability Index, back Visual Analog Scale (VAS), and leg VAS were assessed preoperatively and at 6 weeks and 6 months after surgery. Patients' expectations were measured preoperatively by asking them to score the level of pain and disability that would be least acceptable for them to undergo surgery and be satisfied. Satisfaction was assessed 6 weeks postoperatively with a Likert scale. Differences in patient expectations between actual and expected improvements were quantified. RESULTS: Most patients had a clinically relevant improvement, but only about half achieved their expectations. Satisfaction did not correlate with preoperative pain or disability, or with patient expectation of improvement. Instead, satisfaction correlated with positive outcomes. CONCLUSIONS: Patient expectations have little bearing on final outcome and satisfaction. [Table: see text].
Evid Based Spine Care J
· 2012 Aug · PMID 23531624
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STUDY DESIGN: Retrospective cohort study. CLINICAL QUESTION: What is the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) after major spine surgery when no prophylactic measures were used? METHODS: ...STUDY DESIGN: Retrospective cohort study. CLINICAL QUESTION: What is the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) after major spine surgery when no prophylactic measures were used? METHODS: A prospective evaluation of 121 patients who underwent 128 major spine surgeries was conducted to determine the incidence of clinically identifiable DVT. As a matter of practice, no patient was given thromboprophylaxis, either mechanical or chemical. RESULTS: Only one patient developed the signs and symptoms of DVT, which was further confirmed by a Doppler study. The overall incidence of DVT was 0.78%. There was no clinically evident case of PE. CONCLUSIONS: Considering the low rate of incidence of DVT and PE, routine screening and prophylaxis for DVT appears unwarranted in major spine surgery. [Table: see text].
Evid Based Spine Care J
· 2012 Aug · PMID 23531493
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STUDY DESIGN: Prospective case series. OBJECTIVE: To evaluate the effect of three repetitive transforaminal steroid injections in a large series of selected patients with cervical radiculopathy caused by spondylosis. M...STUDY DESIGN: Prospective case series. OBJECTIVE: To evaluate the effect of three repetitive transforaminal steroid injections in a large series of selected patients with cervical radiculopathy caused by spondylosis. METHODS: Consecutively, 140 patients with long-lasting medical history, clinical findings, and MRI indicating a cervical nerve root origin based on degenerative disease and a positive selective transforaminal diagnostic nerve root blocks with local anesthetics resulting in at least 50% temporary arm pain reduction were included. Before treatment started, patients underwent a clinical examination by a neurosurgeon. All patients were followed-up and evaluated by one physiotherapist at the neurosurgery outpatient clinic. A designed outcome questionnaire including Neck Disability Index (NDI), Symptoms Frequency Index, and Visual Analog Scale for pain intensity were used. A series of three transforaminal steroid injections, with 3 weeks in between, were performed by a neuroradiologist using image intensifier guidance in an x-ray suite. At 12-14 weeks after the first injection, follow-up was performed. Criteria for positive response to the treatment was >50% radicular arm pain reduction. Except for occasional painkillers, no other treatment was given to the patients. RESULTS: Positive response to the treatment was achieved in 49% (n = 69) with a significant difference in NDI and pain intensity between responders and nonresponders. CONCLUSIONS: Repetitive transforaminal steroid injections may reduce symptoms (frequency, intensity, and fewer limitations of daily living activities) of radiculopathy in patients with degenerative disease in the cervical spine at a short time follow-up. [Table: see text].
Evid Based Spine Care J
· 2012 Nov · PMID 23526915
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STUDY DESIGN: Retrospective review. INTRODUCTION: Lumbar radiculopathy and claudicant leg pain are common degenerative spinal conditions often treated by elective microdiscectomy or decompression. Published outcome dat...STUDY DESIGN: Retrospective review. INTRODUCTION: Lumbar radiculopathy and claudicant leg pain are common degenerative spinal conditions often treated by elective microdiscectomy or decompression. Published outcome data for these procedures have focused on improvement in pain scores, and not on grounded functional outcome or depression scores.1,2,3 Moreover, depression is considered by many surgeons to be a red flag for poor outcome for surgical treatment. We asked what effect lumbar microdiscectomy and laminectomy procedures had on functional outcome and depression scores in our clinical population. METHODS: Beginning in January 2010, the following outcome data were prospectively gathered before and after surgery from all patients at the Cleveland Clinic undergoing either lumbar microdiscectomy or lumbar decompression: EQ-5D (EuroQOL, quality-of-life measure), PHQ-9 (measure of depressive symptoms), PDQ (pain disability questionnaire), and Rankin scores (disability or dependence in daily activities). RESULTS: The mean EuroQOL scores improved by 35% (from 0.4-0.75 of a maximum of 1.0) for both microdiscectomy and lumbar laminectomies. The mean PHQ-9 scores (measure of depressive symptoms) significantly improved for most patients undergoing either procedure. In line with previously published reports, we also found improvement in Rankin scores and Pain Disability Questionnaire scores. CONCLUSIONS: Our outcome data indicate that microdiscectomy and lumbar decompression not only reduce disability and pain but also improve depressive symptoms and overall quality of life for patients. These findings support operative treatment of lumbar radiculopathy and neurogenic claudication including treatment performed in the depressed population.
Evid Based Spine Care J
· 2012 Nov · PMID 23526913
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Consistent with EBSJ's commitment to fostering quality research, we are pleased to feature some of the most highly rated abstracts from the 10th Annual AOSpine North America Fellows Forum in Banff, Canada. Enhancing the...Consistent with EBSJ's commitment to fostering quality research, we are pleased to feature some of the most highly rated abstracts from the 10th Annual AOSpine North America Fellows Forum in Banff, Canada. Enhancing the quality of evidence in spine care means acknowledging and supporting the efforts of young researchers within our AOSpine North America network. We look forward to seeing more from these promising researchers in the future.
Evid Based Spine Care J
· 2012 Nov · PMID 23526912
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BACKGROUND: Aneurysmal bone cysts are rare occurrences in the cervical spine. Surgical treatment in pediatric patients is a challenge. Complete tumor resection offers the best chance for cure. DESCRIPTION: Diagnosis an...BACKGROUND: Aneurysmal bone cysts are rare occurrences in the cervical spine. Surgical treatment in pediatric patients is a challenge. Complete tumor resection offers the best chance for cure. DESCRIPTION: Diagnosis and surgical management of an expansile aneurysmal bone cyst of the cervical spine involving all three spinal columns in a 10-year-old boy. RESULTS: Surgical treatment included tumor excision and circumferential fusion, and produced no neurological or vascular sequelae. This approach minimizes the risk of recurrence and the possibility of postoperative spinal instability. CONCLUSION: Spinal instability is preferably addressed with reconstruction and stabilization. Cervical aneurismal bone cyst lesions are ideally treated with complete resection to minimize the chance of recurrence. In pediatric cases, defects created by resection should be corrected by fusion to minimize the risk of postoperative instability and growth abnormality.
Spiker WR, Lawrence BD, Raich AL
… +2 more, Skelly AC, Brodke DS
Evid Based Spine Care J
· 2012 Nov · PMID 23526911
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STUDY DESIGN: Systematic review. STUDY RATIONALE: Chronic sacroiliac joint pain (CSJP) is a common clinical entity with highly controversial treatment options. A recent systematic review compared surgery with denervati...STUDY DESIGN: Systematic review. STUDY RATIONALE: Chronic sacroiliac joint pain (CSJP) is a common clinical entity with highly controversial treatment options. A recent systematic review compared surgery with denervation, but the current systematic review compares outcomes of surgical intervention with therapeutic injection for the treatment of CSJP and serves as the next step for evaluating current evidence on the comparative effectiveness of treatments for non-traumatic sacroiliac joint pain. Objective or clinical question: In adult patients with injection-confirmed CSJP, does surgical treatment lead to better outcomes and fewer complications than injection therapy? METHODS: A systematic review of the English-language literature was undertaken for articles published between 1970 and June 2012. Electronic databases and reference lists of key articles were searched to identify studies evaluating surgery or injection treatment for injection-confirmed CSJP. Studies involving traumatic onset or non-injection-confirmed CSJP were excluded. Two independent reviewers assessed the level of evidence quality using the grading of recommendations assessment, development and evaluation (GRADE) system, and disagreements were resolved by consensus. RESULTS: We identified twelve articles (seven surgical and five injection treatment) meeting our inclusion criteria. Regardless of the type of treatment, most studies reported over 40% improvement in pain as measured by Visual Analog Scale or Numeric rating Scale score. Regardless of the type of treatment, most studies reported over 20% improvement in functionality. Most complications were reported in the surgical studies. CONCLUSION: Surgical fusion and therapeutic injections can likely provide pain relief, improve quality of life, and improve work status. The comparative effectiveness of these interventions cannot be evaluated with the current literature.
Schroeder JE, Dettori JR, Brodt ED
… +1 more, Kaplan L
Evid Based Spine Care J
· 2012 Nov · PMID 23526910
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STUDY DESIGN: Systematic review. STUDY RATIONALE: Disc degeneration is a common process starting early in life. Often disc herniation is an early step in disc degeneration, which may cause pain or stenosis. How quickly...STUDY DESIGN: Systematic review. STUDY RATIONALE: Disc degeneration is a common process starting early in life. Often disc herniation is an early step in disc degeneration, which may cause pain or stenosis. How quickly this subsequent disc degeneration occurs following a disc herniation and subsequent surgical treatment and whether certain spinal procedures increase the rate of degeneration remain unclear. OBJECTIVES: To investigate the risk of subsequent radiographic disc degeneration following discectomy, discography, and conservative care in patients with a first-time diagnosed herniated nucleus pulpous (HNP) and to ascertain whether this risk in these defined groups changes over time. METHODS: A systematic review of pertinent articles published up to June 2012. Key articles were searched to identify studies evaluating the risk of subsequent radiographic disc degeneration following treatment for HNP. Studies that included patients undergoing secondary surgery for disc herniation or that did not use a validated classification system to measure the severity of disc degeneration were excluded. Two independent reviewers assessed the strength of evidence using the GRADE criteria and disagreements were resolved by consensus. RESULTS: From a total of 147 possible citations, three cohort studies (class of evidence III) met our inclusion criteria and form the basis for this report. The risk of subsequent lumbar disc degeneration following standard discectomy was significantly greater compared with both microdiscectomy (48.7% vs 9.1%) and asymptomatic controls (90% vs 68%) in two studies with mean follow-ups of 5.5 and 25.3 years, respectively. Following conservative care for first-time HNP in the third study, the risk of progression of lumbar disc degeneration was 47.6% over the first 2 years of follow-up and 95.2% over the next 6 years of follow-up. In the same study, the risk of lumbar disc degeneration was shown to increase incrementally over the course of the 8-year follow-up, with all patients showing signs of degeneration at final examination. CONCLUSION: Standard discectomy in first-time lumbar HNP may increase the risk of subsequent same-level lumbar disc degeneration compared with microdiscectomy as seen in one low-quality study. However, disc degeneration is likely a natural, temporal consequence following HNP, as demonstrated in a second low-quality study. The overall strength of evidence for the conclusions is very low.
Evid Based Spine Care J
· 2012 Aug · PMID 23526907
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STUDY DESIGN: Case report. OBJECTIVE: To describe a case of spinal cord transection in a 6-year-old child. BACKGROUND INFORMATION: Non-missile injury of the spinal cord is not common and its incidence varies according...STUDY DESIGN: Case report. OBJECTIVE: To describe a case of spinal cord transection in a 6-year-old child. BACKGROUND INFORMATION: Non-missile injury of the spinal cord is not common and its incidence varies according to the country. In addition, to our knowledge, there are no published reports of spinal cord injury (SCI) from a penetrating nail. Here, we report the case of a child who developed complete SCI because of cord transection by a nail. METHODS: A detailed history and physical examination were performed along with careful review of the patient's medical records. In addition, a review of the literature was conducted to assess the incidence and treatment of similar injuries. CASE DESCRIPTION: A 6-year-old boy was admitted to the hospital after falling from a tree and landing on a nail. His physical examination revealed an emaciated child with multiple decubitus ulcers, lying on his side in bed. Visible was a well-healed posterior puncture wound at the T8 vertebral level. On neurological examination, the patient had 0/5 muscle strength in his lower extremities, symmetrical areflexia, and hypoesthesia below the T8 level. Plain x-ray of the thoracolumbar spine was normal. Magnetic resonance imaging revealed a transected spinal cord at the T8 vertebra, consistent with his nail puncture wound. DISCUSSION: This report describes an unusual case of a complete SCI in a pediatric patient caused by penetrating trauma from a nail. To our knowledge, this is the first case to report on complete SCI due to trauma from a nail.
Evid Based Spine Care J
· 2012 Aug · PMID 23526906
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Recurrent cervical symptoms frequently occur after cervical disc replacement and fusion. To date, no algorithm for the diagnostic assessment of these symptoms has been established. We present a case report and review of...Recurrent cervical symptoms frequently occur after cervical disc replacement and fusion. To date, no algorithm for the diagnostic assessment of these symptoms has been established. We present a case report and review of the literature to illustrate the need for interdisciplinary diagnostics in recurrent cervicobrachialgia without pathological cervical imaging. The hospital chart, medical history, physical examination, and imaging of a single patient were reviewed. A 53-year-old man with preexisting cervical disc replacement and fusion presented with a new episode of cervicobrachialgia after a 2-year symptom-free interval. Cervical magnetic resonance imaging (MRI) showed no pathological findings. Six months later the patient reported increasing symptoms including numbness and weakness of the right arm. Repeated cervical MRI and thoracic computed tomography revealed cervical metastases with intraspinal tumor growth and an underlying extensive small cell bronchial carcinoma. In recurrent cervicobrachialgia, without pathological cervical imaging, interdisciplinary diagnostics are needed. Basic diagnostic tests may assist to exclude severe non-vertebrogenic pathologies.
Barbagallo GM, Yoder E, Dettori JR
… +1 more, Albanese V
Evid Based Spine Care J
· 2012 Aug · PMID 23526905
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STUDY DESIGN: Comparative effectiveness review. OBJECTIVE: To determine the comparative effectiveness and safety of percutaneous minimally invasive versus open spine surgery for fractures of the thoracolumbar junction....STUDY DESIGN: Comparative effectiveness review. OBJECTIVE: To determine the comparative effectiveness and safety of percutaneous minimally invasive versus open spine surgery for fractures of the thoracolumbar junction. METHODS: A systematic review of the English-language literature was undertaken for articles published between 1970 and March 15, 2012. Reference lists of key articles were also systematically checked. We attempted to identify all articles that reported on the effectiveness and/or safety comparing minimally invasive surgery (MIS) with open surgery for thoracolumbar fractures in the adult population. Articles containing hematological or neoplastic fractures primarily were excluded. Other exclusions included reviews, editorials, case series, non-English-language written studies, and animal studies. We rated the overall body of evidence using a modified Grades of Recommendation Assessment, Development and Evaluation (GRADE) system for diagnostic and therapeutic studies. RESULTS: • Two studies (Level of Evidence III) met our inclusion criteria. • Radiographic outcomes were similar between treatment groups. • Postoperative incisional pain was less in patients undergoing percutaneous MIS. • Patient function as assessed by the Hannover Spine Score, the SF-36 and the MacNab criteria were slightly higher in the percutaneous minimally invasive group, but not statistically significant. • Percutaneous MIS resulted in less blood loss and shorter length of hospital stay than open surgery. • No complications were reported using percutaneous MIS. CONCLUSION: Limited data suggest that percutaneous techniques are associated with less postoperative pain, less blood loss, a shorter hospital stay, and a slightly better functional outcome. However, concerns remain on the effectiveness of percutaneous techniques in correcting spinal deformity and achieving bony fusion. Further studies are needed to verify these preliminary findings.
Singh A, Tetreault L, Fehlings MG
… +2 more, Fischer DJ, Skelly AC
Evid Based Spine Care J
· 2012 Aug · PMID 23526904
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STUDY DESIGN: Systematic review. STUDY RATIONALE: Cervical spondylotic myelopathy (CSM) is a common cause of spinal cord dysfunction that may be asymptomatic or may present with severe symptoms. Since CSM has an insidi...STUDY DESIGN: Systematic review. STUDY RATIONALE: Cervical spondylotic myelopathy (CSM) is a common cause of spinal cord dysfunction that may be asymptomatic or may present with severe symptoms. Since CSM has an insidious manifestation, identification of risk factors associated with this condition may aid clinicians in monitoring high-risk patients and implementing appropriate management strategies. OBJECTIVE: To assess sociodemographic, clinical, radiographic, and genetic risk factors associated with presence of CSM in patients 18 years or older. METHODS: A systematic review of the literature was performed using PubMed, the National Guideline Clearinghouse Databases, and bibliographies of key articles to assess risk factors associated with CSM. Articles were reviewed by two independent reviewers based on predetermined inclusion and exclusion criteria. Each article was evaluated using a predefined quality-rating scheme. RESULTS: From 486 citations, eight articles met all inclusion and exclusion criteria. Larger vertebral body and smaller spinal canal and Torg/Pavlov ratio were associated with CSM diagnosis, while gender was not associated with a CSM diagnosis across multiple studies. There were inconsistent reports with respect to increased age as a risk factor for CSM diagnosis. CONCLUSION: The limited data available suggests that inherent anatomical features that may contribute to congenital cervical stenosis may be associated with CSM. This systematic review is limited by the small number of high-quality studies evaluating prognostic factors for CSM. The overall strength of evidence for all risk factors evaluated is low.