Gruenberg MF, Petracchi M, Valacco M
… +1 more, Solá C
Evid Based Spine Care J
· 2011 Aug · PMID 23532378
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STUDY DESIGN: Retrospective case series. Evidence level IV. OBJECTIVES: To evaluate surgical candidates with foraminal or extraforaminal lumbar disc herniation treated with CT-guided periradicular injection (CTGPI) as...STUDY DESIGN: Retrospective case series. Evidence level IV. OBJECTIVES: To evaluate surgical candidates with foraminal or extraforaminal lumbar disc herniation treated with CT-guided periradicular injection (CTGPI) as a valid treatment option for avoiding surgery. METHODS: We carried out a retrospective evaluation of 46 consecutive patients with foraminal or extraforaminal disc herniation treated with CTGPI. CTGPI was performed only when radicular pain could not be controlled, or in patients who continued requiring pain medication following an acute episode and whose radicular pain precluded them from resuming their daily activities. Forty-six patients with a minimum 2-year follow-up met the inclusion criteria. There were 21 women and 25 men, with a mean age of 47 years. RESULTS: At 1 month after injection, 41 (89%) patients experienced a decrease in radicular pain; 3 experienced no change; and 2 had received surgical treatment. At the final follow-up visit (mean, 74 months) 6 additional patients underwent surgery while 38 (83%) did not require surgery. Pain level comparison between pre-injection and last examination showed that low back pain had decreased a mean of 5 points and radicular pain diminished a mean of 7 points. Twenty-two (58%) of the 38 nonoperated patients had no pain at all and 35 patients had resumed their normal daily activities. No complications were recorded. CONCLUSION: Based on these results, we consider that the use of CTGPI is a reliable alternative before surgery for patients with foraminal or extraforaminal disc herniation without severe motor deficit but with intractable radicular pain. [Table: see text].
Arnold PM, Rice LR, Anderson KK
… +3 more, McMahon JK, Connelly LM, Norvell DC
Evid Based Spine Care J
· 2011 Aug · PMID 23532355
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STUDY DESIGN: Retrospective cohort study. BACKGROUND: Several studies focus on the long-term results of anterior cervical discectomy and fusion (ACDF) surgeries, but little information exists regarding how various pati...STUDY DESIGN: Retrospective cohort study. BACKGROUND: Several studies focus on the long-term results of anterior cervical discectomy and fusion (ACDF) surgeries, but little information exists regarding how various patient-related, procedure-related, and payer-related variables may affect postoperative hospital length of stay (LOS). OBJECTIVE: To determine what factors, if any, contribute to increased hospital LOS in patients who have had an ACDF. METHODS: Retrospective cohort study of 108 consecutive patients who underwent elective ACDF at a Midwest academic medical center. Extensive preoperative, intraoperative, and postoperative data were abstracted and analyzed to identify prognostic factors for an increased LOS. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on hospital LOS. RESULTS: 103 patients met inclusion and exclusion criteria. The mean LOS for patients undergoing ACDF was 1.98 (±1.6) days. Only 29% of patients had one level fused. The mean blood loss during surgery was 87.4 ± 99.6 mL. One subject lost 700 mL of blood. Complications, though rare, included uncontrolled postoperative pain (13%), cardiac (6%), pulmonary (4%), and urinary (3%). Covariates included in the final model were age, sex, cardiac complication, urinary complication, and pulmonary complication. Factors that contributed to increased LOS and their associated adjusted mean days were: ≥50 years of age (2.5 ± 1.2 days), female gender (2.3 ± 1.2 days), and three particular types of complications. The complications that had the largest effect on increased LOS from least to most severe were cardiac (3.5 ± 1.3 days), urinary (4.7 ± 1.3 days), and pulmonary (5.3 ± 1.3 days). CONCLUSIONS: The information presented in this study may be useful for patients, clinicians, and insurance companies, including precertification and case-management services. Our results can be instrumental in designing future prospective studies using more detailed analyses with more patients, more surgeons, and multiple institutions. [Table: see text].
Evid Based Spine Care J
· 2011 Aug · PMID 23532301
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STUDY DESIGN: Retrospective cohort study. CLINICAL QUESTION: This study aimed to describe the outcome of stabilization surgery with dynamic instrumentation for degenerative disc disease. The results were compared with...STUDY DESIGN: Retrospective cohort study. CLINICAL QUESTION: This study aimed to describe the outcome of stabilization surgery with dynamic instrumentation for degenerative disc disease. The results were compared with age- and gender-matched peers treated with traditional fusion with rigid instrumentation. If necessary, additional nerve elements decompression was undertaken in both groups. METHODS: This study analyzed the success rates of 25 patients aged 47.4 years (mean 95% confidence interval: 43.1-51.7) treated with stabilization of the involved vertebral dynamic unit(s) with either dynamic or rigid instrumentation with or without additional decompression. Clinical outcome was assessed with Oswestry disability index (ODI) and visual analogue scale (VAS) for back pain, leg pain, and activity level. Satisfaction outcome was measured with Stauffer and Coventry overall satisfaction criteria and VAS for satisfaction. Health-related quality of life was estimated with Short Form-36 (SF-36) questionnaires. Fusion rate and adjacent level(s) was checked with x-ray. Complications recorded in patients' files were evaluated and revision surgeries were stated as treatment failures. RESULTS: At the 4-year follow-up (range, 2-5 years) significant improvement was noted on some subjective parameters in both groups. No statistical differences were seen between the groups at final follow-up. Five patients (42%) in the rigid group and two patients (20%) in the dynamic group were rated good or excellent according to the overall Stauffer and Coventry satisfaction criteria. Radiologically, seven patients (58%) in the rigid group were undoubtedly fused and all the involved discs in the dynamic group continued to degenerate. Adjacent segments showed loss of disc height in both groups but only loss of upper adjacent discs in the rigid group was statistically significant. Two patients in the dynamic group and one patient in the rigid group required reoperation because of the pedicle screw misplacement. CONCLUSION: The results of this study indicate no significant difference between dynamic and rigid stabilization of the lumbar spine for patients with degenerative disc disease (DDD). However, the study is underpowered and further studies on larger and homogeneous group of patients should be undertaken. [Table: see text].
Evid Based Spine Care J
· 2011 Aug · PMID 23526897
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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 9th Annual AOSpine North America Fellows Forum in Banff, Canada. Enhancing the q...Consistent with EBSJ's commitment to fostering quality research, we are pleased to feature some of the most highly rated abstracts from the 9th 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.
Schroeder JE, Dettori JR, Ecker E
… +1 more, Kaplan L
Evid Based Spine Care J
· 2011 Aug · PMID 23526896
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STUDY DESIGN: Systematic review. STUDY RATIONALE: It is commonly believed that scoliosis treated nonoperatively does not worsen in pregnancy; however, at times patients with scoliosis progress rapidly during these mont...STUDY DESIGN: Systematic review. STUDY RATIONALE: It is commonly believed that scoliosis treated nonoperatively does not worsen in pregnancy; however, at times patients with scoliosis progress rapidly during these months. Objective or clinical question: What is the level of evidence to support or deny the claim that scoliosis treated nonoperatively does not worsen in pregnancy? METHODS: A systematic review of the literature was undertaken for articles published through March 2011. PubMed, Cochrane, National Guideline Clearinghouse Databases as well as bibliographies of key articles were searched. Two independent authors reviewed articles. Inclusion and exclusion criteria were set and each article was subject to a predefined quality-rating scheme. RESULTS: We identified two articles meeting our inclusion criteria. There was no difference in risk of curve progression > 5° or > 10° between women who had one or more pregnancies compared with those who had never been pregnant. However, among women who had been treated with an orthosis, those with one or more pregnancies had a higher risk of curve progression > 5° compared with never-pregnant women: relative risk = 8.1 (95% confidence interval: 1.8-35.8) in one study and 1.9 (95% confidence interval: 0.8-4.3) in the other. While women with more severe curves had a higher risk of curve progression, having one or more pregnancies did not appear to modify the effect of curve severity. CONCLUSIONS: Having one or more pregnancies does not appear to affect curve progression in scoliosis. However, among patients who had prior orthotic treatment, there is some evidence to suggest that women experiencing one or more pregnancies had a higher risk of curve progression compared with never-pregnant women. The overall strength of evidence for this conclusion is low.
Evid Based Spine Care J
· 2011 Aug · PMID 23526895
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STUDY DESIGN: Comparative effectiveness review. STUDY RATIONALE: Spinal fusion is believed to accelerate the degeneration of the vertebral segment above or below the fusion site, a condition called adjacent segment dis...STUDY DESIGN: Comparative effectiveness review. STUDY RATIONALE: Spinal fusion is believed to accelerate the degeneration of the vertebral segment above or below the fusion site, a condition called adjacent segment disease (ASD). The premise of dynamic stabilization is that motion preservation allows for less loading on the discs and facet joints at the adjacent, non-fused segments. In theory, this should decrease the rate of ASD. However, clinical evidence of this theoretical decrease in ASD is still lacking. We performed a systematic review to evaluate the evidence in the literature comparing dynamic stabilization with fusion. CLINICAL QUESTION: In patients 18 years or older with degenerative disease of the cervical or lumbar spine, does dynamic stabilization lead to better outcomes and fewer complications, including ASD, than fusion in the short-term and the long-term? METHODS: A systematic search and review of the literature was undertaken to identify studies published through March 7, 2011. PubMed, Cochrane, and National Guideline Clearinghouse Databases as well as bibliographies of key articles were searched. Two individuals independently reviewed articles based on inclusion and exclusion criteria which were set a priori. Each article was evaluated using a predefined quality-rating scheme. RESULTS: No significant differences were identified between fusion and dynamic stabilization with regard to VAS, ODI, complications, and reoperations. There are no long-term data available to show whether dynamic stabilization decreases the rate of ASD. CONCLUSIONS: There are no clinical data from comparative studies supporting the use of dynamic stabilization devices over standard fusion techniques.
Crabtree KL, Spurgeon A, Arzi H
… +2 more, Beaver B, Arnold PM
Evid Based Spine Care J
· 2011 May · PMID 23637682
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STUDY DESIGN: A case report. OBJECTIVE: Pyogenic osteomyelitis is the most common form of vertebral infection and typically resolves following conservative treatment with antibiotics administered long term and immobili...STUDY DESIGN: A case report. OBJECTIVE: Pyogenic osteomyelitis is the most common form of vertebral infection and typically resolves following conservative treatment with antibiotics administered long term and immobilization. In cases of spinal instability, severe neurological deficit or disease refractory to medical management, neurosurgical intervention is warranted. Historically, these patients have undergone radical vertebral debridement and grafting with or without posterior instrumentation. We report the case of a 46-year-old female intravenous drug user presenting with L5 pyogenic osteomyelitis with L5 vertebral compression and cortex retropulsion following L2-L4 laminectomy for epidural abscess 8 weeks prior. METHODS: The patient underwent an anterior approach single-stage L5 corpectomy, L4/5 and L5/S1 discectomies, expandable titanium-cage insertion and anterior plating from L4 to the sacrum. RESULTS: The patient recovered without any complications. The infection was successfully eradicated and her fusion remains solid 18 months postoperatively. CONCLUSIONS: To our knowledge, this is the first case of L5 vertebral osteomyelitis treated with a single-stage corpectomy and anterior instrumentation.
Evid Based Spine Care J
· 2011 May · PMID 23637681
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Dropped head syndrome (DHS) is a relatively rare condition, with a broad differential diagnosis. This deformity has significant implications on the health and quality of life of affected individuals. While surgery seems...Dropped head syndrome (DHS) is a relatively rare condition, with a broad differential diagnosis. This deformity has significant implications on the health and quality of life of affected individuals. While surgery seems to be an obvious therapeutic option, there is a paucity of information on surgical intervention with no clear consensus on an optimal approach or timing. We present a case of DHS in a young woman to illustrate this condition, and review the current literature. Although at present the only definitive solution for correction and stabilization of DHS is surgical intervention involving multilevel instrumented fixation and fusion, this condition requires a persistent medical workup and treatment of reversible causes before surgical intervention is contemplated.
Evid Based Spine Care J
· 2011 May · PMID 23637680
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STUDY DESIGN: Systematic review. Study rationale and context: Bone graft from the iliac crest has been the gold standard in posterolateral spinal fusion procedures, but is associated with chronic pain at the harvest si...STUDY DESIGN: Systematic review. Study rationale and context: Bone graft from the iliac crest has been the gold standard in posterolateral spinal fusion procedures, but is associated with chronic pain at the harvest site. Bone graft harvested locally from the spine and combined with extenders may decrease the morbidity associated with iliac graft harvest, but questions remain on the success of this technique to achieve bone union. OBJECTIVES: Compare the fusion rate, functional outcomes, and safety of local bone graft plus bone extender compared with iliac crest bone graft in posterolateral spinal fusion procedures. METHODS: A systematic review of the literature was undertaken for articles published through January 2011. Pubmed, Cochrane, National Guideline Clearinghouse Databases, and bibliographies of key articles were searched. Two independent reviewers studied the articles. Inclusion and exclusion criteria were set and each article was subject to a predefined quality-rating scheme. RESULTS: We identified three articles meeting our inclusion criteria. Fusion rates were high across studies, with no significant differences between treatment groups in fusion, functional outcomes, or quality of life. There were two deep infections (5.3%) in one study among patients receiving local bone graft plus extender. CONCLUSION: Local bone graft plus bone extender has similar fusion rates, functional outcomes, and patient quality-of-life scores as iliac crest bone graft in posterolateral spinal fusion procedures. Additional randomized trials with standardized methods of measuring fusion and functional outcomes are needed.
Evid Based Spine Care J
· 2011 May · PMID 23637679
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STUDY DESIGN: Systematic review. OBJECTIVES: (1) Does brace treatment compared with observation of curves lead to lower rates of surgery and failure for patients with idiopathic scoliosis? (2) Does brace treatment comp...STUDY DESIGN: Systematic review. OBJECTIVES: (1) Does brace treatment compared with observation of curves lead to lower rates of surgery and failure for patients with idiopathic scoliosis? (2) Does brace treatment compared with observation of curves lead to better quality of life outcomes for patients with idiopathic scoliosis? (3) Does brace treatment compared with observation of curves lead to improved curve angle for patients with idiopathic scoliosis? METHODS: A systematic review of the English-language literature was undertaken for articles published between 1970 and December 2010. Electronic databases and reference lists of key articles were searched to identify studies comparing brace treatment with observation of curves in patients with idiopathic scoliosis. Two independent reviewers assessed the strength of evidence using the GRADE criteria assessing quality, quantity, and consistency of results. Disagreements were resolved by consensus. RESULTS: We identified eight studies meeting our inclusion criteria. The pooled studies comparing surgical rates between observation and brace treatment showed no statistical significance (P = .65). One study showed a statistically significant difference in failure rate between observation (45%) and brace (15%) treatment (P < .001). Findings with respect to posttreatment quality of life at 2 years were inconsistent. Two studies favored the brace group, and one the observation group using the SRS-22 and Quality of Life Profile for Spine Deformities (QLPSD) measures. Two of three studies reporting pretreatment and posttreatment curve angles demonstrated a treatment effect favoring bracing; however, statistical significance for these treatment effects could not be calculated. One study described a treatment effect favoring observation but the differences were not statistically significant (P = .26). CONCLUSION: This systematic review identified and summarized only the highest level of evidence by limiting to comparison studies. Case-series were not included. This allowed for comparisons among the same patient populations. Findings with respect to surgical rates, quality of life, and change in curve angle demonstrate either no significant differences or inconsistent findings favoring one treatment or the other. If bracing does not cause a positive treatment effect, then its rejection will lead to significant savings for healthcare providers and purchasers. Given the very low to low level of evidence and inconsistent findings, a randomized trial is necessary to determine if bracing should be recommended.
Schroeder JE, Kaplan L, Barzilay S
… +1 more, Barzilay Y
Evid Based Spine Care J
· 2011 May · PMID 23637678
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STUDY DESIGN: A retrospective cohort of 68 patients who underwent insertion of the DIAM (Medtronic Sofamor Danek, Switzerland) interspinous device (ISD) during 2006-2008 at one medical center. OBJECTIVES: To assess the...STUDY DESIGN: A retrospective cohort of 68 patients who underwent insertion of the DIAM (Medtronic Sofamor Danek, Switzerland) interspinous device (ISD) during 2006-2008 at one medical center. OBJECTIVES: To assess the short- and intermediate-term outcomes and complications associated with ISD. METHODS: Evaluation of files and all patients who underwent insertion of a DIAM ISD was performed. Patients walking distances and pain (visual analog scale score) were compared with data gathered before surgery. Outcome and all complications related to ISD have been identified and analyzed. RESULTS: All 68 patients were available for follow-up. Mean follow-up was 34 months (23-52 months). The average age was 57 (±13) years. Walking distance increased by 890% and patient's pain score improved by 3.27 points on visual analog scale. Twenty-one (32%) of the 68 patients had perioperative or late complications. Nine complications (75%) were unrelated to ISD and included 5 dura tears, 3 wound-related complications, and 1 transient ischemic attack. Spinous process fractures occurred in 5 cases, leading to revision in 2 cases. In total, 7 of the patients required revision surgery. These patients were older, with an average age of 69 years. CONCLUSION: The outcome of patients who had an implantation of the DIAM ISD is good. In this cohort, 6% developed recurrent claudication symptoms in the second postoperative year. In an older population, the combination of softer bone and rigid stenosis increase the risk of spinous process fracture, resulting in failure and leading to revision surgery. Other solutions should be sought for these patients. [Table: see text] The definiton of the different classes of evidence is available on page 55.
McCarthy MJ, Gatehouse S, Steel M
… +2 more, Goss B, Williams R
Evid Based Spine Care J
· 2011 May · PMID 23637677
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STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To find out: (1) if the energy of trauma (high and low) influence the outcome after cervical spinal cord injury; (2) if time to decompression and degree of injury (...STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To find out: (1) if the energy of trauma (high and low) influence the outcome after cervical spinal cord injury; (2) if time to decompression and degree of injury (complete and incomplete) influence the outcome after high- and low-energy cervical spinal cord injury. METHODS: Twenty-one consecutive patients with low-energy cervical spinal cord injury were identified from the spinal injuries unit database (eg, ball sports, diving, surfing, and falls). Twenty-one aged-matched patients with high-energy cervical spinal cord injury (eg, motor vehicle trauma) were then randomly selected and the groups were compared. All patients had formal American Spinal Injuries Association assessment on admission and at 6 months. RESULTS: At the 6-month follow-up, the energy of the initial trauma was not found to influence the neurological outcome (P = .76). Early definitive intervention (<8 hours) for patients with incomplete cord lesions was shown to significantly affect outcome (P = .049). As expected, patients with an incomplete spinal cord injury at presentation showed significantly greater neurological improvement at follow-up compared with those with complete injuries (P = .006). CONCLUSIONS: We were unable to find a correlation between the energy of the initial trauma causing a spinal cord injury and the neurological outcome. Early definitive decompression improved outcomes for patients with spinal cord injury, especially those with incomplete spinal cord injury. [Table: see text] The definiton of the different classes of evidence is available on page 55.