bluuebunny/crossref_metadata_2025 huggingface dataset:
Elderly Patients Older than 75 Years Undergoing Reconstructive Spinal Deformity Surgery Have Significantly Improved Health-Related Quality of Life Measures versus those Managed Nonoperatively Despite High Surgical Complication Rate
Authors: Sciubba Daniel , Scheer Justin , Smith Justin , Klineberg Eric , Gupta Munish , Mundis Gregory , Protopsaltis Themistocles , Lafage Virginie , Kim Han Jo , Koskim Tyler , Kebaish Khaled , Shaffrey Christopher , Bess Shay , Hart Robert , Schwab Frank , Ames Christopher
Published: May 2015

Introduction

Elderly patients with adult spinal deformity (ASD) often report worse health-related quality of life (HRQOL) than younger patients. Increasing age is associated with increased surgical morbidity. The objective of this study was to compare the outcomes of patients with ASD older than 75 years managed operatively (OP) and nonoperatively (NONOP).

Materials and Methods

A retrospective review of a multicenter prospective ASD database was conducted. Inclusion criteria included age ≥ 75 years, ASD. Demographics, comorbidities, radiographs, complications, and HRQOL measures collected included pain with visual analog scale (VAS), Oswestry Disability Index (ODI), Short Form-36 (SF-36), and Scoliosis Research Society-22 (SRS22) at baseline, 1 and 2 years.

Results

A total of 32 patients met criteria (OP: 17, NONOP: 15), all had a minimum 2-year clinical and radiographic follow-up. Of the 32 patients, 13 were at least 80 years of age. There were no significant differences between OP and NONOP for age, BMI, and Charlson Comorbidity Index ( p > 0.05 for all). OP had worse baseline ODI, PCS, SRS Activity, Appearance, and Total than NONOP ( p < 0.05 for all). There were no significant differences in any baseline radiographic parameters. OP had significant improvement in LL, C7SVA, PI–LL, ODI, PCS, and all SRS subdomains except mental compared with pre-op ( p < 0.05 for all). OP had significantly higher 2-year SRS appearance and satisfaction ( p < 0.05) than NONOP. There were no significant differences between baseline and 2-year HRQOL for NONOP ( p > 0.05). Of the 17 OP patients, 10 (58.8%) had at least one complication with a total of 27 complications including a 64.7% rate of PJK and a 35.3% rate of reoperation.

Conclusion

Elderly patients ≥ 75 years undergoing ASD surgery had significantly improved HRQOL and radiographic measures over baseline at 2 years compared with a similar nonoperative cohort, despite substantial operative morbidity. This data may be used for preoperative patient counseling in this high-risk elderly population.
Preoperative Cervical Hyperlordosis and C2–T3 Angle are Correlated to Increased Risk of Post-Op Sagittal Spinal Pelvic Malalignment in Adult Spinal Deformity Patients at 2-Year Follow-Up
Authors: Passias Peter , Yang Sun , Soroceanu Alex , Scheer Justin , Schwab Frank , Shaffrey Christopher , Kim Han Jo , Protopsaltis Themistocles , Mundis Gregory , Gupta Munish , Klineberg Eric , Lafage Virginie , Smith Justin , Ames Christopher
Published: May 2015

Introduction

Cervical deformity (CD) is prevalent among patients with adult spinal deformity (ASD). The effect of baseline cervical alignment and achieving optimal TL alignment in ASD surgery is unclear. This study assesses the relationship between preoperative cervical spinal parameters and global alignment following thoracolumbar ASD surgery at 2-year follow-up.

Patients and Methods

Using a multicenter prospective database of surgical patients with ASD, we included patients with 2-year follow-up and cervical X-rays. SRS-Schwab sagittal modifiers (PT, GA, and PI–LL) were assessed at 2-year postoperative as either normal (0) or abnormal (“ + ” or “ + +”). Patients were classified in the aligned group (AG) or maligned group (MG) if all the three sagittal modifiers were normal or abnormal, respectively. Patients were assessed for CD based on the following criteria: C2–C7 SVA > 4 cm, C2–C7 SVA < 4 cm, cervical kyphosis (CL > 0), cervical lordosis (CL < 0), any deformity (C2C7 SVA > 4 cm or CL > 0), and both CD (C2C7 SVA > 4 cm and CL > 0). Univariate testing was performed using t test or chi-square test, looking at the following pre-op parameters: CD, C2–C7 SVA, C2–T3 SVA, CL, T1S, T1S–CL, C2–T3 angle, LL, TK, PT, C7–S1 SVA, and PI–LL.

Results

A total of 184 patients met initial inclusion criteria with 70 in the AG and 34 in MG. Pre-op, patients in the MG had a higher cervical lordosis (11.7 vs. 4.9, p = 0.03), higher C2–T3 angle (13.59 vs. 4.9 p = 0.01), and higher PT ( p < 0.0001), higher SVA ( p < 0.0001), and higher PI–LL ( p < 0.0001) compared with the AG. Interestingly, the prevalence of CD at baseline was similar for both the groups: MG and AG. There was no statistically significant difference in the amount of improvement over 2 years on the ODI or the SF-36 PCS.

Conclusion

Patients with 2-year sagittal TL malalignment also have preoperative sagittal TL malalignment and concomitant cervical hyperlordosis as a compensatory mechanism to maintain horizontal gaze. Cervical radiographs suggestive of cervical hyperlordosis should be followed up with complete standing radiographs to asses for sagittal TL malalignment.
Impact of Ethnicity on Adult Spinal Deformity Surgical Outcomes: An Analysis of Japanese and North American Databases
Authors: Lafage Virginie , Matsumoto Morio , Hosogane Naobumi , Smith Justin , Protopsaltis Themistocles , Yamato Yu , Matsuyama Yukihiro , Taneichi Hiroshi , Liu Shian , Ferrero Emmanuelle , Shaffrey Christopher , Schwab Frank , Ames Christopher
Published: May 2015

Introduction

Adult spinal deformity (ASD) research and treatment has continued to evolve and grow globally. International studies are now frequently presented at the SRS, but surgeons are unsure of the data comparisons and global relevance of conclusions across ethnicities. We compared HRQOL and radiographs between two countries (United States and Japan) to help define the effect of geographic variation.

Materials and Methods

Retrospective, multicenter case series of 337 operative patients with ASD with baseline radiographs and ODI from 11 sites across USA ( n = 235) and Japan (JPN, n = 102). Patients were compared preoperatively and postoperatively in ODI, ODI need for improvement (ODIni, using age/ethnic normative values), and radiographs. Regression was used to define thresholds for disability: USA ODI 41.9, JPN ODI 33.7.

Results

Differences in age (USA 55 years, JPN 65 years, p < 0.001) and primary cases (USA 59%, JPN 98%, p < 0.001) existed at baseline (BL), but not gender (USA 84%, JPN 84%). BL ODIni was significantly higher in JPN, without a difference in BL ODI. JPN was significantly more deformed at BL (Table). At 2-year follow-up, both cohorts improved significantly ( p < 0.05), however, JPN had significantly higher ODIni without a difference in 2-year ODI (Table). Both cohorts improved significantly radiographically ( p < 0.05); however, JPN was more malaligned (Table). Applying thresholds of deformity, 46% United States ( n = 54) were disabled compared with 60% JPN ( n = 36; p = 0.014).

Conclusion

Despite having a greater deformity at BL, there were no significant differences in BL ODI. Although both the groups improved in ODI and alignment, JPN cohort still had higher offset from the normative age-/ethnicity-matched values and more spino-pelvic malalignment at 2 years—for the same ODI, JPN patients may be masking a greater disability than represented by the score. When population-specific thresholds of disability were applied, JPN patients had a large percentage over the threshold, revealing that 60% were still with lower scores at 2 years. The ethnicity of a patient should be considered when interpreting ODI and comparing surgical outcomes for ASD using standard metrics.
Vitamin D deficiency and its Relation with Adolescent Idiopathic Scoliosis
Authors: Batista Rodrigo , Martins Delio , Hayashi Lilian , Terreri Maria , Lazaretti-Castro Marise , Wajchenberg Marcelo , Puertas Eduardo
Published: May 2015

Introduction

Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine occurring in up to 4% of children between 10 and 18 years of age. AIS is considered multifactorial, and probably genetics play an important role in its genesis. Family history may present several individuals affected. Classical progression risk factors such as curve magnitude, remaining growth potential, and skeletal maturity help us to identify which curves are likely to worsen. Scientists have tried to link the AIS to vitamin D receptor gene (VDRG) polymorphism. Approximately 90% of the daily recommended intake of vitamin D should be provided by sunlight through a process housed in the skin, the 10% remaining (around 400 IU) must be ingested. After hydroxylation processes hosted by the liver and kidneys, calcitriol (1,25OHVitD—active form) will play an important role in bone homeostasis and muscle strength. Vitamin D levels are considered insufficient under 30 ng/mL and deficient when lower than 20 ng/mL. Recently, bone mineral density has been studied and included as a potential explanation to the developing of skeletal deformities and its progression. Benefits of vitamin D include adequate management of muscle and bone quality, and this hormone could be implicated on AIS development. This study had the objective of comparing vitamin D serum levels of children being treated for AIS in our institution to those of normal individuals.

Patients and Methods

Patient recruitment was undertaken along 2013 from the outpatient clinics of Spine Pathology of the Department of Orthopedics. Children younger than 10 or older than 18 years, and those carrying neurologic or muscular disorders, congenital deformities, or genetic syndromes were excluded. Calcium, phosphorus, creatine, urea, and human parathyroid hormone dosage were taken to rule out renal or parathyroid dysfunctions. Patients were measured and weighted, and 25-OHVitD levels were determined through electrochemiluminescence by an automated test after an 8-hour fasting, during Brazilian Spring. The results were compared with a paired group composed of healthy individuals.

Results

The majority of the patients in both groups are nonblack females. In group 1 (controls), all children were eutrophic according to their body mass index and 63.3% showed abnormal vitamin D levels. Group 2 presented 12.7% incidence of malnutrition, and only 9% presented normal vitamin D level. Statistical analysis through unpaired t tests found relevant difference ( p < 0.001) between the means of vitamin D levels of the two groups.

Conclusions

There is a significant difference of vitamin D levels between patients with AIS and normal individuals. However, more studies are necessary to establish a cause–consequence relation between low vitamin D levels and AIS.
Protocol to Anticipate the Possibility and the Risk of the Anterior Approach to the Cervicothoracic Junction
Authors: Falavigna Asdrubal , Righesso Orlando , Volquind Daniel , Teles Alisson Roberto
Published: May 2015

Introduction

Several authors have previously described their radiological methods to identify in which cases the anterior approach could be performed and when the manubriotomy was needed; nevertheless, the reproducibility of the technique was not straightforward, several different measurements were described and analyzed, without considering the vascular anatomy and the relationship of the inclination of the vertebrae above the lesion to the manubrium was not taken into account. The purpose of this study was to present a straightforward preoperative protocol to define the possibility and the risk of the anterior approach to the cervicothoracic junction (CTJ).

Patients and Methods

A prospective cohort study of 19 consecutive patients who underwent an anterior approach in cervicothoracic surgery. Radiographic evaluation of the patients was performed with magnetic resonance imaging to study the disease features and to address the feasibility of the anterior approach through knowledge of the vascular anatomy. Computed tomography with sagittal reconstructions images including the manubrium was done to apply the “surgeons' view line.” This line is parallel to the inferior plateau of the superior healthy vertebrae or the vertebrae above the herniated intervertebral disc and the decision concerning the feasibility and need for manubriotomy depends on the correlation between this line and the great vessels and the manubrium, respectively.

Results

A preoperative planning of the need for manubriotomy was correct in all cases. Manubriotomy was never performed in C7 corpectomy or C7–T1 discectomy cases, nevertheless manubriotomy was needed in half the cases when the T1 corpectomy was the lowest level to be resected ( n = 8), and in four cases, the lowest level to be approached was T2 ( n = 5). The mean surgical time, bleeding volume, postoperative pain intensity, and length of hospital stay were less in the cervicotomy group when compared with the manubriotomy group.

Conclusion

Using the “surgeons' view line” and its correlation with the manubrium, the need for manubriotomy can be predicted without compromising decompression and reconstruction. The statistical differences observed in the surgical variables between the manubriotomy and cervicotomy cases justified the usefulness of the preoperative evaluation of the need for manubriotomy to perform surgical planning and give the patient and family realistic expectations about the surgery.
Anterior Cervical Interbody Fusion with Hydroxyapatite Graft: Clinical and Radiological Analysis of Graft Breakage
Authors: Falavigna Asdrubal , Righesso Orlando , Teles Alisson Roberto , Volquind Daniel
Published: May 2015

Introduction

The most common complication related to the use of hydroxyapatite (HA) grafts for cervical anterior fusion is graft breakage. However, the implication of graft breakage in terms of loss of graft height, cervical alignment, plate migration, and clinical outcomes has not been adequately evaluated. The objective of this study is to evaluate the efficacy of HA grafts in combination with cervical plates in terms of fusion, restoration, and maintenance of cervical lordosis and to compare clinical and radiologic outcomes of patients who experienced graft breakage with patients who did not.

Patients and Methods

A prospective study of 40 patients who underwent anterior cervical fusion in which HA graft and plate systems were used. The chemical analysis of the implants showed 65% HA and 35% tricalcium phosphate and other ionic constituents found in bone mineral, such as carbonate, sodium, and magnesium ions. Preoperative assessments included clinical examinations, plain radiography, and magnetic resonance imaging. Postoperative assessments included clinical examinations, use of analgesics, and plain radiography. Flexion-extension radiography and computerized tomography scanning with sagittal and coronal reconstructions were also performed at the last visit.

Results

At the final follow-up evaluation, 80% of patients had an excellent clinical outcome, 15% had a good outcome, and 5% had a fair outcome based on Odom classification. All patients achieved lordotic alignment in the immediate postoperative period. Graft breakage was observed in 25% of cases. Patients who experienced HA block breakage have a 21 times greater chance of having an intervertebral height loss greater than 2 mm, a 4.9 times greater likelihood of undergoing loss of cervical alignment exceeding 3 degrees, and are 12.4 times more likely to present migration of the plates when compared with patients who had normal HA grafts.

Conclusion

Despite the positive clinical results observed in this study, breakage of HA grafts was a common complication occurring in 25% of patients. Graft breakage was associated with strut height loss of more than 2 mm, loss of cervical alignment exceeding 3 degrees, and a higher rate of plate migration. These changes related to the HA graft breakage demonstrate the necessity to continue searching for better grafting methods to perform cervical interbody fusion.
Clinical Outcomes and Considerations of the Lumbar Interbody Fusion Technique for Lumbar Disk Disease in Adolescents
Authors: Kuh Sung-Uk , Kim Kyung-Hyun , Kang Moo-Sung , Ryu Dal-Sung , Lee Won-Chul
Published: May 2015

Introduction

The posterior lumbar interbody fusion (PLIF) technique is a commonly used surgical method for wide indications such as degeneration or trauma. Although it is rarely required for lumbar disc disease in younger patients, there are a few children and adolescents who are indicated for PLIF for other reasons such as congenital severe stenosis with or without lumbar instability that requires wide decompression, or severe bony spurs that need to be removed. In such cases, different pathophysiology and outcomes are expected compared with adult patients.

Patients and Methods

We retrospectively reviewed data of 23 patients who underwent PLIF techniques when less than 20 years old. Clinical and radiographic outcomes were assessed during a mean 36.4-month follow-up period. The indications of PLIF, success of fusion, complications, and visual analogue scale (VAS) scores were analyzed.

Results

Radiographs of all patients taken 6 months after the surgery showed fusion. Clinical outcome was also satisfactory, with improvement of VAS score from 7.7 preoperatively to 2.3 at 6 months after surgery. Only one patient had reoperation because of the adjacent segment disease.

Conclusions

For adolescent patients with severe bony spur, massive central disc rupture, or severe spondylolisthesis, PLIF surgery has good surgical outcomes with few complications.
Surgical Treatment of Lumbar Degenerative Problems with CD HORIZON BalanC Spinal System
Authors: Enercan Meric , Gokcen Bahadir , Sanli Tunay , Popovski Neron , Kahraman Sinan , Erturer Erden , Ozturk Cagatay , Hamzaoglu Azmi
Published: May 2015

Introduction

Adjacent segment degeneration (ASD) is a common (34%) problem following posterior spinal fusions which may deteriorate functional outcomes in long-term follow-up. CD HORIZON BalanC rod has a dynamic portion made of silicone and polyetheretherketone (PEEK) aiming motion preservation, and fusion portion is entirely made of PEEK. The aim of this study is to evaluate the efficacy of CD HORIZON BalanC Spinal System in the treatment of multilevel lumbar degenerative disease and to identify fusion and ASD rates with MRI and 3D CT scan for both adjacent (AL) and dynamic (DL) levels with clinical outcomes.

Patients and Methods

A total of 30 patients (18 F and 12 M) mean age 47.3 years (range, 26–65 years) with 50 levels of TLIF with more than 2-year follow-up were reviewed. TLIF were single level in 12 patients, 2 levels in 16 patients and 3 levels in 2 patients. Pre-op, post-op AP/L X-rays were measured for pelvic and sagittal parameters. Disc angles, ROM, anterior disc height (ADH), and posterior disc height (PDH) were measured for AL and DL. Disc and facet degenerations for AL and DL were evaluated with MRI and 3D CT scan at the end of 2-year follow-up. Clinical evaluation was done with ODI and VAS.

Results

Mean follow-up was 26.3 months (range, 24–38 months). Av instrumented levels was 3.33 (range, 2–5) and av. fused levels was 1.66 (range, 1–3). TLIF were at L5–S1 in 23 patients, L4–L5 in 20 patients, L3–L4 in 6 patients, and L2–L3 in 1 patient. Pre-op LL was restored to 42.7 and 49.3 degrees. There were no significant differences in ADH, PDH, and disc angles between pre-op and follow-up for AL and DL ( p > 0.05). Pre-op AL av. ROM of 5.85 degrees changed to 6.57 degrees. Pre-op DL av. ROM of 6.72 degrees was decreased to 5.07 degrees with a limitation of 24.6% post-op. There were no significant changes in terms of disc and facet degeneration grades for both AL and DL at final follow-up ( p > 0.05). 3D CT evaluation revealed solid fusions for all TLIF levels. Mean of 43.51% ODI was improved to 18.93 and pre-op VAS score 7.2 was improved to 2.2.

Conclusion

In lumbar spinal fusion surgeries performed with CD HORIZON BalanC Spinal system, MRI and 3D CT scan studies at the end of 2-year follow-up did not show any significant deterioration in terms of disc and facet degeneration for AL and DL. Dynamic portion of the rod limits ROM by 24.6% at dynamic level. Dynamic portion seems to be effective in preventing ASD at the end of 2-year follow-up.
Analysis of Intra- and Postoperative Complications during Lumbar XLIF Surgery in a Consecutive Series of 144 Cases
Authors: Buric Josip , Del Gaizo Carmine
Published: May 2015

Introduction

Retrospective analysis of intra- and postoperative complications in a consecutive series of 144 patients operated for lumbar extreme lateral interbody fusion (XLIF).

Patients and Methods

A total of 144 patients, with a minimum follow-up of 6 months, affected with degenerative spinal conditions of the lumbar spine, were treated with XLIF with and without posterior instrumentation. Data were collected by retrospective analysis of hospital files and confidential computer-held database. Documented complication types and rates of this series were compared with previous reports on lateral approach fusions.

Results

A total 179 levels were treated of whom 61% at one level, 30% at two levels, 6% at three levels, and 3% at four levels. Overall, 55% included level L4–L5. A total of 82.7% included supplemental internal fixation with 96% including bilateral pedicle screw fixation. A total of 27 (25.6%) events occurred in 22 (21.1%) patients. There were 9 (8.6%) permanent complications lasting longer than 6 months and 18 (17.3%) temporary complications that resolved inside the 6 months post-op period. Overall, 10 (9.6%) complications were judged severe: three cases of permanent nerve root lesion, two surgically treated adjacent level syndromes, one surgically treated subsidence, one deep infection, one vascular lesion, and one post-op pancreatitis. Overall, 17 (16.3%) were judged nonsever complications and solved during the 6-month follow-up. Overall, 24 events were XLIF related whereas 3 were not related to XLIF (one pancreatitis and two infection of posterior instrumentation).

Conclusion

Compared with open anterior interbody fusion approaches, the extreme lateral approach with XLIF technique resulted in a lower incidence of infection, visceral and neurologic injury. Some specific approach-related mild and temporary events such as nerve-root irritation could be regarded more like a approach comorbidity rather than a real complication.
Is the Lasègue Sign a Predictor of Outcome in Lumbar Disc Herniation Surgery?
Authors: Falavigna Asdrubal , Righesso Orlando , Teles Alisson Roberto , Volquind Daniel , da Silva Pedro Guarise
Published: May 2015

Introduction

The Lasègue Sign (LS) is frequently observed in patients with LDH. There is evidence that the persistence of the LS in the postoperative period is related to poor clinical outcome. However, the clinical relevance of this sign in the preoperative period of LDH is controversial. The purpose of this study is to evaluate the predictive value of the LS in patients who undergo microdiscectomy because of LDH, and to investigate its relation with the health-related quality of life (HRQoL) measures during 1-year follow-up.

Patients and Methods

A total of 95 patients with clinical and radiological diagnosis of LDH who underwent microdiscectomy were included. The patients were assessed by a neurological examination and answered validated instruments to assess pain, disability, QoL, and mood disorder in the preoperative period, and 1, 6, and 12 months after surgery.

Results

A preoperative LS was identified in 56.8% ( n = 54/95) of the cases. There was no difference between the groups in the preoperative period regarding HRQoL. At 1-year follow-up, no statistically significant difference in HRQoL was observed in the Lasègue group. The discrimination capacity of the preoperative LS to determinate variations in HRQoL outcomes 1-year postoperatively was low.

Conclusion

LS is not a good predictor of outcome after microdiscectomy for LDH.
Laminar Dye Injection in Dorsal Tumor Level Localization
Authors: El Fiki Ahmed
Published: May 2015

Introduction

Dorsal lesions localization has been always challenging with high incidence of missed level. Although development of diagnostic tools but it is not always available in many centers.

Patients and Methods

During the period from December 2010 to June 2013, 14 cases with dorsal intraspinal lesions were operated with preoperative localization using dye injection in the assigned laminae over the lesion. CT dorsal spine done preoperative and fluoresce was injected into the proper level lamina.

Results

In the 14 patients, it was easy to localize the target lamina by the color of the dye and in 13 patients it was over the lesion. There was no side effect from injecting dye locally in spine. The use of intraoperative fluoroscope was obviously limited.

Conclusion

Preoperative laminar dye injection is safe and effective technique in dorsal spine leveling especially in limited resource centers. Although it is little invasive but its results are much better than surface metallic localizers.
Efficiency in Adult Spinal Deformity Surgery: A Multicenter Comparison of Resource Use
Authors: Robinson Chessie , Hostin Richard , O'Brien Michael , McCarthy Ian , Gupta Munish , Lafage Virginie , Hart Robert , Schwab Frank , Smith Justin , Ames Christopher
Published: May 2015

Introduction

Decision makers and payers are placing increasing scrutiny on the costs and outcomes associated with complex spine surgery. To justify higher cost practice patterns, there must be evidence of additional patient benefit; however, little is currently known regarding the variation in resources used and associated outcomes in complex spine surgeries. Our study examines multicenter variability in patient-level surgical resource use, including implants, biologics, and length of stay, alongside health-related quality-of-life (HRQoL) improvements following adult spinal deformity (ASD) surgery.

Material and Methods

This is a retrospective analysis of a multicenter prospective database of consecutive patients with ASD. HRQoL outcomes were calculated from the ODI, SRS-22, and SF-36 domain scores. Changes in HRQoL were estimated as the difference between baseline and 2-year values. Patient-level surgical resources included blood use, bone morphogenetic protein (BMP), volume (ccs), length of stay (LOS), and implants. Patients were classified by sagittal modifier and analyzed across centers. The three sagittal modifier types are defined as follows: mild (SVA < 4 cm, PT < 20 degrees, PI–LL within 10 degrees), moderate (at least 1 of SVA 4–9.5 cm, PT 20–30 degrees; PI–LL 10–20 degrees, and no severe modifiers); and severe (at least 1 of SVA > 9.5 cm, PT > 30 degrees, PI–LL > 20 degrees). Statistical analysis was performed using analysis of variance (ANOVA) and multivariable regression methods comparing HRQoL outcomes and resource use across center, considering the overall patient cohort and each modifier group.

Results

Baseline and 2-year HRQoL data were available for 226 surgical patients with ASD, with an average age of 56 (range, 18–84 years) years who were predominantly female ( N = 189, 84%). Significant differences were found in the average 2-year change in HRQoL across centers, however, this difference becomes insignificant after controlling for patients within the same major modifier groups ( p > 0.05). Significant differences were found across centers in average resources used per surgery ( p < 0.05), with only LOS not reaching significance ( p > 0.05). Significant differences were found in average BMP and screw use across all modifier groups. After accounting for clinical, demographic, and regional characteristics at the patient level, variation among centers persisted in both screw use and total BMP volume with no corresponding statistical differences in HRQoL outcomes.

Conclusion

The use of additional surgical resources does not appear to impact 2-year HRQoL outcomes following surgery for ASD. To improve efficiency in ASD surgery, standardization of physician practice patterns and resource use could help curb costs without negatively impacting patient HRQoL.
Long-Term Cost-Effectiveness of Adult Spinal Deformity Surgery
Authors: McCarthy Ian , Robinson Chessie , Hostin Richard , O'Brien Michael , Ames Christopher , Gupta Munish , Lafage Virginie , Hart Robert , Smith Justin , Schwab Frank
Published: May 2015

Introduction

There is a lack of long-term outcomes in the existing cost-effectiveness literature. This study examines the long-term cost-effectiveness of surgical treatment of ASD with a Markov model populated by estimates from literature and observed data on hospital costs and outcomes. Using estimates from literature and observed data on costs and health-related quality-of-life (HRQOL) outcomes, we simulate costs and outcomes for surgical and nonsurgical treatment to estimate incremental cost-effectiveness ratios (ICERs) after 10- and 20-year follow-up.

Material and Methods

We develop a robust Markov model with parameter uncertainty, incorporating costs, and outcome distributions from published literature and observed patient data. Summary statistics on mortality rates, revision rates, and nonsurgical costs are taken from the literature, whereas statistics for surgical costs and QALYs are taken from a single-center, retrospective administrative data set and a multicenter prospective data set. Costs of surgery are measured as total hospital costs from administrative records. QALYs were calculated from the SF-6D. We projected costs and QALYs for the surgical and nonsurgical populations allowing varied readmission, cost, and QALY outcomes over 10- and 20-year follow-up. Costs for surgical and nonsurgical patients are intended to reflect the full spectrum of services incurred for surgical or nonsurgical care (e.g., physical therapy, pain management, etc.). Costs and QALYs were in 2010 dollars and discounted at 3.5%. Our results are based on 1,000 simulated patients, each proceeding through 6-month cycles over a 10- and 20-year follow-up periods. Confidence intervals are formed by repeating the simulations for 1,000 iterations.

Results

Discounted surgical costs averaged $170,523 over 10-year follow-up, with average discounted QALYs of 6.3. Meanwhile, nonsurgical costs averaged $40,046 over 10-year follow-up with average QALYs of 5.4. This resulted in an average ICER from surgical treatment of $144,000 (95% CI: $121,500–$177,500) per QALY gained. Over 20-year follow-up, surgical costs averaged $208,616 and QALYs averaged 9.8, whereas nonsurgical costs averaged $63,467 and QALYs averaged 8.6. Over 20-year follow-up, the ICER decreased (became more cost-effective) to $115,000 (95% CI: $88,850–$156,200) per QALY gained.

Conclusion

Our results illustrate the potential for surgical treatment for ASD to be cost-effective over extended follow-up compared with nonsurgical treatment. These findings argue in favor of longer follow-up in ASD studies for accurate cost-effectiveness comparison. Future research should also pursue measurement of indirect costs/benefits resulting from changes in absenteeism or productivity.
A Model of Spinal on Call: Orthopedic Spinal Rapid Access Service: Results of 6-Month Prospective Audit
Authors: Khatri Manoj , Kelsall Catherine
Published: May 2015

Introduction

Provision of structured on-call rota for spinal conditions can be challenging in the most orthopedic department because of the limited number of spinal surgeons. Spinal emergencies are therefore managed often by general orthopedic surgeons with potential of suboptimal outcome. Spinal conditions are managed in our institute with a team of spinal surgeons and nonmedically qualified spinal clinicians. Orthopaedic Spinal Rapid Access Service (OSRAS) was developed in our institute to provide a structured pathway for management of urgent spinal pathologies during working hours of Monday to Friday. It was delivered through a published rota by a multidisciplinary team of nonmedically qualified spinal clinicians carrying a bleep and a spinal surgeon.

Aim

This study aims to evaluate the efficacy of OSRAS through a prospective audit.

Materials and Method

New service development protocol was followed and board approval for this project was obtained. A spinal on-call rota was designed and was published to limited number of clients. The data obtained for all patients who were referred to the OSRAS services were collected prospectively in a predesigned performa that was approved by the audit department in our institute and analyzed.

Results

Between Nov 2013, 1, and April 30, 2014, 177 patients (48 males and 119 females) with an average age of 50 (range, 17–95 years) years were referred to OSRAS. Wednesday was the busiest day with 26% referral in AM and 74% in PM. Main source of referrals were as follows: regional MSK services (50), triage (34), ED (27), and GPs (20). The reasons were as follows: suspected CESI ( n = 100), acute LBP ( n = 30), pathological fractures ( n = 23), progressive neurology ( n = 16), discitis ( n = 5), and spinal stenosis ( n = 2). Depending on clinical needs, 29 patients were seen on the same day, 33 next day, 53 within 2 to 5 days, and 31 patients more than 5 days. Overall, 80 patients were discharged, 36 listed for surgery, 27 required further follow-up, and 31 patients were given telephone advise only. High user satisfaction rating was obtained.

Conclusion

We propose an OSRAS model as a safe and cost-effective alternate to often unsatisfactory current emergency department model that can provide a structured pathway for timely expert management of serious spinal pathologies therefore prevent potential consequences while avoid unnecessary admissions.
Unilateral Tubular Approach for Bilateral Laminectomy: Effect on Ipsilateral and Contralateral Buttock and Leg Pain
Authors: Alimi Marjan , Hofstetter Christoph P. , Torres-Campa Jose M. , Cong Guang-Ting , Njoku Innocent , Härtl Roger
Published: May 2015

Introduction

Tubular laminectomy is an effective treatment for lumbar spinal stenosis (LSS) with neurogenic claudication. Most surgeons familiar with the procedure agree that the tubular approach appears to afford a more complete decompression of the contralateral thecal sac and nerve root, as compared with the ipsilateral side. With this study, we sought to answer the question whether this is reflected in clinically significant differences between the ipsilateral and contralateral side pain improvements.

Patients and Methods

Patients with isolated LSS and equal preoperative leg VAS scores, who underwent a tubular (MIS) laminectomy between 2004 and 2011 were identified. The extent of VAS score improvement on the approach side was compared with the extent of improvement on the contralateral side, at the last follow-up. We tested the hypothesis that the pain relief would be the same on both sides regardless of the approach side.

Results

A total of 33 patients were included in our retrospective cohort. At the latest follow-up of 25.8 ± 3.4 months, there were statistically significant improvements in ODI and back VAS scores ( p = 0.002 and p < 0.0001, respectively). In addition, buttock VAS scores were significantly improved both on the ipsilateral and the contralateral side ( p < 0.001, and p = 0.001, respectively). Similarly, leg VAS scores were improved significantly on both the sides ( p < 0.001, and p = 0.001, respectively). There were no statistically significant differences between the extent of pain improvement on the ipsilateral and the contralateral side, either for buttock or leg pain.

Conclusions

Minimally invasive tubular laminectomy through a unilateral approach results in clinically effective bilateral decompression.
Accuracy of Pedicle Screw Placement in Dystrophic Neurofibromatosis Scoliosis: A Comparison between Free-Hand and 3D O-Arm Navigation Technique
Authors: Liu Zhen , Jin Mengran , Zhu Zezhang , Qian Bang-Ping , Wang Bin , Sun Xu , Zhu Feng , Yu Yang , Qiu Yong
Published: May 2015

Introduction

Recently, the importance of intraoperative navigation in scoliosis surgery has been increasing. Multiple studies have proven the superiorities of computer-assisted scoliosis surgery. Using intraoperative 3D images for navigational purposes has several advantages and should increase the accuracy and safety of pedicle screw placement. The purpose of the present study was to assess the accuracy of O-arm navigation-based pedicle screw insertion in dystrophic neurofibromatosis scoliosis and compare it with free-hand pedicle screw insertion technique.

Patients and Methods

A total of 32 patients with dystrophic neurofibromatosis scoliosis were nonrandomly included in the two groups, one consisting of O-arm navigation-based pedicle screw insertion (13 patients, Group A) and the other with free-hand technique (19 patients, Group B). A total of 213 pedicle screws were placed in apical region, 92 pedicles were inserted assisted by O-arm navigation system and the rest were inserted by free-hand technique. The postoperative CT scan image were reviewed and analyzed for pedicle violation. The screw penetration was divided into the following four grades: grade 0 (ideal placement), grade 1 (penetration < 2 mm), grade 2 (penetration between 2 and 4 mm), grade 3 (penetration > 4 mm).

Results

The mean age in group A was 14.8 years (range,11–22 years), whereas in group B was 15.3 years (range, 6–30 years). The preoperative Cobb angle of the main curve in group A was 70.3 ± 6.7 degrees compared with 62.2 ± 8.7 degrees in group B. The correction rates were comparable between group A (75.7%) and group B (78.1%), and the difference was not statistically significant ( p > 0.05). The overall perforation rate was 27.7% (59/213) in all 32 patients, and group A had a perforation rate of 20.7% (19/92) in comparison to 33.1% (40/121) noted in group B ( p < 0.05, χ2 test) separately. Moreover, the lateral margin was the most common site of perforation for 73.4% (14/19) in group A and 50.0% (20/40) in group B.

Conclusion

O-arm navigation does provide superiority over conventional free-hand technique in terms of accuracy of pedicle screw insertion in dystrophic curves associated with neurofibromatosis type 1. The lateral cortex is the most common site of screw perforation in either technique.
The Role of Minimal Invasive Split Laminotomy, the Alternative Parasplit Approach and the “Arch bone” Technique in Surgical Removal of Axial Longitudinal Pathologies in the Spinal Canal
Authors: Banczerowski Peter , Papp Zoltán , Veres Róbert , Vajda János
Published: May 2015

Introduction

Conventional approaches to open the spinal canal carries the risk of spinal deformities, instability, subluxation, and invariably separate the muscle attachments from the spinous processes and laminae. Damage to these muscles and bony connections can lead to persistent axial pain and cervical malalignment. With the aim of preserving and reconstructing the posterior structures, the authors developed a novel minimal invasive multilevel spinous process splitting and distraction laminotomy approach, the “arch bone” and the additional rescue parasplit technique.

Patients and Methods

These novel techniques were used in 70 adult patients with mainly midline located intramedullary pathologies of the cervical, thoracic, and thoracolumbar spine. All muscle attachments on the spinous processes and laminas, as well as the laminas themselves, were completely preserved. With the aim of moderate enlargement of the spinal canal, a spacer was placed between the bony parts facing each other in case of total resection of an intramedullary tumor was not possible. When midline splitting is not feasible or convenient because of anatomical differences of the spinous processes and laminas, we used the parasplit approach. The patients were followed with regular MRI, CT scans, fluoroscopy, and neurological examinations.

Results

The midline opening of the spinal canal gave a key-hole approach, achieving an adequate view of the intraspinal space for surgery in its entire longitudinal extension. The approach used did not affect the extent of resection proved by MRI evaluation or neurological outcome. The numbers of splitted laminae were 3 to 10. The incidence of postoperative local pain was lower, within acceptable limits (VAS: 2–4). The average length of hospital stay was 6.7 days. Average follow-up was 58 months. Instability and deformity was detected in none of the patients on the flexion–extension lateral radiographs during the follow-up period.

Conclusion

These surgical approaches suitable for exploring and removing different intramedullary pathologies, help in preventing damage to crucial posterior stabilizers of the spine. Its major advantage is that unnecessary exposure and tissue trauma is reduced, and structures not directly involved in the pathologic process are preserved. In contrast to conventional spinal canal approaches, leaves the muscle attachments intact, disintegration of vertebral arches and facet joints is reduced. Furthermore, these techniques are suitable methods for all spinal segments in all age group. Although the clinical and radiological results are very promising, the limited follow-up period precludes conclusions regarding the long-term results of the procedure, especially with respect to kyphotic deformity.
The Value of Routine Postoperative Radiographs after Elective Lumbar Spinal Fusion Surgery
Authors: Carter Sarah , Khatri Manoj , Ali Syed
Published: May 2015

Introduction

Both intra- and postoperative radiographs are traditionally obtained after instrumented lumbar spinal surgery; however, the clinical advantage of routine postoperative images has not been demonstrated. The aim of this study is to explore the usefulness of routine predischarge postoperative radiographs in patients undergoing instrumented spinal surgery.

Patients and Methods

Patients ( n = 124) who underwent a lumbar spinal fusion were identified from a retrospective database, 58 patients were excluded. Unaltered intraoperative and predischarge postoperative PACS images for 66 patients were reviewed and were scored for the following: (1) Quality (0 = nondiagnostic, 1 = suboptimal, 2 = diagnostic, and 3 = good quality), (2) Focus (number of vertebra and disc seen), (3) Centering using a numbered [1–9] grid system, and (4) Rotation.

Results

A total of 66 radiographs were analyzed for the following: (1) Quality: 60 AP and 56 lateral intraoperative images whereas 57 AP and 39 lateral postoperative images were diagnostic; (2) Focus: average number of unnecessary vertebra seen in intraoperative AP and lateral images were 0.89 and 1.09, whereas on postoperative AP and lateral images were 8.05 and 6.45, respectively; (3) Centering: 48 AP and 51 lateral intraoperative images, whereas 27 AP and 20 lateral postoperative images were adequately centered; and (4) Rotation was adequate in both intraoperative and postoperative images.

Conclusion

Intraoperative images scored higher in all parameters suggesting that routine postoperative prehospital discharge radiographs are unnecessary unless specifically indicated and this practice should be discontinued with benefits including reduction of radiation dose (and subsequent sequelae), fiscal burden, and length of stay.
The Radiographical Feature of Osteoporotic Verbal Fracture Nonunion in Extended CT Reconstruction Images
Authors: Jiang Xiaobing , Ye Linqiang , Zhang Shuncong , Liang De , Mo Ling
Published: May 2015

Introduction

This study is to summarize the main radiographical feature of osteoporotic vertebral fracture nonunion (VFNU) in extended CT reconstruction images, and to evaluate reducibility and stability of the vertebrae.

Patients and Methods

All of the senior patients suffered from thoracolumbar spine fracture (December 2009 to March 2013) were retrospectively reviewed, 36 cases of VFNU with 39 level of vertebrae were included in this study according to inclusion criteria. The main radiographical features of 39 level of VFNU vertebrae were analyzed, including the specific segment, the type of substance in the intravertebral cleft, the starting points and terminals of intervertebral cleft, to explore the different radiographic feature of various type of VFNU.

Results

According to the over extension CT, new classification criteria are reported in the literature, all of VFNU patients were divided into the following three subgroups: reducible type (type A), unstable but can be reset type (type B), and loss of reducibility type (type C). Overall, 39 level of VFNU vertebrae in 36 patients were located in the region of T9 to L4, in which the thoracolumbar segments were compromised frequently, and 16 level of VFNU existed in L1. According to extended CT reconstruction images, 25 level of type A, 7 level of type B, and 7 level of type C VFNU were identified with the radiographic analysis, the starting points of intervertebral cleft located in the anterior edge of vertebral body (18 levels) or disc plate (21 levels), the terminals of cleft located in the intersecting point of pedicle and posterior–inferior edge of vertebral body (18 level) or superior disc plate (14 levels), the fracture line could be displayed clearly in the all coronal CT reconstruction images, however, terminals of intravertebral cleft in type C VFNU located in the trabecular bone region in the middle one-third part of vertebral body(4 level), and the middle one-third part of superior disc plate, even though there were significant collapse or intracranial retropulsion of posterior one-third part of vertebral body, fracture line could rarely be shown except for one patient, the fracture lines lateral cortex united in three patients, or just be shown in anterior–middle part of vertebral body in three patients according to the coronal CT reconstruction images.

Conclusion

Thoracolumbar segments are the most common region compromised by VFNU. There is a difference between the terminals of intravertebral cleft of types A, B, and C VFNU, and existence of fracture lines from the anterior edge to the posterior cortex might explain the mechanism of reducibility of types A and B.
Radiation Exposure during Fluoroscopic Assistance for Pedicle Screw Insertion during Instrumented Spine Surgery
Authors: Ballesteros Plaza José Vicente , Yurac Barrientos Ratko Jovan , Viveros Pereira Enrique Andrés
Published: May 2015

Introduction

The purpose of this study is to quantify the radiation exposure of the operating room personnel in fluoroscopy-assisted pedicle screw insertion during instrumented spine surgery, and to determine the protective effect of using a lead apron and increasing the distance between the subject and the X-ray source.

Material and Methods

We conducted a qualitative and quantitative analysis of personal dosimetry among the different members of the operating room personnel during 35 instrumented spine surgeries, using a pseudo experimental model (input–output) to determine the effect of protective measures (lead apron and distance from the radiation source). Statistical analysis was performed using a Student t test and one-way ANOVA.

Results

The mean radiation rate per procedure was 43.97 mGy (range, 12.3–137 mGy; SD = 30.9 mGy), with a mean exposure duration of 3 minutes and 6 seconds (1′14″–8′57″; SD = 2′02″). The use of a lead apron decreased the dose equivalent by 72.64% ( p = < 0.00001). A distance of 70 cm from the fluoroscopy beam was associated with a 50.14% ( p = 0.0089) dose equivalent reduction, while at 1 meter a 60.56% ( p = 0.0013) reduction was observed. Finally, a distance of 1.5 m showed a reduction of 50.61% ( p = 0.023). No statistically significant associations between exposure reduction and distance from the radiation source were detected (difference: 0.0005, p = 0.714).

Conclusion

Our study confirms the effectiveness of the use of a lead apron and highlights the importance of its proper use for reducing radiation exposure during instrumented spine surgery. It also confirms the benefit of increasing the distance from the radiation source for reducing the equivalent dose received by the operating room personnel. However, we did not identify a proportional association between dose reduction and greater distance from the X-ray beam.