bluuebunny/crossref_metadata_2025 huggingface dataset:
Incidence, Risk Factors, and Mortality of Reintubation in Adult Spinal Deformity Surgery
Authors: De la Garza Ramos Rafael , Passias Peter G. , Schwab Frank , Bydon Ali , Lafage Virginie , Sciubba Daniel M.
Published: March 2018

Study Design:

Retrospective study of an administrative database.

Objective:

The objective was to investigate the incidence, risk factors, and mortality rate of reintubation after adult spinal deformity (ASD) surgery.

Background Data:

There are limited data regarding the occurrence of reintubation after ASD surgery.

Materials and Methods:

The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify adult patients who underwent elective surgery for scoliosis. Patients who required reintubation were identified and compared with controls (no reintubation). A multivariable logistic regression analysis was performed to identify independent factors associated with reintubation.

Results:

A total of 9734 patients who underwent surgery for ASD were identified, and 182 required reintubation [1.8%; 95% confidence interval (CI), 1.6%–2.1%] on average 2 days after surgery (range, 0–28 d). After multivariable analysis, the strongest independent risk factors associated with reintubation included postoperative acute respiratory failure [odds ratio (OR), 12.0; 95% CI, 8.6–16.6], sepsis (OR, 6.9; 95% CI, 3.5–13.6), and deep vein thrombosis (OR, 5.7; 95% CI, 3.0–10.9); history of chronic lung disease (OR, 1.6; 95% CI, 1.1–2.3) and fusion of 8 or more segments (OR, 1.5; 95% CI, 1.1–2.2) were also independent risk factors. Mortality rates were significantly higher in reintubated patients (7.3%) compared with that in nonreintubated patients (0.2%, P<0.001). More importantly, reintubation was an independent risk factor for inpatient mortality (OR, 9.8; 95% CI, 4.1–23.5; P<0.001).

Conclusions:

The reintubation rate after ASD surgery is approximately 1.8%. Patients with a history of chronic lung disease and patients undergoing fusion of 8 or more segments may be at an increased risk for reintubation; other associated factors included acute respiratory failure, sepsis, and deep vein thrombosis. Patients who required postoperative airway management after ASD surgery were 9.8 times more likely to die during their hospital stay compared with controls.
Evaluating the Extent of Clinical Variability Among Treatment Options for Patients With Adult Spinal Deformity
Authors: Phan Philippe , Ploumis Avraam , Hess Kathryn , Wood Kirkham B.
Published: March 2018

Study Design:

This is a surgical strategy survey.

Objective:

The purpose of this study was to evaluate the variability in in surgical strategy planning of adult spinal deformity (ASD) based on patients’ clinical and radiographic data.

Background:

Literature guiding the management of ASD consists primarily of studies with low levels of evidence. Recent studies have demonstrated good agreement among surgeons about the factors influencing surgical decision but poor agreement about the need for surgery. Therefore there is a relative lack of consensus and guidelines in the clinical practice and treatment of ASD.

Methods:

A total of 28 adult deformity surgeons were asked to fulfill an online survey of 10 spinal deformity cases. Case presentation included a clinical vignette with photographs, Oswestry Disability Index and Visual Analog Scale scores and imaging with radiographic measurements. For each case, the surgeons were asked whether surgical management would be beneficial and if so, their surgical plan (approach, staging, need for fusion, osteotomy or decompression and the techniques used). Intraobserver and interobserver reliability were studied using average Cohen and Feiss Kappa statistics, respectively. Descriptive statistics were calculated to evaluate the frequency of each of the alternatives in surgical planning.

Results:

Average intrarater and interrater agreement for surgical strategy were evaluated to be substantial (κ=0.62) and fair (κ=0.24), respectively. Detailed interrater statistics demonstrates that there was only slight agreement on the need for surgery (κ=0.15), the approach (κ=0.15), and the need for fusion (κ=0.16) while moderate agreement was reached for the need for decompression (κ=0.42) and osteotomy (κ=0.29).

Conclusions:

Among surgeons, agreement about the need for surgery and the surgical strategy for ASD is limited. Findings from this survey highlight the need for comprehensive classifications for ASD, higher-level studies including randomized trials to set guidelines and lessen the variability in clinical practices, which would then hopefully lead to improved outcomes.
Kinematic Effects of Cervical Laminoplasty for Cervical Spondylotic Myelopathy on the Occipitoatlantoaxial Junction
Authors: Desroches Asuka , Morishita Yuichiro , Yugue Itaru , Maeda Takeshi , Flouzat-Lachaniette Charles-Henri , Hernigou Philippe , Shiba Keiichiro
Published: March 2018

Study Design:

A retrospective evaluation of sagittal angular motion from cervical spinal flexion to extension.

Objective:

To evaluate the kinematic effects of cervical laminoplasty for cervical spondylotic myelopathy (CSM) on the occipitoatlantoaxial junction.

Summary of Background Data:

The kinematic effects of cervical laminoplasty for CSM on the occipitoatlantoaxial junction remain controversial.

Methods:

A total of 65 CSM patients who were treated with cervical laminoplasty ranging from the C3 to C7 vertebrae were included in the study. After surgery, all patients wore a Philadelphia collar for the first week and began cervical range of motion exercises as soon as possible. Functional plain radiographs were obtained preoperatively and at 1 and 3 years postoperatively. Sagittal angular motion from cervical spinal flexion to extension was measured using the Cobb technique at 7 cervical segments (Oc–C1, C1–C2, C2–C3, C3–C4, C4–C5, C5–C6, and C6–C7). We defined the contribution of each segment’s mobility to the total angular mobility of the cervical spine as percent segmental mobility.

Results:

Total cervical angular mobility significantly decreased after cervical laminoplasty. There were no significant differences in Oc–C2 angular mobility; however, C2–C7 angular mobility had significantly decreased by 3 years postoperatively. No significant differences in percent segmental mobility were observed at 1 year postoperatively except at the C3–C4 segment. By 3 years postoperatively, percent mobility at the Oc–C1 and C1–C2 segments had significantly increased, whereas that at the C3–C4 and C5–C6 segments had significantly decreased.

Conclusions:

Our results suggest that, although the contribution of occipitoatlantoaxial junctional mobility to total cervical mobility increases, dynamic mechanical stress to the occipitoatlantoaxial junction does not increase following laminoplasty, and no adjacent segmental disorder at the occipitoatlantoaxial junction was observed within 3 years postoperatively. We hypothesized that early removal of the cervical collar and early cervical range of motion exercises may contribute to these kinematic changes.
Clinical Outcomes With Midline Cortical Bone Trajectory Pedicle Screws Versus Traditional Pedicle Screws in Moving Lumbar Fusions From Hospitals to Outpatient Surgery Centers
Authors: Chin Kingsley R. , Pencle Fabio J.R. , Coombs André V. , Elsharkawy Mohamed , Packer Corrine F. , Hothem Elijah A. , Seale Jason A.
Published: March 2018

Study Design:

Level III.

Objective:

To report on the outcomes of midline cortical bone trajectory (CBT) pedicle screw surgical technique for posterior lumbar fixation in the outpatient surgery center (OSC) compared with traditional pedicle screws in the hospital.

Summary of Background Data:

Traditional pedicle screws have been the gold standard for posterior lumbar fusion. Advances in spine surgery, including less invasive procedures have propelled the design of instruments and implants to achieve greater posterior spinal fixation, with decreased tissue destruction and higher safety margins. Biomechanical studies have validated the superior pullout strength of cortical screws versus the traditional pedicle screws and represent an opportunity to perform safe lumbar fusions in OSCs with same day discharge.

Materials and Methods:

The medical records of 60 patients with prospectively collected data were reviewed. Two matched cohort groups consisting of 30 patients each, CBT pedicle screws performed in OSC patients (group 1) was compared with traditional pedicle screws performed in hospital patients (group 2). Outcomes were assessed with self-reported Visual Analog Scale (VAS) scores, Oswestry Disability Index scores, and radiologic fusion rate.

Results:

Totally, 33 males and 27 females, age range (28–75), average 58±3 years. Average body mass index was 29±1.15 kg/m2. A total of 65% of surgeries were at L5–S1 level. Significant improvement noted in VAS back pain scores in the OSC group from 7.8±0.5 to 2.5±0.7,P=0.001. Comparing intergroup VAS back pain scores and Oswestry Disability Index scores, OSC group demonstrated significant improvement,P=0.004 and 0.027, respectively. Fusion rate at 2 years was similar,P=0.855 between groups.

Conclusions:

We successfully transitioned our lumbar fusions from hospitals to OSCs using a midline CBT pedicle screw technique. Although traditional pedicle screw placement is effective and may be viable in an OSC, we see more advantages to use midline cortical screws over traditional pedicle screws.
Correlations Between the SF-36, the Oswestry-Disability Index and Rolland-Morris Disability Questionnaire in Patients Undergoing Lumbar Decompression According to Types of Spine Origin Pain
Authors: Ko Sangbong , Chae Seungbum
Published: March 2018

Study Design:

Cross-sectional study.

Objective:

To determine the correlation between SF-36 (a measure for overall health status in patients) and Oswestry-Disability Index (ODI) or Rolland-Morris Disability Questionnaire (RMDQ) confined to spine according to the type of pain from the spine.

Summary of Background Data:

Data showed moderate correlation between ODI and SF-36 Physical Component Score (PCS), Physical Functioning (PF) (r=−0.46), Physical Role Functioning (RP) (r=−0.284), Bodily Pain (BP) (r=−0.327), and Mental Component Score (MCS), Emotional Role Functioning (r=−0.250), Social Role Functioning (r=0.254), Vitality (r=0.296).

Materials and Methods:

Between January 1, 2008 and December 31, 2013, a total of 69 patients were enrolled in this study. They were diagnosed with lumbar spinal stenosis and underwent decompression surgery such as laminotomy in this hospital. The 3 standardized questionnaires (ODI, RMDQ, and SF-36) were given to these patients, at least 1 year after the surgery.

Results:

ODI and SF-36 had a statistically significant (P=0.001) and moderate correlation. Small correlations were also seen between Physical Functioning (r=−0.46), Physical Role Functioning (r=−0.284), and Bodily Pain (r=−0.327) of SF-36 PCS and ODI, and between Emotional Role Functioning (r=−0.250), Social Role Functioning (r=−0.254), and Vitality (r=−0.296) of SF-36 Mental Component Score and ODI. Items in ODI for the level of pain while standing and traveling were mostly related to axial back pain, while item of lifting was related to referred buttock pain. Sleeping disturbance section in the ODI was mainly caused by radiated leg pain. In addition, RMDQ was also associated to the 3 types of pain.

Conclusions:

Moderate correlation was found between ODI or RMDQ as a condition-specific outcome and the SF-36, indicating overall health status. ODI was found to be a more adequate measure to evaluate axial back pain rather than referred pain or radiating pain. RMDQ was adequate to measure the health status and to evaluate the 3 types of spine pain. These 3 instruments could therefore provide the clinician with complementary information about the patient’s status.
Can an Anchored Cage be Substituted for an Anterior Cervical Plate and Screw for Single-Level Anterior Cervical Fusion Surgery?
Authors: Seo Dong Kwang , Kim Moon Kyu , Choi Soo Jung , Sohn Jun Young , Kim Young Ki , Jeong Eui Kyun , Ha Jung-Ki , Kim Chung Hwan , Park Jin Hoon
Published: March 2018

Study Design:

This is a case series of device failure patients.

Objective:

To identify poor candidates for anterior cervical discectomy and fusion (ACDF) using an anchored cage.

Summary of Background Data:

An anchored cage has been used as an alternative implant for ACDF surgery because of ease of use, relatively acceptable fusion rate, and lower risk of plate-related complications, including dysphagia.

Materials and Methods:

We retrospectively reviewed the outcomes of 36 patients who underwent ACDF using an anchored cage between January 2012 and December 2013. The initial diagnoses included 8 traumatic soft disk herniations without posterior ligamentous complex injury, 25 degenerative soft disk herniations, 1 degenerative foraminal stenosis, 1 traumatic soft disk herniation after reducing a unilaterally dislocated facet joint, and 1 subluxation of a previously implanted cervical artificial disk. We encountered 5 cases with poor outcomes and performed 3 revisions on the index level. We reviewed the clinical and radiologic data for 31 patients with reasonable outcomes and reviewed the failed 5 cases separately.

Results:

Among the 31 patients with reasonable outcomes, all the clinical parameters improved. For the radiologic outcomes, 10 cases of cage subsidence occurred and no patient experienced instability.

Among the 5 patients with poor outcomes, 1 patient had traumatic soft disk herniation and a reduced unilaterally dislocated facet joint, 1 patient had subluxation of a previously implanted cervical artificial disk, and 3 patients had degenerative soft disk herniation and poor bone quality. Although 3 patients required revision surgeries, 2 patients showed only radiologic failures without revision.

Conclusions:

We analyzed the short-term outcomes of ACDF using an anchored cage and observed 5 patients with poor outcomes among 36 patients. We recommend the use of a single anchored cage for patients with definite evidence of posterior column stability and healthy bone.

Level of Evidence:

Level 3.
A Posterior Oblique Approach to the Lumbar Disk Spaces, Vertebral Bodies, and Lumbar Plexus
Authors: Spiessberger Alexander , Baumann Fabian , Häusler Martin , Rühli Frank , Fandino Javier , Muroi Carl
Published: March 2018

Study Design:

A laboratory cadaveric study.

Objective:

We aimed to demonstrate the feasibility of a posterior oblique approach, sharing the same advantages as the transpsoas technique while minimizing the risk of lumbar plexus or psoas muscle injuries.

Summary of Background Data:

The transpsoas approach for interbody fusion and corpectomy offers advantages over posterior and anterior approaches. However, possible risks include traumatization of the psoas muscle or lumbar plexus.

Methods:

All lumbar disk spaces and vertebral bodies were exposed by a posterior oblique approach from left and right on a human cadaveric specimen. The exposure obtained and a step-by-step documentation of the procedure is outlined in detail.

Results:

We were able to achieve wide exposure of all lumbar disk spaces and vertebral bodies above the L5/S1 disk space. Only the psoas muscle was retracted, and the lumbar plexus nerves were easily visualized and gently retracted. Sharp dissection was only required around the tip of the transverse processes.

Conclusions:

A posterior oblique approach seems to be less invasive than the transpsoas approach. Exposure of the anterior column structures above the iliac crest is comparable. The oblique approach offers direct access to the lumbar plexus and the extraforaminal segments of the nerve roots.
Five-Year Reoperation Rates of 2-Level Lumbar Total Disk Replacement Versus Fusion
Authors: Radcliff Kris , Spivak Jeffrey , Darden Bruce , Janssen Michael , Bernard Thierry , Zigler Jack
Published: March 2018

Study Design:

Long-term analysis of prospective randomized clinical trial data.

Summary of Background Data:

Lumbar total disk replacement (TDR) has been found to have equivalent or superior clinical outcomes compared with fusion and decreased radiographic incidence of adjacent level degeneration in single-level cases.

Objective:

The purpose of this particular analysis was to determine the incidence and risk factors for secondary surgery in patients treated with TDR or circumferential fusion at 2 contiguous levels of the lumbar spine.

Methods:

A total of 229 patients were treated and randomized to receive either TDR or circumferential fusion to treat degenerative disk disease at 2 contiguous levels between L3 and S1 (TDR, n=161; fusion, n=68).

Results:

Overall, at final 5-year follow-up, 9.6% of subjects underwent a secondary surgery in this study. The overall rate of adjacent segment disease was 3.5% (8/229). At 5 years, the percentage of subjects undergoing secondary surgeries was significantly lower in the TDR group versus fusion (5.6% vs. 19.1%, P=0.0027).

Most secondary surgeries (65%, 17/26) occurred at the index levels. Index level secondary surgeries were most common in the fusion cohort (16.2%, 11/68 subjects) versus TDR (3.1%, 5/161 subjects, P=0.0009). There no statistically significant difference in the adjacent level reoperation rate between TDR (2.5%, 4/161) and fusion (5.9%, 4/68). The most common reason for index levels reoperation was instrumentation removal (n=9). Excluding the instrumentation removals, there was not a significant difference between the treatments in index level reoperations or in reoperations overall.

Conclusions:

There were significantly fewer reoperations in TDR patients compared with fusion patients. However, most of the secondary surgeries were instrumentation removal in the fusion cohort. Discounting the instrumentation removals, there was no significant difference in reoperations between TDR and fusion. These results are indicative that lumbar TDR is noninferior to fusion.
Halo-Vest Immobilization in Elderly Odontoid Fracture Patients
Authors: DePasse J. Mason , Palumbo Mark A. , Ahmed Abdul-Kareem , Adams Charles A. , Daniels Alan H.
Published: March 2018

Study Design:

Retrospective cohort study.

Objective:

To evaluate the utilization and effectiveness of halo-vest (HV) immobilization for type II odontoid fractures from 2004 to 2014.

Summary of Background Data:

Controversy persists regarding the optimal treatment method for odontoid fractures in the elderly. Management options include immobilization in a cervical orthosis, HV immobilization, and operative intervention. Over the past decade, high mortality and morbidity rates have been reported following HV immobilization in this patient population.

Materials and Methods:

In a retrospective study, patient demographics, presentation, Charlson comorbidity index, treatment method, and outcome data for patients over 65 who had suffered type II odontoid fractures from 2004 to 2014 were compared with a historical cohort from 1997 to 2004.

Results:

One hundred twenty-six patients met inclusion criteria. The mean age was 82.7±8.8 compared with 80.7±0.9 in the 1997–2004 cohort. The in-hospital mortality rate from 2004 to 2014 was 11.1% (14/126) compared with 31% in the historical cohort, and 10 (7.9%) patients were treated with HV compared with 49%. Mortality in the HV group was higher than the surgical group (P=0.01) but no different from the orthosis group (P=0.63).There were no differences in injury severity score, Charlson comorbidity index, or complications between treatment groups.

Conclusions:

Over the past decade, HV use for elderly odontoid fractures has decreased at our institution. Mortality and morbidity of elderly patients treated with HV has also decreased. These findings are likely the result of improved patient selection and greater attention to respiratory care. This study demonstrates that HV immobilization of odontoid fractures in elderly patients can be as safe as cervical orthosis treatment in select patients.
Lateral Extracavitary Approach Versus Posterior Extensive Circumferential Decompression in the Treatment of Complicated Thoracic and Lumbar Tuberculous Spondylitis
Authors: Omran Khaled , Abdel-Fattah Ahmed S. , Othman Ahmed M.A. , Youssef Ahmed O. , Solimen Amr , ElRefai Mohamed A. , Saleh Ahmed N. , Ali Mohammed
Published: March 2018

Objectives and Study Design:

The aim of this study was to retrospectively evaluate 45 patients operated upon either by posterior extensive circumferential decompression (PECD) or by the lateral extracavitary (LEC) technique and compare the clinical, radiologic, laboratory, and functional outcomes.

Summary of Background:

The debate continues on the best decompression-fusion technique for treating complicated spinal tuberculosis. In recent times, the advantages of combined surgery have been successfully achieved using the 1-stage salvage technique, with enough accessibility to all 3 spinal columns.

Materials and Methods:

From January 2011 to December 2013, 51 patients with complicated spinal tuberculous were surgically treated at our department. After gaining the approval of the local ethics committee, 45 patients and their records were available for evaluation. The patients were divided into 2 groups. Group I included 23 patients treated with PECD and group II included 22 patients treated with LEC. Two authors and an independent observer performed the final clinical assessment by means of clinical examination and by using the Visual Analog Scale and Oswestery Disability Index for determining pain, disability, and quality of life. The radiographs were reviewed independently by 3 authors and a radiologist for fusion, kyphotic angle, and angle loss rate. Neurological assessment using the American Spinal Injury Association motor index was performed by 2 authors and a neurologist independently.

Results:

The mean follow-up period was 36±5.5 months. In all patients, local symptoms were relieved significantly postoperatively. There were no major complications in this series. Three patients contracted superficial wound infection and 2 developed intercostal neuralgia. Both complications resolved uneventfully and did not influence the outcome. Solid interbody fusion was diagnosed in 43 cases (95.6%). Deformity correction and neurological recovery were significantly improved in both groups (P<0.001). PECD showed better results than LEC.

Conclusions:

Both procedures attained good results for maintained deformity correction, bony fusion, spinal cord decompression, and neurological improvement in complicated tuberculous spondylitis. However, PECD may be superior to LEC.
Is Preexisting Cervical Disk Degeneration a Prognostic Factor in Whiplash-associated Disorders?
Authors: Chung Nam-Su , Jeon Chang-Hoon , Lee Yu-Sang , Park Jang-Ho , Lee Han-Dong
Published: March 2018

Study Design:

This is a retrospective control study.

Objective:

We aimed to determine whether preexisting cervical disk degeneration is a prognostic factor in Whiplash-associated disorder (WAD).

Summary of Background Data:

WAD is a common injury of traffic accident and has a broad range of prognoses. Although numerous studies have investigated prognostic factors in WAD, few have evaluated the effect of preexisting disk degeneration.

Materials and Methods:

This study involved 45 consecutive patients with grade I or II WAD having advanced disk degeneration (at least 1 disk of Miyazaki grade≥III on magnetic resonance imaging) and a control cohort of 52 patients with no or mild disk degeneration (all disks having Miyazaki grades≤II). Clinical assessment included pain severity (assessed by the visual analog scale), neck pain-related disability (assessed by the neck disability index), and physical and mental health condition [assessed by the short-form 36 (SF-36) physical composite score and SF-36 mental composite score, respectively]. Changes in each parameter were evaluated at baseline and at 3-month, 6-month, and 1-year follow-ups and compared between the 2 groups.

Results:

There were no differences between the 2 groups regarding demographics and baseline outcome parameters (all P>0.05). There were also no differences in improvement in visual analog scale for neck pain, neck disability index, SF-36 physical composite score, or SF-36 mental composite score between the 2 groups (all P>0.05) for each visit. The number of claim closures was significantly lower among patients with advanced degeneration than among controls at 6-month and 1-year follow-ups (P=0.004 and 0.006, respectively).

Conclusions:

In the present study, the clinical presentation and prognosis of WAD were not affected by preexisting disk degeneration. However, claim closure was delayed in patients with preexisting disk degeneration. These results suggest that misunderstanding of disk degeneration on magnetic resonance imaging may create persistent illness and lead to continued compensation in WAD.
Reliability of Sagittal Spinopelvic Alignment Measurements After Total Hip Arthroplasty
Authors: Pernaa Katri , Seppänen Matti , Mäkelä Keijo , Saltychev Mikhail
Published: March 2018

Study design:

This is a observational study.

Objective:

To evaluate the reliability of measuring sagittal spinopelvic alignment after hip arthroplasty.

Summary of Background Data:

Pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), and lumbar lordosis (LL) are widely used in planning the treatment of people with spinal and hip disorders. Previously, these measures have proved reliable when hip heads are intact. Thus far, it is not known whether they are also reliable after total hip replacement.

Materials and Methods:

Two observers assessed PI, SS, PT, and LL in the radiographs of 97 patients who had undergone total hip replacement. Test-retest (intraobserver) and interobserver reliability were estimated.

Results:

The intraclass correlation coefficient ranged from 0.92 to 0.97 and 0.85 to 0.94 for the intraobserver and interobserver settings, respectively, indicating an almost perfect correlation between observers or observations. The absolute intrarater measurement errors were 1.41 [95% confidence interval (CI), 0.98–2.03) for PI, 1.16 (95% CI, 0.78–1.74) for SS, 0.49 (95% CI, 0.31–0.76) for PT, and 1.75 (95% CI, 1.22–2.51) degrees for LL. The respective interrater figures were 2.82 (95% CI, 2.04–3.9), 2.44 (95% CI, 1.78–3.35), 0.73 (95% CI, 0.48–1.13), and 2.28 (95% CI, 1.55–3.34) degrees.

Conclusions:

It seems that total hip arthroplasty does not affect the reliability of spinopelvic sagittal alignment measurements.

Level of evidence:

Level II.
Role of Posterior Stabilization and Transpedicular Decompression in the Treatment of Thoracic and Thoracolumbar TB
Authors: D’souza Areena R. , Mohapatra Bibhudendu , Bansal Murari L. , Das Kalidutta
Published: March 2018

Study Design:

A retrospective study.

Objective:

To evaluate the results of posterior pedicle-screw fixation with transpedicular decompression in 21 cases of thoracic and thoracolumbar spinal tuberculosis (TB) in terms of functional, neurological, and radiologic outcomes.

Summary of Background Data:

Spinal TB is predominantly an anterior disease that can lead to kyphotic deformity. Hence, anterior debridement and fusion was considered as the gold standard. However, with remarkable improvements in chemotherapy regimens and diagnostic tools, it is possible to detect the disease process early and treat them with less radical approaches. In the present study, authors have shown the results of posterior pedicle-screw fixation with transpedicular decompression in thoracic and thoracolumbar spinal TB.

Materials and Methods:

The study reviewed 21 patients with thoracic or thoracolumbar TB with kyphotic deformity who were operated with posterior pedicle-screw fixation and transpedicular decompression (pus aspiration through a Jamshidi needle) with kyphosis correction for either neurological deficits (11) or intractable pain (10), not responding to at least 4–6 weeks of chemotherapy. Patients with <3 spinal segment involvement, <30 degrees kyphosis, and <50% vertebral body destruction were included in the study.

Results:

The mean age of patients was 43.9 years and the mean kyphosis angle at the level of involvement was 21.61±3.72 degrees. Kyphosis improved postoperatively to 5.79±3.48 degrees. The mean follow-up period was 24.09 months, and final kyphosis correction was maintained at 8.74±3.65 degrees. Bony fusion was achieved in 80.5% cases. Eleven patients had neurological deficits, and all of them recovered. All patients had a Visual Analog score improvement from 9.52 to 2.57 postoperatively.

Conclusions:

Posterior stabilization with transpedicular decompression can be considered as a good treatment option for the management of thoracic and thoracolumbar TB in patients with <50% vertebral body destruction and <30-degree kyphosis. It provides rapid relief of instability pain, improvement of neurological deficit, and prevents progression of deformity.
Value-based Insurance Design
Authors: Sharan Alok D. , Schroeder Gregory D. , West Michael E. , Vaccaro Alexander R.
Published: March 2018

The increasing awareness of the scarcity of health care resources is forcing the health care industry to improve quality while lowering the cost. One method by which employers and insurance companies are attempting to do this is with value-based insurance design. In these plans, patients pay a lower amount for certain services that are considered high value and a higher amount for services that are considered low value.
Value in Single-level Lumbar Discectomy
Authors: Rosenbaum Benjamin P. , Modic Michael T. , Krishnaney Ajit A.
Published: March 2018

Study Design:

This is a retrospective study.

Objective:

Compare improvements in health status measures (HSMs) and surgical costs to determine whether use of more costly items has any relationship to clinical outcome and value in lumbar disc surgery.

Summary of Background Data:

Association between cost, outcomes, and value in spine surgery, including lumbar discectomy is poorly understood. Outcomes were calculated as difference in mean HSM scores between preoperative and postoperative timeframes. Prospective validated patient-reported HSMs studied were EuroQol quality of life index score (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire (PHQ-9). Surgical costs consisted of disposable items and implants used in operating room.

Methods:

We retrospectively identified all adult patients at Cleveland Clinic main campus between October 2009 and August 2013 who underwent lumbar discectomy (652) using administrative billing data, Current Procedural Terminology (CPT) code 63030. HSMs were obtained from Cleveland Clinic Knowledge Program Data Registry.

Results:

In total, 67% of operations performed in the outpatient or ambulatory setting, 33% in the inpatient setting. Among 9 surgeons who performed >10 lumbar discectomies, there were 72.4 operations per surgeon, on average. Mean surgical costs of each surgeon differed (P<0.0001). In a multivariable regression, only the surgeon and surgery type (outpatient or inpatient) were statistically correlated with surgical costs (P<0.0001 and 0.046, respectively). Changes in EQ-5D, PDQ, and PHQ-9 were not correlated with surgical costs (P=0.76, 0.07, 0.76, respectively). In multivariable regression, only surgical cost was significantly correlated to mean difference in PDQ (P=0.030). More costly surgeries resulted in worse PDQ outcomes.

Conclusions:

Mean surgical costs varied statistically among 9 surgeons; costs were not shown to be positively correlated with patient outcomes. Performing an operation using more costly disposable supplies/implants does not seem to improve patient outcomes and should be considered when constructing preference cards and during an operation.
Randomization Strategies
Authors: Kepler Christopher K.
Published: March 2018

An understanding of randomization is important both for study design and to assist medical professionals in evaluating the medical literature. Simple randomization can be done through a variety of techniques, but carries a risk of unequal distribution of subjects into treatment groups. Block randomization can be used to overcome this limitation by ensuring that small subgroups are distributed evenly between treatment groups. Finally, techniques can be used to evenly distribute subjects between treatment groups while accounting for confounding variables, so as to not skew results when there is a high index of suspicion that a particular variable will influence outcome.
Morphometric Analysis of the Retroperitoneal Vessels With Respect to Lateral Access Surgery in Adult Scoliosis
Authors: Makanji Heeren S. , Le Hai , Wood Kirkham B. , Jenis Louis G. , Cha Thomas D.
Published: March 2018

Study Design:

Cross-sectional study reviewing 62 magnetic resonance imaging or computed tomography scans from consecutive adult patients with scoliotic spinal deformity in the thoracolumbar spine.

Objective:

To investigate the variation in anatomic position of retroperitoneal vessels in relationship to curve direction, location, magnitude, and axial rotation of curves in adult scoliosis.

Summary of Background Data:

The minimally invasive lateral approach to the thoracolumbar spine avoids manipulation of abdominal and retroperitoneal structures and decreases risk of injury to paraspinal musculature. In adult patients with scoliosis, the varying anatomic relationship between retroperitoneal vessels and intervertebral disk spaces can increase the risk of vascular injury.

Materials and Methods:

Axial images were used to measure the anterior-posterior diameter of the inferior vertebral endplate with respect to the disk space perpendicular to the widest length of the disk. The overlap of the retroperitoneal vessels with the endplate were measured at the cephalad end vertebra, apex, and caudad end vertebra of each curve. Overlap and accessible disk space for individual disk spaces were also measured.

Results:

There was a significant difference in percentage overlap of the apex and cephalad vertebral endplate and inferior vena cava in right versus left-sided curves (P=0.002). Overlap between the inferior vertebral endplate and inferior vena cava at the cephalad, apex, and caudad end of the curve was significantly different between thoracolumbar and lumbar curves (P<0.05). Axial rotation significantly affected vessel overlap at multiple curve locations. There was a statistically significant difference in accessible disk space when approaching the curve from the concavity versus convexity.

Conclusions:

Overlap between retroperitoneal vessels and inferior vertebral endplates at the disk level in scoliotic spines varies significantly with direction of the curvature, level of the deformity, and degree of axial rotation. There is decreased accessible disk space and increased vessel overlap on the concavity of the curve. Surgeons, as usual, will take an individualized case by case approach to avoid approach-related vascular complications, but the general relationships reported in this study can guide side of approach.
Organizational Structural Design in Spine Care
Authors: Sharan Alok D. , Schroeder Gregory D. , West Michael E. , Vaccaro Alexander R.
Published: March 2018

For a company to provide high value to its customers, its organization design is critical. As health care transitions to a value-based model, it is critical that spinal care organizations are structured in such a way that they can maximize value to both the patient and the payers. This article will discuss the 3 most common ways that an organization can be structured, and the benefits and problems of each design in spinal care.
Understanding Financial Statements in Clinical Practice: A Primer
Authors: Makanji Heeren S. , Jenis Louis G.
Published: March 2018

The purpose of this article is to describe the different types of financial statements and the information they contain regarding the current and long-term financial health of a business practice. These statements are essential to guiding strategic decision making for physicians and executives.
Does Age Influence the Efficacy of Demineralized Bone Matrix Enriched with Concentrated Bone Marrow Aspirate in Lumbar Fusions?
Authors: Ajiboye Remi M. , Eckardt Mark A. , Hamamoto Jason T. , Sharma Akshay , Khan Adam Z. , Wang Jeffrey C.
Published: March 2018

Study Design:

Retrospective study.

Objective:

Evaluate the effect of age on the efficacy of allograft/demineralized bone matrix (DBM) enriched with concentrated bone marrow aspirate (BMA) in posterolateral lumbar fusions (PLFs).

Summary of Background Data:

Cell-based therapies such as concentrated BMA have been developed as a potential alternative to iliac crest bone graft (ICBG). BMA contains mesenchymal stem cells (MSCs) and growth factors that can confer osteogenic and osteoinductive potential to osteoconductive scaffolds such as DBM/allograft. To date, no studies have examined the role of age on fusion outcomes when BMA is utilized despite the well-established deleterious effects of advanced age on bone marrow and MSC potential.

Materials and Methods:

Fifty-one patients that underwent PLF were divided into 3 groups. Group A (n=14) composed of patients age 65 years and older who received BMA with DBM. Group B (n=17) consisted of patients younger than 65 years of age who received BMA with DBM. Group C (n=20) composed of patients age 65 years and older who received ICBG. Fusion rates and clinical outcomes were assessed.

Results:

Fusion was significantly lower in group A (35.7%) compared with both groups B (76.4%) and C (80%) (A vs. B, P=0.03; A vs. C, P=0.01). There were no differences in clinical outcomes among all groups except for pseudarthrosis which occurred in 28.6% of patients in group A compared with none and 5% of patients in groups B and C, respectively (A vs. B, P=0.03; A vs. C, P=0.13).

Conclusions:

Elderly patients undergoing PLF using DBM enriched with BMA achieved lower radiographic fusion success compared with their nonelderly counterparts and compared with elderly patients that had fusion with ICBG. This may be partly due to the effect of advanced age on MSC potential.
The Effect of Hospital Ownership on Health Care Utilization in Orthopedic Surgery
Authors: Schroeder Gregory D. , Kurd Mark F. , Kepler Christopher K. , Radcliff Kris E. , Maltenfort Mitchell G. , Murphy Hamadi , Rihn Jeffery A. , Anderson D. Greg , Hilibrand Alan S. , Vaccaro Alexander R.
Published: March 2018

Purpose:

To determine if ownership of a specialty hospital or ambulatory surgery centers (ASC) affects surgical volume.

Materials and Methods:

All surgeries performed by 75 orthopedic surgeons at a single practice between January 1, 2010 and March 1, 2015 were identified. During this time, the practice purchased an ownership stake in 1 hospital and 3 ASC. The total surgical volume by partnership status and location was collected and analyzed.

Results:

A total of 104,661 surgical surgeries were performed by 75 surgeons. Over the 62 months, there was an average increase in the number of surgical cases performed per surgeon per year of 2.82±0.48 cases; however, the average increase in cases per year was lower for equity partners by 1.51 cases per year (P<0.0001). In the 2 years before purchasing the specialty hospital, the increase in the number of surgical cases per surgeon per month was 0.093±0.087 cases. In the 2 years after investing in the physician-owned specialty hospital, there was a decrease in the number of cases performed per surgeon per month by 0.027±0.110 (P=0.92).

Conclusions:

In a well-established large orthopedic practice, surgeon ownership of a hospital or ASC does not lead to an increase in surgical volume.

Level of Evidence:

Level 4.
Payor Reform Opportunities for Spine Surgery
Authors: Scalise Jason , Jacofsky David
Published: March 2018

The pressures on spine surgery to adopt value-based reimbursement models are being seen in the increased implementation of bundled payment strategies. Given that bundled payment models typically link payments to the initiation of the surgical episode in question, despite their potential cost-saving attributes, financial incentives remain tied to the volume of services being provided. As payors and policy makers look to find savings by focusing on waste and variation of care, more comprehensive models such population health strategies are now being develop and deployed. The clinical delivery and cost variation currently seen in spine health management make spine surgery an acute target of such population health strategies. Spine surgeons should understand the forces driving such changes and the opportunities to optimize performance within them.
Percutaneous Nucleoplasty for the Treatment of a Contained Cervical Disk Herniation
Authors: de Rooij Judith D. , Gadjradj Pravesh S. , Soria van Hoeve John S. , Huygen Frank J. , Aukes Hans A. , Harhangi Biswadjiet S.
Published: March 2018

Cervical radiculopathy is characterized by compression of the roots of the nerve. When conservative treatment fails and symptoms persist or increase in severity, surgical treatment is considered. Anterior cervical discectomy with or without fusion is regarded as the standard treatment for cervical disk herniation. Recently, there is an evolving trend in spinal surgery towards less invasive techniques. Nucleoplasty is a minimally invasive technique in which radiofrequency technology is used for percutaneous decompression. During the last years nucleoplasty has been proven to be a safe and effective treatment to alleviate radiculopathy, caused by a contained disk herniation. Nucleoplasty is usually performed on an outpatient basis and is associated with a fast recovery time. This paper will describe the preoperative and postoperative management of cervical nucleoplasty as well as the surgical technique, accompanied by a video.
Prognostic Role of Rib Hump in Overlying Thoracic Curve Correction Above Selective Fusion for Lenke 5 Idiopathic Adolescent Scoliosis
Authors: Solla Federico , Gallo Massimiliano , Doria Carlo , Caci Hervé , Voury Audrey , Rosello Olivier , Clément Jean-Luc , Rampal Virginie
Published: March 2018

Study design:

Prospective study.

Objective:

To assess whether rib hump is a prognostic factor of final thoracic Cobb angle.

Summary of Background Data:

Correction of thoracolumbar/lumbar curve, preoperative thoracic curves angle, thoracic curves angle on bending, the thoracolumbar-lumbar angle/thoracic curves angle ratio, thoracic kyphosis, and growth stage influences spontaneous correction of uninstrumented thoracic curves angle above selective fusion for Lenke 5 Adolescent Idiopathic Scoliosis. Indeed, preoperative rib hump has never been expressly evaluated as a prognostic factor of final thoracic curves angle.

Methods:

In total, 50 patients with Lenke 5 Adolescent Idiopathic Scoliosis, selectively instrumented with posterior construct were included. Two patients were lost to follow-up and 48 had follow-up ≥2 years. Demographic data, preoperative thoracic rib hump (measured in millimeter in trunk anteflexion), and radiologic spinal parameters were recorded preoperatively and at last consultation. T test was used to compare mean values, linear and logistic regressions to assess predictability of final thoracic curve angle.

Results:

Main thoracolumbar-lumbar curve angle decreased from 47 degrees (range, 36–72 degrees) to 12 degrees at the final consultation (range, 1–28 degrees). Thoracic curves angle decreased from 26 degrees (range, 2–40 degrees) preoperatively to 16 degrees (range, 2–41 degrees) at the final consultation (P=0.001) (correction=37%). Preoperative rib hump was present in 10 patients. Final thoracic Cobb angle was 27 degrees (8–41 degrees) in patients with rib hump and 14 degrees (0–32 degrees) in patients without rib hump (P<0.001).

Multiregression highlighted thoracic curves angle on bending (P=0.001), preoperative thoracic curves angle (P=0.011) and rib hump (P=0.012) as prognostic factors of higher final thoracic curves angle.

Conclusion:

Rib hump significantly influenced final thoracic curves angle.

Level of Evidence:

Level III—prospective study.
Cervical Artificial Disc Replacement With Discover Prosthesis Does Not Reduce the Midterm Risk of Heterotopic Ossification
Authors: Miao Jinhao , Shen Ye , Li Chao , Fang Lei , Zhang Lei , Zhang Xiangyi , Li Yiman , Kuang Yong
Published: March 2018

Study Design:

A prospective cohort study with 79 patients.

Objective:

To analyze the midterm incidence of heterotopic ossification (HO) after cervical artificial disc replacement with Discover prosthesis in treatment of cervical degenerative disc disease.

Materials and Methods:

A cohort of 79 patients with 102 Discover prostheses (56 monosegment and 23 bisegments) was evaluated. Clinical and radiographic follow-up was performed. The performance of HO of the operative segments was assessed annually after the operation for 4 years.

Results:

Early follow-up at 2 years postsurgical treatment showed satisfactory clinical outcomes. No significant changes on the mean Japanese Orthopaedic Association and Visual Analog Scale scores were detected at 3 and 4 years postoperation. The occurrence rate of HO was 5.9% in 1-year follow-up and 17.6% in 2-year follow-up, and then the percentages increased to 49.2% in 3-year follow-up and 65.6% in 4-year follow-up, respectively. No association between the HO grades and the type of the surgical segment was detected by the Fisher exact test (P-value=0.56). No prosthesis subsidence or excursion was identified during the whole follow-up period.

Conclusions:

The use of Discover prosthesis resulted in satisfactory clinical outcomes after operation. However, the new prosthesis did not reduce the midterm risk of HO, despite the fact that the observed incidence was relatively low in the early follow-up.
The Effect of Ketorolac on Thoracolumbar Posterolateral Fusion
Authors: Li Jesse , Ajiboye Remi M. , Orden Michael H. , Sharma Akshay , Drysch Austin , Pourtaheri Sina
Published: March 2018

Study Design:

Systematic review and meta-analysis.

Objective:

The purpose of this study was to evaluate the effect of postoperative ketorolac administration (ie, dosage and duration of use) on pseudarthrosis following thoracolumbar posterolateral spinal fusions.

Summary of Background Data:

Ketorolac is a nonsteroidal anti-inflammatory drug often administered for pain control after spine surgery. The main concern with ketorolac is the risk of pseudarthrosis following fusion.

Materials and Methods:

A systematic search of multiple medical reference databases was conducted for studies detailing postoperative ketorolac use in lumbar fusion and scoliosis surgery in adult and pediatric patients, respectively. Meta-analysis was performed using the random-effects model for heterogeneity as this study analyzes heterogenous patient populations undergoing variable approaches to fusion and variable numbers of levels with variable means of detection of pseudarthrosis. Outcome measure was pseudarthrosis.

Results:

Overall, 6 studies totaling 1558 patients were reviewed. Pseudarthrosis was observed in 119 (7.6%) patients. Pseudarthrosis were observed in adults with ketorolac administered for >2 days [odds ratio (OR), 3.44, 95% confidence interval (95% CI), 1.87–6.36;P<0.001], adults with doses of ≥120 mg/d (OR, 2.93, 95% CI, 1.06–8.12;P=0.039), and adults with ketorolac administered for >2 days and at doses ≥120 mg/d (OR, 4.75, 95% CI, 2.34–9.62;P<0.001). Ketorolac use in smokers was associated with pseudarthrosis (OR, 8.71, 95% CI, 2.23–34.0;P=0.002).

Conclusion:

Ketorolac, when administered for >2 days and/or at a dose of ≥120 mg/d, is associated with pseudarthrosis in adults after posterolateral lumbar fusion. Ketorolac use in smokers is also associated with pseudarthrosis.