bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of Structural Disease Burden to Health-related Quality of Life Scores in 264 Adult Spinal Deformity Patients With 2-Year Follow-up
Authors: Bakhsheshian Joshua , Scheer Justin K. , Gum Jeffrey L. , Horner Lance , Hostin Richard , Lafage Virginie , Bess Shay , Protopsaltis Themistocles S. , Burton Douglas C. , Keefe Malla , Hart Robert A. , Mundis Gregory M. , Shaffrey Christopher I. , Schwab Frank , Smith Justin S. , Ames Christopher P.
Published: March 2018

Study Design:

This is a review of a prospective multicenter database.

Objective:

To investigate the relationship between preoperative disability and sagittal deformity in patients with high Oswestry Disability Index (ODI) and no sagittal malalignment, or low ODI and high sagittal malalignment.

Summary of Background Data:

The relationship between ODI and sagittal malalignment varies between each adult spinal deformity (ASD) patient.

Methods:

A prospective multicenter database of 365 patients with ASD undergoing surgical reconstruction was analyzed. Inclusion criteria entailed: age 18 years or above and the presence of spinal deformity as defined by a coronal Cobb angle≥20 degrees, sagittal vertical axis (SVA)≥5 cm, pelvic tilt (PT) angle≥25 degrees, or thoracic kyphosis≥60 degrees. Radiographic and health-related quality of life (HRQOL) variables were examined and compared, preoperatively and at 2-year postoperative follow-up. Group 1 (low disability high sagittal—LDHS) consisted of ODI<40 and SVA≥5 cm or PT≥25 degrees or pelvic incidence-lumbar lordosis≥11 degrees and group 2 (high disability low sagittal—HDLS) consisted of ODI>40 and SVA<5 cm and PT<25 degrees and pelvic incidence-lumbar lordosis<11 degrees.

Results:

Of 264 patients with follow-up, 58 (22.0%) patients were included in LDHS and 30 (11.4%) were included in HDLS. Both groups had similar demographics and preoperative coronal angles. HDLS had worse baseline HRQOL for all measures (P<0.05) except leg and back pain. HDLS had a higher rate of self-reported leg weakness, arthritis, depression and neurological disorder. Both groups had similar 2-year improvements in HRQOL (P>0.05), except only HDLS had a significant Scoliosis Research Society Mental improvement and a significantly higher rate of reaching minimal clinically important differences in Scoliosis Research Society Mental scores (P<0.05).

Conclusions:

There is an association of worse baseline HRQOL measures, weakness, arthritis, and mental disease in HDLS. Furthermore, HDLS patients demonstrated similar improvements to LDHS. However, HDLS had greater improvements in the mental domains, perhaps indicating the responsiveness of the mental disability to surgical treatment.

Level of Evidence:

Level III.
Facet Preserving Technique by En Bloc Flavectomy in Microscopic Posterior Decompression Surgery for Lumbar Spinal Stenosis
Authors: Fujiwara Yasushi , Manabe Hideki , Sumida Tadayoshi , Izumi Bunichiro , Nakanishi Kazuyoshi , Tanaka Nobuhiro , Adachi Nobuo
Published: March 2018

Posterior decompression surgery which enlarges the spinal canal in cases with lumbar spinal stenosis is the most fundamental technique in spine surgery, but controversy still remains for the exact technique. Because nerve roots run under the ventral side on the superior articular process (SAP), achieving both facet joint preservation and nerve root decompression is problematic. In conventional laminotomies or laminectomies, medial facetectomies are performed to decompress the nerve root, but it is ideal to preserve the facet joints completely for preserving joint stability. We handle this problem with an original decompression technique, called “semicircumferential decompression.” The main features of this procedure are an en bloc flavectomy and total preservation of facet joints. The procedure is performed under the microscope with a midline approach. The flavum is detached from the ventral surface of the SAP using a currete without disturbing the SAP. The facet joints are preserved completely. The advantage of an en bloc flavectomy is that we can remove the flavum attachment to the ventral surface of SAP totally without a medial facetectomy. Since 1991, we have performed this technique in more than 5000 cases. In this paper, we will explain the tips, pitfalls, and advantages of this technique.
BMP Use and the Risk of Revision Surgery After Long Posterolateral Fusions in the Elderly
Authors: Puvanesarajah Varun , Jain Amit , Cancienne Jourdan M. , Stein Benjamin E. , Novicoff Wendy M. , Shimer Adam L. , Shen Francis , Hassanzadeh Hamid
Published: March 2018

Study Design:

Retrospective database review.

Objective of the Study:

The objective of the study was to assess whether bone morphogenetic protein (BMP) decreases the risk of revision surgery in elderly patients treated with 3–7 level or 8 or greater level fusions.

Summary of Background Data:

Revision spine surgery in the elderly is a complex undertaking, highlighting the importance of discovering methods to decrease the risk of repeat procedures. The role of BMP in modulating risk of future revision surgery is not well studied in the elderly.

Materials and Methods:

The PearlDiver database (2005–2012) was queried for elderly adult spinal deformity patients treated with a primary thoracolumbar posterolateral fusion of 3 or more levels. To compare how BMP modifies revision surgery rates in 3–7 level versus 8 level or greater fusions, 4 mutually exclusive cohorts were created and matched to one another: 1043 patients treated with 8 or greater level fusions with BMP; 1111 patients with 8 or greater level fusions without BMP; 2813 patients with 3–7 level fusions with BMP; and 4770 patients with 3–7 level fusions without BMP. Revision and complication rates were compared. Complications included seroma formation, heterotopic ossification, and postoperative neuritis within 90 days.

Results:

Patients treated with BMP during an 8 or greater level fusion were significantly less likely to require a revision surgery than matched controls (relative risk, 0.75, P=0.015). BMP use was not associated with a decreased risk of revision surgery in 3–7 level fusions (relative risk, 0.89, P=0.20). Patients treated with BMP during 3–7 level fusions were significantly less likely to develop any of the assessed complications (P=0.02). There were no other significant differences in pairwise comparisons of subcohorts of each of the fusion lengths.

Conclusions:

BMP use decreases revision rates in elderly adult spinal deformity patients treated with 8 or greater level fusions, but not in those treated with 3–7 level fusions.

Level of Evidence:

Level III.
Correlation Analysis Between Modic Change of Cervical Vertebrae and Intramedullary High Signal Intensity
Authors: Zhou Hao , Fan Jin , Sun Peng , Zhou Wei , Li Qingqing , Yu Lipeng , Yin Guoyong
Published: March 2018

Purpose:

Clinical studies have shown that endplate Modic change in the cervical spine and intramedullary high signal intensity often occurs simultaneously. We aimed to investigate whether there is a correlation between Modic change and intramedullary high signal intensity, and to explore the possible risk factors.

Materials and Methods:

In total, 133 patients with cervical spondylotic myelopathy treated at the First Affiliated Hospital of Nanjing Medical University between May 2009 and March 2013 were enrolled in the study. Preoperative cervical magnetic resonance imaging and radiographs in hyperextension and hyperflexion were analyzed. With regard to magnetic resonance imaging, all patients were classified into groups according to Modic change types and intramedullary high signal intensity; the ratio of spinal cord compression reflected the degree of spinal stenosis. For plain radiographs, total range of motion (ROM) and segmental ROM of the cervical vertebrae were measured.

Results:

Modic change of the cervical vertebral endplate and intramedullary high signal intensity demonstrated a significantly positive correlation. In patients with Modic change and intramedullary high signal intensity, the segmental angle of motion of the cervical vertebrae in hyperextension, cervical segmental ROM, and ratio of spinal cord compression were significantly higher than in patients without Modic change and intramedullary high signal intensity.

Conclusions:

The occurrence of Modic change and intramedullary high signal intensity are related to cervical instability and spinal canal stenosis. Severe disc protrusion may cause an increase of ROM in cervical hyperextension. Such patients are more prone to Modic change of the cervical vertebral endplate and intramedullary high signal intensity.
3D Navigation-guided Resection of Giant Ventral Cervical Intradural Schwannoma With 360-Degree Stabilization
Authors: Hussain Ibrahim , Navarro-Ramirez Rodrigo , Lang Gernot , Härtl Roger
Published: March 2018

Giant schwannomas are defined as intradural extramedullary tumors that span >2 vertebral body lengths. Although uncommon, these lesions can cause significant mass effect on the spinal cord and subsequent neurologic compromise. Gross total resection is the goal of operative intervention, however, is extremely challenging in cases where the tumor occupies a ventral, midline position within the lower cervical thecal sac. Using a representative case presentation, we describe an adult male with insidious progression of upper extremity radicular pain and paresthesias, found to have a ventral, solid/cystic C5–C7 giant schwannoma. We demonstrate the step-by-step surgical technique for an anterior approach 2-level cervical corpectomy, microsurgical resection of an intradural giant schwannoma, watertight dural closure, and lastly 360-degrees instrumented stabilization of the cervicothoracic spine. In addition we incorporate the utilization of a portable intraoperative computed tomography for stereotactic localization and 3-dimensional navigation-guided screw implantation. Finally, we discuss various preoperative, perioperative, and postoperative considerations that can have profound impact on successful outcomes.
Complication Rate in Minimally Invasive Revision Lumbar Discectomy
Authors: Felbaum Daniel R. , Stewart Jeffrey J. , Distaso Casey , Sandhu Faheem A.
Published: March 2018

Revision lumbar discectomy, given the disruption of anatomic planes, can be a more technically complicated operation. Historically, it may have higher complication rates than first-time microdiscectomy. Recently, minimally invasive tubular discectomy (MITD) has been reported as an equivalent treatment to traditional approaches and may have better utility for revision surgery. A retrospective review of MITDs performed by the senior surgeon (F.A.S.) on 42 patients with single-level, recurrent disk herniation was analyzed. Surgical technique, preoperative and postoperative visual analogue score, modified Macnab criteria, and complication rate were compared with similar patient series in the literature. One case is reviewed and the technique is described in detail. There were no significant differences across age (49.5±14.1), sex, or obesity status. Visual analogue scores improved significantly from 7.24±1.75 to 2.45±2.12 (P<0.001). Successful clinical outcome (excellent or good Macnab score) was reported in 83.3% of patients. There were no postoperative complications, including dural tears or wound infections: fewer than any reported series of this size to date. MITD can be safely performed for revision discectomies with low morbidity. A paramedian approach helps to decrease the exposure to preexisting scar tissue and may offer a significant advantage over the traditional midline approach to treat recurrent disk herniation.
Narcotic Consumption Following Anterior and Lateral Lumbar Interbody Fusion Procedures
Authors: Bohl Daniel D. , Narain Ankur S. , Hijji Fady Y. , Ahn Junyoung , Mayo Benjamin C. , Massel Dustin H. , Long William W. , Modi Krishna D. , Singh Kern
Published: March 2018

Study Design/Setting:

This is a retrospective analysis of a prospectively maintained surgical registry.

Objective:

To characterize postoperative narcotic consumption in patients undergoing either an anterior lumbar interbody fusion (ALIF) or a lateral lumbar interbody fusion (LLIF).

Background Context:

There is substantial interest in evaluating the safety, efficacy, and outcomes following minimally invasive techniques for lumbar fusion procedures. However, few studies have characterized postoperative narcotic consumption in patients undergoing ALIF or LLIF procedures.

Methods:

Consecutive patients who underwent either an ALIF or LLIF during 2007–2014 were identified. Inpatient narcotic consumption was recorded in oral morphine equivalents and dichotomized as greater or less than the 75th percentile total consumption (elevated or normal inpatient consumption). Demographic, comorbidity, and perioperative characteristics were tested for independent association with inpatient narcotic consumption and with continued narcotic usage during the months following surgery.

Results:

A total of 169 patients met inclusion criteria. Of these, 118 (69.8%) underwent ALIF and 51 (30.2%) underwent LLIF procedures. The risk for elevated inpatient narcotic consumption was greater in patients whose body mass index was≥30 kg/m2 [relative risk (RR), 2.8; 95% confidence interval (CI), 1.6–4.8; P<0.001). The risk for continued narcotic usage at the first postoperative visit was elevated in patients with worker’s compensation payment status (RR, 2.0; 95% CI, 1.5–2.7; P<0.001). The risk for continued narcotic usage at the second postoperative visit was elevated in patients with worker’s compensation payment status (RR, 2.6; 95% CI, 1.7–4.1; P<0.001) and in patients with preoperative narcotic utilization (RR, 2.2; 95% CI, 1.4–3.5; P<0.001).

Conclusions:

The present study suggests that while patients with greater body mass index have increased narcotic consumption as inpatients, preoperative narcotic consumption and worker’s compensation payment status are the best predictors of continued narcotics usage during the months following surgery. Worker’s compensation patients and patients who utilize narcotics preoperatively should be the targets of efforts to reduce continued postoperative narcotic usage.
The Safe Correction Angle of Osteotomy at T12 and L1 for Ankylosing Spondylitis Kyphosis
Authors: Liu Chao , Yu Wen , Zheng Guoquan , Guo Yue , Song Kai , Tang Xiangyu , Wang Zheng , Wang Yan , Zhang Yonggang
Published: March 2018

Study Design:

This is a retrospective clinical study.

Objective:

To investigate the correction angle and safety of the spinal osteotomy at the T12 or L1 vertebra.

Summary of Background Date:

Monosegment subtraction osteotomy cannot effectively correct severe kyphosis in ankylosing spondylitis (AS), generally 2-level spinal osteotomy was taken for achieving expected correction. According to literature, the T12 or L1 were usually taken as the upper spinal osteotomy vertebra. Because of the canalis vertebralis at the T12 and L1 were spinal cord and medullary cone, so the spinal osteotomy at the T12 or L1 vertebra were more dangerous than at lower level. The correction angle and safety of the spinal osteotomy at the T12 or L1 vertebra have not yet been reported.

Materials and Methods:

From July 2009 to 2014, 33 patients in our department with severe AS kyphosis underwent 2-level pedicle subtraction osteotomy were studied. Preoperative and postoperative relevant parameters and complications were recorded.

Results:

The upper spinal osteotomy was taken at the T12 vertebra for 10 patients. The upper spinal osteotomy was taken at the L1 vertebra for 23 patients. The mean amount of correction of T12 and L1 was 26.230 and 27.952 degrees, respectively. All patients could walk with orthophoria and lie horizontally postoperatively. No deadly vascular and neurological lesion occurred.

Conclusions:

Performing pedicle subtraction osteotomy at T12 and L1 can safely achieve a mean correction of 26.230 and 27.952 degrees, respectively. Two-level osteotomy was safely and advocated for correcting severe AS kyphosis.

Level of Evidence:

Level III.
Initial Experience With Real-Time Continuous Physical Activity Monitoring in Patients Undergoing Spine Surgery
Authors: Scheer Justin K. , Bakhsheshian Joshua , Keefe Malla K. , Lafage Virginie , Bess Shay , Protopsaltis Themistocles S. , Burton Douglas C. , Hart Robert A. , Shaffrey Christopher I. , Schwab Frank , Smith Justin S. , Smith Zachary A. , Koski Tyler R. , Ames Christopher P.
Published: March 2018

Study Design:

Multicenter prospective pilot study.

Objective:

To evaluate if continuous physical activity monitoring by a personal electronic 3-dimensional accelerometer device is feasible and can provide objective data that correlates with patient-reported outcomes following spine surgery.

Summary of Background Data:

Self-reported health-related quality-of-life (HRQOL) metrics are inherently limited by being very subjective, having a low frequency of data collection, and inconsistent follow-up.

Methods:

Inclusion criteria: adults (18+), thoracolumbar deformity or degenerative disease, and regular access to a computer with internet connection. Physical activity parameters included: number of daily steps, maximum hourly steps, and activity intensity. Patients completed the Oswestry Disability Index (ODI), the Short-Form Health Survey 36 (SF-36), and the Scoliosis Research Society-22r (SRS22) preoperatively and postoperatively at 6 weeks, 3 months, and 6 months.

Results:

Thirty-two patients were enrolled, 8 (25%) withdrew, 1 (3.1%) died, and 1 (3.1%) did not end up undergoing surgery resulting in 22 (68.8%) available patients. Mean preoperative and postoperative step ranges were 1278±767 to 17,800±6464 and 891±587 to 12,655±7038, respectively. Eleven patients improved in mean total daily steps at the final postoperative month with 2 having significant improvements (P<0.05). Five patients did not significantly change (P>0.05) and 6 patients had significantly lower mean total daily steps at 6 months (P<0.05). The entire cohort significantly improved in ODI, SF-36 Physical Component Summary, SRS Activity, SRS Appearance, SRS Mental, SRS Satisfaction, and SRS Total score at 6 months postoperative (P<0.05 for all). Both ODI and Physical Component Summary were significantly correlated with preoperative average total daily steps (r=−0.61, P=0.0058 and r=0.60, P=0.0114, respectively). No other HRQOL metrics were significantly correlated at baseline or at 6 months postoperative (P>0.05).

Conclusions:

A prospective pilot study for continuous real-time physical activity monitoring was successfully completed. This is the first study of its kind and demonstrates a foundation to continuous physical activity monitoring following spine surgery. A larger and longer prospective study is needed to confirm long-term results and its relationship with HRQOL scores.
Iatrogenic Flatback and Flatback Syndrome
Authors: Boody Barrett S. , Rosenthal Brett D. , Jenkins Tyler J. , Patel Alpesh A. , Savage Jason W. , Hsu Wellington K.
Published: March 2018

Flatback syndrome can be a significant source of disability, affecting stance and gait, and resulting in significant pain. Although the historical instrumentation options for thoracolumbar fusion procedures have been commonly regarded as the etiology of iatrogenic flatback, inappropriate selection, or application of modern instrumentation can similarly produce flatback deformities. Patients initially compensate with increased lordosis at adjacent lumbar segments and reduction of thoracic kyphosis. As paraspinal musculature fatigues and discs degenerate, maintaining sagittal balance requires increasing pelvic retroversion and hip extension. Ultimately, disc degeneration at adjacent levels overcomes compensatory mechanisms, resulting in sagittal imbalance and worsening symptoms. Nonoperative management for sagittally imbalanced (sagittal vertical axis>5 cm) flatback syndrome is frequently unsuccessful. Despite significant complication rates, surgical management to recreate lumbar lordosis using interbody fusions and/or osteotomies can significantly improve quality of life.
Metastatic Spinal Cord Compression and Steroid Treatment
Authors: Kumar Abhishek , Weber Michael H. , Gokaslan Ziya , Wolinsky Jean-Paul , Schmidt Meic , Rhines Laurence , Fehlings Michael G. , Laufer Ilya , Sciubba Daniel M. , Clarke Michelle J. , Sundaresan Narayan , Verlaan Jorrit-Jan , Sahgal Arjun , Chou Dean , Fisher Charles G.
Published: March 2018

Study Design:

Systematic review.

Objectives:

We conducted a systematic review of the literature to answer the following questions regarding the use of steroid therapy in metastatic spinal cord compression (MSCC): 1. In cases of MSCC, what is the effect of steroid administration before definitive radiotherapy or surgery on ambulatory status, bowel and bladder function and survival? 2. What steroid dosing regimens are associated with the best outcomes concerning neurological symptoms and complication prevention in cases of MSCC?

Summary of Background Data:

Currently, there is significant variation in the initial bolus dose, daily maintenance dose and duration of treatment when steroids are used as a bridge to definitive therapy for MSCC.

Methods:

A literature search following PRISMA guidelines was conducted in June 2016, using Medline via Ovid SP, Medline via PubMed, Embase, Biosis Previews and the Cochrane Library. Search terms used in each database varied slightly to optimize results. All generic steroid formulations were included along with spinal cord compression or myelopathy combined with metastatic or malignant tumors. Papers discussing acute traumatic causes of spinal cord compression were excluded, as were papers discussing cord compression from nonmetastatic tumors or epidural lipomatosis. Subjects were limited to adult humans undergoing definitive treatment with radiotherapy or surgery.

Results:

Of the 309 papers retrieved, 66 full text studies were reviewed and 6 papers were found to address the stated questions.

Conclusions:

There is a paucity of high quality literature evaluating the use of steroids in MSCC. On the basis of the evidence available an initial 10 mg intravenous bolus of dexamethasone followed by 16 mg PO QD has been associated with fewer complications compared with 100 mg bolus and 96 mg QD. Weaning of steroids should occur rapidly after definitive treatment. Risk of gastric bleeding or perforation can be managed with the routine use of proton-pump inhibitors.

Level of Evidence:

Level IIIa.
Understanding Traditional Research Impact Metrics
Authors: Butler Joseph S. , Sebastian Arjun S. , Kaye I. David , Wagner Scott C. , Morrissey Patrick B. , Schroeder Gregory D. , Kepler Christopher K. , Vaccaro Alexander R.
Published: March 2018

Traditionally, the success of a researcher has been judged by the number of publications he or she has published in peer-review, indexed, high impact journals. However, to quantify the impact of research in the wider scientific community, a number of traditional metrics have been used, including Impact Factor, SCImago Journal Rank, Eigenfactor Score, and Article Influence Score. This article attempts to provide a broad overview of the main traditional impact metrics that have been used to assess scholarly output and research impact. We determine that there is no perfect all-encompassing metric to measure research impact, and, in the modern era, no single traditional metric is capable of accommodating all facets of research impact. Academics and researchers should be aware of the advantages and limitations of traditional metrics and should be judicious when selecting any metrics for an objective assessment of scholarly output and research impact.
Cryopreserved Amniotic Membrane Improves Clinical Outcomes Following Microdiscectomy
Authors: Anderson D. Greg , Popov Victor , Raines Andrew L. , O’Connell Julie
Published: March 2018

Study Design:

Prospective, randomized controlled trial.

Objective:

To compare pain, physical/mental functional recovery and recurrent herniation for patients following lumbar microdiscectomy with and without the use of a cryopreserved amniotic tissue graft.

Summary of Background Data:

Although microdiscectomy procedures are routinely successful for patients with lumbar radiculopathy due to herniated disc disease, residual low back pain, and recurrent herniation remain unsolved clinical problems.

Methods:

Following Investigated Review Board approval, 80 subjects were randomized in a 1:1 ratio to either receive cryopreserved amniotic (cAM) tissue or no tissue following elective lumbar microdiscectomy surgery. cAM grafts were applied to the annular defect at the conclusion of the procedure. Patients provided preoperative and postoperative clinical assessment data out to 24 months using the Oswestry Disability Index (ODI), Short Form-12 (SF-12) Health Survey, and Visual Analog Pain Scale for back and leg pain. Patients with symptomatic recurrent disc herniation were recorded.

Results:

In total, 48 males and 32 females with an average age of 47.2 years were included. Mean ODI scores for subjects treated with cAM graft demonstrated statistically greater improvement at 6 weeks (14.49 vs. 21.82; P=0.05) and 24 months (6.62 vs. 14.40; P=0.02) compared with controls. Similarly, SF-12 Physical Component Scores demonstrated statistically greater gains in the cAM group at both the 6 weeks and 24 months. None of the subjects in the cAM graft group sustained a recurrent herniation at the same surgical level, whereas 3 patients in the control group sustained a recurrent herniation at the same surgical level, with 2 requiring fusion to manage persistent pain.

Conclusions:

The data demonstrate statistically superior clinical outcomes following lumbar microdiscectomy as measured by ODI and SF-12 (physical composite scale) and a lower rate of recurrent herniation with the use of a cAM tissue graft compared with traditional microdiscectomy.
Functional Recovery Following Early Kyphoplasty Versus Conservative Management in Stable Thoracuolumbar Fractures in Parachute Jumpers
Authors: Masoudi Mohammad S. , Haghnegahdar Ali , Ghaffarpasand Fariborz , Ilami Ghazal
Published: March 2018

Study Design:

A randomized clinical trial.

Objective:

To compare the functional recovery between early kyphoplasty and conservative care in paratroopers with stable thoracolumbar fractures.

Summary of Background Data:

Treatment of traumatic stable thoracolumbar fractures in young individuals is still a debate. Conservative management and kyphoplasty are options of therapy. But enough data are not available for supporting each.

Methods:

We included 70 paratroopers with stable thoracolumbar fractures (A1 and A2 classification according to AOSpine thoracolumbar spine injury classification system) presenting <60 days after trauma and hyperintensity in T2-weighted magnetic resonance imaging. Old fractures and those requiring fixation were excluded. Patients were randomly assigned to 2 study groups to undergo percutaneous balloon kyphoplasty (n=34) or conservative care (n=36) by applying orthosis for 2 months. Patients were followed for 12 months and were evaluated clinically using visual analogue scale (VAS) and Oswestry disability index (ODI).

Results:

The baseline characteristics were comparable between 2 study groups. The VAS score and ODI decreased significantly in both study groups after 12 months of treatment. The VAS score was significantly lower in kyphoplasty group after the intervention (P<0.001), 1 month (P<0.001), 3 months (P<0.001), 6 months (P<0.001), and 12 months (P<0.001) after the intervention. In addition, the ODI was significantly lower after the intervention (P<0.001), 1 month (P<0.001), 3 months (P<0.001), 6 months (P<0.001), and 12 months (P<0.001) after the intervention. Kyphoplasty was associated with shorter duration of returning to parachuting (P<0.001) and shorter duration of absence from work (P<0.001).

Conclusions:

Early kyphoplasty in stable thoracolumbar fractures after parachute jumping is associated with less pain, better functional recovery, less days of absence from work, and shorter duration of returning to parachuting.
Radiographic and Clinical Outcomes of Anterior and Transforaminal Lumbar Interbody Fusions
Authors: Ajiboye Remi M. , Alas Haddy , Mosich Gina M. , Sharma Akshay , Pourtaheri Sina
Published: March 2018

Study Design:

Systematic review and meta-analysis.

Objective:

Compare the radiographic and clinical outcomes of anterior lumbar interbody fusion (ALIF) to transforaminal lumbar interbody fusion (TLIF).

Summary of Background Data:

ALIF and TLIF are 2 methods of achieving spinal arthrodesis. There are conflicting reports with no consensus on the optimal interbody technique to achieve successful radiographic and clinical outcomes. The goal of this systematic review and meta-analysis was to compare the radiographic and clinical outcomes of ALIF to TLIF.

Materials and Methods:

A systematic search of multiple medical reference databases was conducted for studies comparing ALIF to TLIF. Studies that included stand-alone ALIFs were excluded. Meta-analysis was performed using the random-effects model for heterogeneity. Radiographic outcome measures included segmental and overall lumbar lordosis, and fusion rates. Clinical outcomes measures included Oswestry disability index (ODI) and visual analog scale (VAS) score for back pain.

Results:

The search yielded 7 studies totaling 811 patients (ALIF=448, TLIF=363). ALIF was superior to TLIF in restoring segmental lumbar lordosis at L4–L5 and L5–S1 (L4–L5; P=0.013, L5–S1; P<0.001). ALIF was also superior to TLIF in restoring overall lumbar lordosis (P<0.001). However, no significant differences in fusion rates were noted between both techniques [odds ratio=0.905; 95% confidence interval, 0.458–1.789; P=0.775]. In addition, ALIF and TLIF were comparable with regards to ODI and VAS scores (ODI; P=0.184, VAS; P=0.983).

Conclusions:

For the restoration of lumbar lordosis, ALIF is superior to TLIF. However, TLIF is comparable to ALIF with regards to fusion rate and clinical outcomes.
A 90-day Bundled Payment for Primary Single-level Lumbar Discectomy/Decompression
Authors: Jain Nikhil , Virk Sohrab S. , Phillips Frank M. , Yu Elizabeth , Khan Safdar N.
Published: March 2018

Episode-based bundling may become the major form of reimbursement for many elective spine procedures. As the amount for a 90-day episode of care is not known for a lumbar discectomy, we analyzed the previous reimbursements from Commercial payers (2007–Q2 2015), Medicare Advantage (2007–Q2 2015), and Medicare (2005–2012) for a primary single-level lumbar discectomy/decompression. Distribution of payments among various service providers was studied and a 90-day bundle was simulated. Depending on the payer type, the average facility costs constituted 59.7% to 73.6% of total payments, followed by surgeon’s fees, which accounted for 13.7% to 18.5%. Postacute services made up 8.8% to 15.8% of the total reimbursement. Surgeries performed in the inpatient setting were significantly more expensive as compared with surgeries performed in the outpatient setting (P<0.01). The average 90-day bundle amount was estimated at $11,091, $6571, and $6239 for Commercial payers, Medicare Advantage, and Medicare, respectively. Overall, service providers in the Southern region were reimbursed the lowest from Commercial payers and Medicare, compared with other regions. Postacute services are not as major cost drivers after discectomy as after total joint arthroplasty or hip fracture repair.
Can Surgeon Demographic Factors Predict Postoperative Complication Rates After Elective Spinal Fusion?
Authors: Chun Danielle S. , Cook Ralph W. , Weiner Joseph A. , Schallmo Michael S. , Barth Kathryn A. , Singh Sameer K. , Freshman Ryan D. , Patel Alpesh A. , Hsu Wellington K.
Published: March 2018

Study Design:

Retrospective cohort.

Objective:

Determine whether surgeon demographic factors influence postoperative complication rates after elective spine fusion procedures.

Background:

Surgeon demographic factors have been shown to impact decision making in the management of degenerative disease of the lumbar spine. Complication rates are frequently reported outcome measurements used to evaluate surgical treatments, quality-of-care, and determine health care reimbursements. However, there are few studies investigating the association between surgeon demographic factors and complication outcomes after elective spine fusions.

Methods:

A database of US spine surgeons with corresponding postoperative complications data after elective spine fusions was compiled utilizing public data provided by the Centers for Medicare and Medicaid Services (2011–2013) and ProPublica Surgeon Scorecard (2009–2013). Demographic data for each surgeon was collected and consisted of: surgical specialty (orthopedic vs. neurosurgery), years in practice, practice setting (private vs. academic), type of medical degree (MD vs. DO), medical school location (United States vs. foreign), sex, and geographic region of practice. General linear mixed models using a Beta distribution with a logit link and pairwise comparison with post hoc Tukey-Kramer were used to assess the relationship between surgeon demographics and complication rates.

Results:

2110 US-practicing spine surgeons who performed spine fusions on 125,787 Medicare patients from 2011 to 2013 met inclusion criteria for this study. None of the surgeon demographic factors analyzed were found to significantly affect overall complication rates in lumbar (posterior approach) or cervical spine fusion.

Conclusions:

Publicly available complication rates for individual spine surgeons are being utilized by hospital systems and patients to assess aptitude and gauge expectations. The increasing demand for transparency will likely lead to emphasis of these statistics to improve outcomes. We conclude that none of the surgeon demographic factors analyzed in this study are associated with differences in overall complications rates in patients undergoing elective spine fusion as published by the ProPublica Surgeon Scorecard.

Level of Evidence:

Level 3.
Intraoperative Radiographic Technique for Visualization of Bicortical or Tricortical Anteromedial Sacral Screw Placement
Authors: Jain Nikhil , Yu Elizabeth
Published: March 2018

The bicortical anteromedial sacral screw trajectory is the most widely used for S1 screw fixation. The assessment of anterior cortex purchase is difficult on a lateral view due to the overlapping bony anatomy of the sacrum and pelvis. We describe the intraoperative radiographic technique for a personalized pelvic inlet view that is perpendicular to the superior sacral surface to visualize sacral screw placement. This technique allows for assessment of anterior cortex purchase with anteromedial angulation in the same view.
Superior Segment Facet Joint Violation During Instrumented Lumbar Fusion is Associated With Higher Reoperation Rates and Diminished Improvement in Quality of Life
Authors: Levin Jay M. , Alentado Vincent J. , Healy Andrew T. , Steinmetz Michael P. , Benzel Edward C. , Mroz Thomas E.
Published: March 2018

Study Design:

A retrospective cohort study at a single tertiary care center.

Objective:

To determine the impact of superior segment facet joint violation (FJV) during lumbar fusion on reoperation rates and quality of life (QOL).

Summary of Background Data:

Although lumbar fusion is an efficacious and durable treatment for numerous spinal pathologies, adjacent segment degeneration remains a serious complication. FJV has been suggested to alter load-bearing capability and potentially contribute to adjacent segment degeneration.

Materials and Methods:

Patients who underwent instrumented lumbar fusion surgery between 2009 and 2013 with postoperative computed tomography imaging were included. Patients were placed in the FJV group if either of the superior segment facet joints were compromised by the pedicle screw or rod. Patients with preserved facet joints were placed in the control group. Demographic, perioperative, QOL, and reoperation data were collected. QOL scores including the Pain Disability Questionnaire, Patient Health Questionnaire-9, and EuroQOL 5 Dimensions (EQ-5D) were acquired.

Results:

Of 240 patients included, 112 patients were found to have FJV and the remaining 128 patients were placed in the control group. One year following lumbar fusion, QOL outcomes and reoperation rates were similar between the FJV and control groups. At 2-year follow-up, patients in the FJV group were less likely to make a significant improvement in EQ-5D (P=0.041). Also, the reoperation rate in the FJV group was significantly higher than in the control group at 2 years (15.2% vs. 6.3%, respectively; P=0.024) and 3 years (19.6% vs. 9.4%, P=0.023). Multivariable logistic regression showed FJV to be an independent predictor of both (1) failing to make a significant improvement in EQ-5D (P=0.046) and (2) undergoing reoperation at both 2 and 3 years postoperatively (P=0.024 and 0.020, respectively).

Conclusions:

FJV was independently associated with a higher reoperation rate and diminished improvement in QOL.
Efficacy of Target Drug Delivery and Dead Space Reduction Using Antibiotic-loaded Bone Cement for the Treatment of Complex Spinal Infection
Authors: Masuda Soichiro , Fujibayashi Shunsuke , Otsuki Bungo , Kimura Hiroaki , Matsuda Shuichi
Published: March 2018

Study Design:

A retrospective study.

Objectives:

We have treated complex cases of surgical site infection (SSI) successfully using antibiotic-loaded bone cement to avoid the need for implant removal. In the present study, we describe a new treatment option for SSI.

Summary of Background Data:

Although there are several treatment options for SSI after spinal surgery involving instrumentation, several types of problems may arise and are difficult to cure.

Materials and Methods:

Eleven patients with SSI after undergoing spinal surgery involving instrumentation were studied. All had been refractory to conventional treatments, including intravenous antibiotic administration and conventional debridement and irrigation. Antibiotic-loaded bone cement was placed on and around the instrumentation to cover them and to occupy the surrounding dead space. Two general types of antibiotics were loaded into the polymethylmethacrylate bone cement. The recipes for the mixture were changed depending on the bacterial cultures. Sensitive antibiotics were administered generally for 2–6 weeks until the C-reactive protein level was normalized.

Results:

All patients were treated successfully using antibiotic-loaded bone cement. Only 1 patient needed a repeat of this procedure to treat an infection. Antibiotic-loaded bone cement was placed in situ in all patients during the follow-up period and there were no significant adverse events.

Conclusions:

Antibiotic-loaded bone cement treatment reduces the dead space and achieves the targeted drug delivery simultaneously. Treatment using antibiotic-loaded bone cement is an effective treatment option for complex spinal SSI.
Risk Factors and Management of Incidental Durotomy in Lumbar Interbody Fusion Surgery
Authors: Enders Frederik , Ackemann Amelie , Müller Simon , Kiening Karl , Orakcioglu Berk
Published: March 2018

Study Design:

This is a retrospective study analysis.

Objective:

In this retrospective study we evaluated risk factors for incidental durotomy and its impact on the postoperative course.

Summary of Background Data:

Lumbar interbody fusion (LIF) is increasingly applied for the treatment of degenerative instability. A known complication is incidental durotomy.

Materials and Methods:

A cohort of 541 patients who underwent primary LIF surgery between 2005 and 2015 was analyzed. Previous lumbar surgery, age, surgeon’s experience, intraoperative use of a microscope, and the number of operated levels were assessed and the risk for incidental durotomy was estimated using the Log-likelihood test and Wald test, respectively. The association of incidental durotomy and outcome parameters was analyzed using the quantile regression model.

Results:

In 77 (14.2%) patients intraoperative cerebrospinal fluid (CSF) fistula was observed. Previous lumbar surgery (P<0.001), number of operated levels (P=0.03), and surgeon’s experience (P=0.01) were significantly associated with incidental durotomy. Incidental durotomy was significantly associated with a prolonged bed rest (P<0.001), hospital stay (P=0.041), and an increased use of postoperative antibiotics (P<0.001). Eleven of 77 patients with incidental durotomy (14.3%) developed postoperative CSF fistula of whom 10 (91%) needed revision surgery for dural repair.

Conclusions:

We could identify important risk factors for incidental durotomy in LIF surgery. In patients who had undergone previous lumbar surgery and those with multilevel disease particular precaution is required. Furthermore, we were able to verify the morbidity associated with CSF fistula as shown by increased immobilization and follow-up surgeries for postoperative CSF fistula which emphasizes the importance to develop strategies to minimize the risk for incidental durotomy.
The Timing of Surgery Affects Return to Work Rates in Patients With Degenerative Lumbar Stenosis in a Workers’ Compensation Setting
Authors: Tye Erik Y. , Anderson Joshua T. , Haas Arnold R. , Percy Rick , Woods Stephen T. , Ahn Uri M. , Ahn Nicholas U.
Published: March 2018

Study Design:

Retrospective Cohort Study.

Objective:

The objective of this study is to determine how time to surgery affects outcomes for degenerative lumbar stenosis (DLS) in a workers’ compensation (WC) setting.

Summary of Background Data:

WC subjects are known to be a clinically distinct population with variable outcomes following lumbar surgery. No study has examined the effect of time to surgery in this clinically distinct population.

Materials and Methods:

A total of 227 Ohio WC subjects were identified who underwent primary decompression for DLS between 1993 and 2013. We allocated patients into 2 groups: those that received operative decompression before and after 1 year of symptom onset. Our primary outcome was, if patients were able to make a stable return to work (RTW). The authors classified subjects as RTW if they returned within 2 years after surgery and remained working for >6 months.

Results:

The early cohort had a significantly higher RTW rate [50% (25/50) vs. 30% (53/117); P=0.01]. A logistic regression was performed to identify independent variables that predicted RTW status. Our regression model showed that time to surgery remained a significant negative predictor of RTW status (P=0.04; odds ratio, 0.48; 95% confidence interval, 0.23–0.91). Patients within the early surgery cohort cost on average, $37,332 less in total medical costs than those who opted for surgery after 1 year (P=0.01). Furthermore, total medical costs accrued over 3 years after index surgery was on average, $13,299 less when patients received their operation within 1 year after symptom onset (P=0.01).

Conclusions:

Overall, time to surgery had a significant impact on clinical outcomes in WC subjects receiving lumbar decompression for DLS. Patients who received their operation within 1 year had a higher RTW rate, lower medical costs, and lower costs accrued over 3 years after index surgery. The results presented can perhaps be used to guide surgical decision-making and provide predictive value for the WC population.
Assessing Online Patient Education Readability for Spine Surgery Procedures
Authors: Long William W. , Modi Krishna D. , Haws Brittany E. , Khechen Benjamin , Massel Dustin H. , Mayo Benjamin C. , Singh Kern
Published: March 2018

Background Context:

Increased patient reliance on Internet-based health information has amplified the need for comprehensible online patient education articles. As suggested by the American Medical Association and National Institute of Health, spine fusion articles should be written for a 4th–6th-grade reading level to increase patient comprehension, which may improve postoperative outcomes.

Purpose:

The purpose of this study is to determine the readability of online health care education information relating to anterior cervical discectomy and fusion (ACDF) and lumbar fusion procedures.

Study Design:

Online health-education resource qualitative analysis.

Methods:

Three search engines were utilized to access patient education articles for common cervical and lumbar spine procedures. Relevant articles were analyzed for readability using Readability Studio Professional Edition software (Oleander Software Ltd). Articles were stratified by organization type as follows: General Medical Websites (GMW), Healthcare Network/Academic Institutions (HNAI), and Private Practices (PP). Thirteen common readability tests were performed with the mean readability of each compared between subgroups using analysis of variance.

Results:

ACDF and lumbar fusion articles were determined to have a mean readability of 10.7±1.5 and 11.3±1.6, respectively. GMW, HNAI, and PP subgroups had a mean readability of 10.9±2.9, 10.7±2.8, and 10.7±2.5 for ACDF and 10.9±3.0, 10.8±2.9, and 11.6±2.7 for lumbar fusion articles. Of 310 total articles, only 6 (3 ACDF and 3 lumbar fusion) were written for comprehension below a 7th-grade reading level.

Conclusions:

Current online literature from medical websites containing information regarding ACDF and lumbar fusion procedures are written at a grade level higher than the suggested guidelines. Therefore, current patient education articles should be revised to accommodate the average reading level in the United States and may result in improved patient comprehension and postoperative outcomes.
Clinical and Radiologic Comparison of Minimally Invasive Surgery With Traditional Open Transforaminal Lumbar Interbody Fusion
Authors: Price Julian P. , Dawson John M. , Schwender James D. , Schellhas Kurt P.
Published: March 2018

Study Design:

Retrospective analysis of prospective data for parallel, consecutive series of patients (Level III).

Objective:

Compare clinical results and radiographic outcomes of minimally invasive surgery (MIS) versus open techniques for transforaminal lumbar interbody fusion (TLIF).

Summary of Background Data:

Minimally invasive techniques allow transforaminal exposure with decreased soft tissue disruption, but the question remains whether surgical and functional outcomes are equivalent to open techniques.

Materials and Methods:

A consecutive series of 452 1 or 2-level TLIF patients at a single institution between 2002 and 2008 were analyzed. A total of 148 were MIS patients and 304 were open. Operative time, estimated blood loss, infection rate, and hospital length of stay were recorded. Oswestry disability index (ODI) and visual analog (VAS) pain scores were documented preoperatively and postoperatively. Fusion was assessed radiologically at a minimum of 1 year follow-up.

Results:

There were proportionally more 2-level than 1-level procedures in the open group compared with the MIS group; there were more Workers’ Compensation patients among 1-level procedures than 2-level. There were more Spondylolisthesis patients and fewer Degenerative Disk Disease patients among one-level procedures compared with 2-level. Blood loss and operative time were lower in the MIS group. Length of hospital stay in the MIS cohort was shorter compared with the open cohort. There were 3 deep wound infections in the open cohort. ODI and VAS (leg and back) scores improved in both groups at 1 year compared with preoperative scores and did not differ between MIS and open cohorts. Fusion rate was similar for both groups (91% overall). One-level procedures and BMP use were associated with higher fusion rate, regardless of approach.

Conclusions:

MIS TLIF produces comparable clinical and radiologic outcomes to open TLIF with the benefits of decreased intraoperative blood losses, shorter operative times, shorter hospital stays, and fewer deep wound infections.