bluuebunny/crossref_metadata_2025 huggingface dataset:
Patient Satisfaction is Not Associated With Self-reported Disability in a Spine Patient Population
Authors: Abtahi Amir M. , Lyman Kade Shumway , Brodke Darrel S. , Lawrence Brandon D. , Zhang Chong , Spiker William Ryan
Published: March 2018

Study Design:

This is a retrospective review.

Objective:

To evaluate the relationship between patient functional status and self-assessment of disability as measured by 3 commonly used clinical assessment instruments—the Oswestry Disability Index (ODI), the Neck Disability Index (NDI), and the EuroQol (EQ)-5D and patient satisfaction scores in a spine surgery clinic population.

Summary of Background Data:

Patient satisfaction surveys, which measure the “patient experience of care” are becoming an increasingly important measure of the quality of medical care. Despite the widespread use of patient satisfaction surveys, little is known about the relationship between patient satisfaction and patient functional status or self-assessed level of disability.

Materials and Methods:

We retrospectively reviewed records of 231 consecutive patients presenting to a single academic spine surgery center between February 2011 and October 2013 who completed both a patient satisfaction survey as well as one or more patient-reported outcome questionnaires (NDI, ODI, and/or EQ-5D) for a single clinical encounter. Statistical analysis was performed to determine if an association exists between the overall patient satisfaction score and each patient-reported outcome score.

Results:

Spearman correlation coefficients demonstrated no correlation between any patient-reported outcome score and the patient satisfaction score [NDI=−0.113 (−0.409 to 0.207) P=0.489] [ODI=−0.008 (−0.149 to 0.133) P=0.912] [EQ-5D=0.011 (−0.119 to 0.140) P=0.872] for a single clinical encounter.

Conclusions:

These results provide evidence against an association between patient-reported functional status or self-assessed level of disability and patient satisfaction in a spine patient population.
Traumatic Sports-Related Cervical Spine Injuries
Authors: Puvanesarajah Varun , Qureshi Rabia , Cancienne Jourdan M. , Hassanzadeh Hamid
Published: March 2018

Cervical spine trauma in the athlete is not an insignificant occurrence with possibly catastrophic results. Football remains one of the most common and most well studied sporting activities associated with spine injuries. Transient spinal cord and peripheral nerve injuries may manifest as quadriparesis or burners/stingers with symptoms that resolve completely. More severe spinal cord injuries, typically from axial loading on the cervical spine, will cause bilateral symptoms with residual neurological deficit. Acute Trauma Life Support principles must always be applied to the player with a potential spine injury. Recent positional statements by National Athletic Trainers’ Association advocate equipment removal on the field by 3 individuals with appropriate training, a shift from previous recommendations. This recommendation is still under debate, but equipment removal in the field is an option depending on staff training. The use of steroids in acute spinal cord injury remains controversial. Moderate systemic hypothermia has theoretical benefits for reducing spinal cord damage in the setting of an acute injury. Although it has been studied in the laboratory, only a few clinical trials have been performed and further research is necessary before routine implementation of hypothermia protocols.
Impact of Glycemic Control on Morbidity and Mortality in Adult Idiopathic Scoliosis Patients Undergoing Spinal Fusion
Authors: Shin John I. , Phan Kevin , Kothari Parth , Kim Jun S. , Guzman Javier Z. , Cho Samuel K.
Published: March 2018

Study Design:

This is a retrospective analysis of administrative database.

Objective:

To elucidate the effect of glycemic control on surgical outcomes of middle-aged and elderly idiopathic scoliosis patients undergoing spinal fusion surgery.

Summary of Background Data:

Diabetes mellitus (DM) is a condition thought to adversely affect outcomes of spine surgery. However, no study has stratified glycemic control levels and their impact on outcome for idiopathic scoliosis patients receiving a spinal fusion surgery. Previous studies may have reported higher than true rates of complications for controlled diabetic patients, who are the majority of diabetic patients.

Materials and Methods:

The Nationwide Inpatient Sample was queried from years 2002 to 2011. We extracted idiopathic scoliosis patients older than 45 years of age that received spinal fusion and analyzed complications and outcomes variables among 3 cohorts: nondiabetic patients, controlled diabetics, and uncontrolled diabetics. Multivariate analyses were used to assess whether glycemic control was a risk factor for adverse postoperative outcomes.

Results:

Controlled diabetics had significantly increased rates of acute renal failure (ARF), while uncontrolled diabetics had significantly increased rates of acute postoperative hemorrhage. In multivariate analyses controlling for patient factors and comorbidities, controlled DM was found to be an independent predictor of ARF [odds ratio (OR), 1.863; 95% confidence interval (CI), 1.346–2.579; P=0.0002), and uncontrolled DM was found to be a significant risk factor for acute postoperative hemorrhage (OR, 2.182; 95% CI, 1.192–3.997; P=0.0115), ARF (OR, 4.839; 95% CI, 1.748–13.392; P=0.0024), deep vein thrombosis (OR, 5.825; 95% CI, 1.329–25.522, P=0.0194) and in-patient mortality (OR, 8.889; 95% CI, 1.001–78.945; P=0.0499).

Conclusions:

Controlled DM was found to be a risk factor for ARF in adult idiopathic scoliosis patients undergoing spinal fusion surgery, while uncontrolled DM was shown to be a risk factor for postoperative hemorrhage, ARF, deep vein thrombosis, and mortality. The present study provides valuable data for better informed consent for patients with diabetes considering surgery for idiopathic scoliosis.

Level of Evidence:

Level III.
Obesity as a Risk Factor for Low Back Pain
Authors: Zhang Ting-Ting , Liu Zhen , Liu Ying-Li , Zhao Jing-Jing , Liu Dian-Wu , Tian Qing-Bao
Published: March 2018

Study Design:

A meta-analysis.

Objective:

To update the current knowledge about the association between overweight, obesity, and low back pain (LBP) risk, we conducted a meta-analysis of published cohort studies.

Summary of Background Data:

The association between obesity and LBP risk has been the research focus in the past decade. However, available data from studies on the association between obesity and LBP remains debatable.

Methods:

An extensive English language literature retrieval regarding the association between overweight, obesity, and the risk of LBP incidence was conducted on PubMed and EMBASE databases through December 2015. Meta-analysis for all the included literature was performed by STATA 12.0 to summarize test performance with Forest plots after a heterogeneity test. Moreover, subgroup and sensitivity analyses were performed to examine the potential candidate-effect factors.

Results:

A total of 10 cohort studies including 29,748 subjects satisfied the predefined eligibility criteria. The pooled odds ratio (OR) for overweight and obesity compared with normal weight was 1.15 [95% confidence interval (CI), 1.08–1.21) and 1.36 (95% CI, 1.18–1.57), respectively. Moreover, subgroup analysis proved that increased body mass index was associated with an increased incidence of LBP in both men (overweight: pooled OR=1.16, 95% CI, 1.04–1.31; obesity: pooled OR=1.36, 95% CI, 1.15–1.61) and women (overweight: pooled OR=1.24, 95% CI, 1.04–1.50; obesity: pooled OR=1.40, 95% CI, 1.08–1.82). There was no evidence of publication bias.

Conclusions:

Our findings consistently show that overweight and obesity are risk factors for LBP in men and women. Maintaining a healthy body weight may be one of the factors preventing the occurrence of LBP.

Level of Evidence:

Level 1.
Comparative Study of the Difference of Perioperative Complication and Radiologic Results
Authors: Jin Jie , Ryu Kyeong-Sik , Hur Jung-Woo , Seong Ji-Hoon , Kim Jin-Sung , Cho Hyun-Jin
Published: March 2018

Study Design:

Retrospective observatory analysis.

Objective:

The purpose of this study was to compare the incidence of perioperative complication, difference of cage location, and sagittal alignment between minimally invasive oblique lateral lumbar interbody fusion (MIS-OLIF) and MIS-direct lateral lumbar interbody fusion (DLIF) in the cases of single-level surgery at L4–L5.

Summary of Background Data:

MIS-DLIF using tubular retractor has been used for the treatment of lumbar degenerative diseases; however, blunt transpsoas dissection poses a risk of injury to the lumbar plexus. As an alternative, MIS-OLIF uses a window between the prevertebral venous structures and psoas muscle.

Materials and Methods:

A total of 43 consecutive patients who underwent MIS-DLIF or MIS-OLIF for various L4/L5 level pathologies between November 2011 and April 2014 by a single surgeon were retrospectively reviewed. A complication classification based on the relation to surgical procedure and effect duration was used. Perioperative complications until 3-month postoperatively were reviewed for the patients. Radiologic results including the cage location and sagittal alignment were also assessed with plain radiography.

Results:

There were no significant statistical differences in perioperative parameters and early clinical outcome between 2 groups. Overall, there were 13 (59.1%) approach-related complications in the DLIF group and 3 (14.3%) in the OLIF group. In the DLIF group, 3 (45.6%) were classified as persistent, however, there was no persistent complication in the OLIF group. In the OLIF group, cage is located mostly in the middle 1/3 of vertebral body, significantly increasing posterior disk space height and foraminal height compared with the DLIF group. Global and segmental lumbar lordosis was greater in the DLIF group due to anterior cage position without statistical significance.

Conclusions:

In our report of L4/L5 level diseases, the OLIF technique may decrease approach-related perioperative morbidities by eliminating the risk of unwanted muscle and nerve manipulations. Using orthogonal maneuver, cage could be safely placed more posteriorly, resulting in better disk and foraminal height restoration.
Outcome of Decompression Alone for Foraminal/Extraforaminal Entrapment of L5 Nerve Root Through Wiltse Paraspinal Approach
Authors: Choi Kyung-Chul , Kim Jin-Sung , Lee Dong Chan , Park Choon-Keun
Published: March 2018

Study Design:

Retrospective analysis.

Objective of the Study:

The objective of the study was to present the surgical outcome and analyze the prognostic factors for postoperative leg pain after posterior decompression alone for foraminal/extraforaminal L5 entrapment at L5–S1 segment (LSS).

Summary of Background Data:

Disk extrusion, hypertrophy of facet joint, osteophyte of vertebral body, thickened lumbosacral ligament, and collapsed disk lead to form the lumbosacral tunnel which compresses the L5 exiting nerve root. There are few reports discussing the outcome and prognostic factors of posterior decompression alone.

Materials and Methods:

One hundred two consecutive patients underwent posterior decompressive surgery through Wiltse approach for foraminal/extraforaminal entrapment at LSS, performed by 2 surgeons. Demography and preoperative radiograph were analyzed for 6 parameters: age, pathology, disk height, relative disk height ratio, depth of L5 vertebrae within the pelvis, and coronal wedging angle of the segment. Clinical outcomes were assessed by the Visual Analog Scale score for back and leg pain, Oswestry Disability Index, and modified Macnab criteria. The incidence of medications of anticonvulsants, opioids, epidural nerve root block and revisional surgery at index level were also examined.

Results:

This study included 93 patients. The mean follow-up period was 40.6±19.7 months. Thirty-six patients had disk herniation and 57 had stenosis. Preoperative Visual Analog Scale score and Oswestry Disability Index significantly improved at the final follow-up. On the basis of the modified Macnab criteria, 83% of the patients had good outcomes at follow-up. The mean duration of the medications of anticonvulsants or opioids is 27.2±37.4 days (0–210 d). 5 patients (5.4%) were reoperated. Relative disk height ratio <0.8 was associated with worsening of postoperative leg pain (P<0.01).

Conclusions:

Decompression as the only method for foraminal/extraforminal lesion of LSS through Wiltse paraspinal approach provided good clinical results. A large difference of disk height between standing and supine positions is associated with poor clinical outcomes.
Patient Factors Contributing to Prolonged Postoperative Length of Stay and Increased Rate of Readmission After Elective Posterior Cervical Fusion
Authors: Shin John I. , Kim Jun S. , Steinberger Jeremy , DiCapua John , Cho Samuel K.
Published: March 2018

Study Design:

This is retrospective study of prospectively collected data.

Objective:

To identify patient factors that are independently associated with prolonged length of stay (LOS) and readmission after posterior cervical fusion (PCF) utilizing a large national database.

Summary of Background Data:

A number of studies have investigated the morbidity and mortality after PCF; however, little is known about the factors that are associated with prolonged LOS and readmission, both of which incur increased costs for patients and hospitals.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2014. Current Procedural Terminology code 22600 was used to identify patients who underwent PCF. All patient factors were assessed for association with LOS and readmission rate using bivariate and multivariate logistic regressions.

Results:

A total of 2667 patients who underwent PCF met the inclusion criteria for LOS analysis. Average (±SD) LOS was 3.92 (±3.24) days, and median LOS was 3 days (interquartile range, 2–5 d). On multivariate analysis, increased LOS was found to be significantly associated with dependent functional status (P<0.001), diabetes mellitus (P=0.021), preoperative anemia (P=0.001), American Society of Anesthesiologists class 3 or 4 (P<0.001), and number of fused levels (P<0.001). A total of 2591 patients met criteria (LOS≤11 d) for analysis of readmission. Readmission rate among these patients was 7.1%. Average (±SD) LOS of the patients not readmitted within 30 days of operation was 3.89 (±3.25), whereas the average (±SD) LOS of the patients readmitted was 4.24 (±3.08). On multivariate analysis, readmission was found to be significantly associated with only dependent functional status (P=0.019) and increased number of fused levels (P=0.032).

Conclusions:

The current study provides valuable information on patient factors that are associated with prolonged LOS and readmission, which would be useful in enhanced informed consent before surgery, surgical planning, discharge planning, and optimizing postoperative care.

Level of Evidence:

Level III.
Clinical Outcomes After Posterior Lumbar Interbody Fusion
Authors: Takenaka Shota , Mukai Yoshihiro , Tateishi Kosuke , Hosono Noboru , Fuji Takeshi , Kaito Takashi
Published: March 2018

Study Design:

This study is a retrospective cohort study using prospectively collected data.

Objective:

To compare the effectiveness of posterior lumbar interbody fusion (PLIF) using the cortical bone trajectory (CBT) and conventional pedicle screw (PS) techniques.

Summary of Background Data:

There are few published studies to date comparing PLIF using CBT technique with PLIF using the conventional PS technique.

Methods:

We studied 119 consecutive patients who underwent single-level PLIF between 2010 and 2014 with a minimum 12-month follow-up. Forty-two patients underwent CBT-PLIF (the CBT group) and 77 underwent conventional PS-PLIF (the PS group). Clinical outcomes were assessed by the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and visual analog scale (VAS). To assess perioperative pain, a 6-point Numeric Rating Scale score and the total amount of diclofenac sodium suppositories used were recorded. The operative time and blood loss were recorded. Muscle damage was evaluated by serum creatine kinase concentrations. Fusion status was evaluated using 3-dimensional computed tomography 12 months postoperatively. We used inverse probability of treatment weighting based on the propensity score to reduce confounding factors.

Results:

There were no significant between-group differences in operative time or fusion rates, whereas the CBT group experienced significantly less blood loss, lower postoperative creatine kinase levels, less diclofenac sodium suppositories, and lower Numeric Rating Scale scores than the PS group did. The change in the JOABPEQ subdomain score for social life function 1 month postoperatively was the only significantly different factor among the JOABPEQ and VAS scores.

Conclusions:

Both procedures were comparable in terms of clinical outcomes and fusion rates, but CBT-PLIF provided the additional benefits of less blood loss, less intraoperative muscle damage, less perioperative pain, and earlier recovery to normal activities.
Symptomatic Adjacent Segment Disease After Anterior Cervical Discectomy for Single-level Degenerative Disk Disease
Authors: Donk Roland D. , Verhagen Wim I. M. , Hosman Allard J. F. , Verbeek Andre , Bartels Ronald H.M.A.
Published: March 2018

Study Design:

A prospective cohort of 142 patients underwent either anterior cervical discectomy alone, anterior cervical discectomy with fusion by cage stand-alone, or anterior cervical discectomy with arthroplasty. We then followed up on their condition for a mean of 9.1±1.9 years (5.6–12.2 y) later.

Objective:

We aimed to evaluate the annual rate of clinically symptomatic adjacent segment disease (ASD) and to analyze predictive factors.

Summary of Background Data:

Until recent, ASD has been predominantly evaluated radiologically. It is not known whether all patients had complaints. A frequent cited annual rate of ASD is 2.9%, but a growing number of studies report a lower annual rate. Furthermore, maintaining motion to prevent ASD is one reason for implanting a cervical disk prosthesis. However, the results of studies contradict one another.

Methods:

Participants took part in a randomized controlled trial that ended prematurely because of the publication of evidence that did not justify continuation of the trial. The patients were randomly allocated to 3 groups, each of which received one of the abovementioned treatments. We defined symptomatic ASD as signs and symptoms caused by degeneration of an intervertebral disk adjacent to a level of previous anterior cervical disk surgery. At the last follow-up, we were able to ascertain whether clinically symptomatic ASD was present in any of the participants.

Results:

The overall annual rate of symptomatic ASD was 0.7%. We found no statistically significant correlations between any of the investigated factors and symptomatic ASD except for the surgical method used. Symptomatic ASD was seen less often in anterior cervical discectomy solely or anterior cervical discectomy with arthroplasty than in anterior cervical discectomy with fusion by plate fixation.

Conclusions:

The annual rate of symptomatic ASD after an anterior cervical discectomy procedure was estimated to be 0.7%. This seems to be related to the procedure, although firm conclusions cannot be drawn.

Level of Evidence:

Level 2—prospective cohort.
Novel Angular Measures of Cervical Deformity Account for Upper Cervical Compensation and Sagittal Alignment
Authors: Protopsaltis Themistocles S. , Lafage Renaud , Vira Shaleen , Sciubba Daniel , Soroceanu Alex , Hamilton Kojo , Smith Justin , Passias Peter G. , Mundis Gregory , Hart Robert , Schwab Frank , Klineberg Eric , Shaffrey Christopher , Lafage Virginie , Ames Christopher
Published: March 2018

Study Design:

This is a retrospective review of a prospective multicenter database.

Objective:

This study introduces 2 new cervical alignment measures accounting for both cervical deformity (CD) and upper cervical compensation.

Summary of Background Data:

Current descriptions of CD like the C2–C7 sagittal vertical axis (cSVA) do not account for compensatory mechanisms such as C0–C2 lordosis and pelvic tilt, which makes surgical planning difficult. The craniocervical angle (CCA) combines the slope of McGregor’s line and the inclination from C7 to the hard palate. The C2-pelvic tilt (CPT) combines C2 tilt and pelvic tilt. Like the T1 pelvic angle, CPT is less affected by lower extremity and pelvic compensation.

Methods:

Novel and existing CD measures were correlated in 781 patients from a thoracolumbar deformity (TLD) database and 61 patients from a prospective CD database. CD patients were subanalyzed by region of deformity driver: cervical or cervico-thoracic junction. TLD patients were substratified according to whether or not they had CD as well, where CD was defined as cSVA>4 cm or T1 slope minus cervical lordosis mismatch (TS-CL) >20.

Results:

TLD cohort: mean cSVA was 31.7±17.8 mm. Subanalysis of TLD patients with CD versus no-CD demonstrated significant differences in CCA (56.2 vs. 60.6, P<0.001) and CPT (32.6 vs. 19.3, P<0.001). CCA and CPT correlated with cSVA (r=−0.488/r=0.418, P<0.001) and C0–C2 lordosis (r=−0.630/r=0.289,P<0.001). CD cohort: mean cSVA was 47.3±32.2 mm. CCA and CPT correlated with cSVA (r=−0.811/r=0.657, P<0.001) and C0–C2 lordosis (r=−0.656/r=0.610, P<0.001). CD cohort subanalysis indicated that CT patients were significantly more deformed by cSVA (71.3 vs 24.0 mm, P<0.001), CCA (47.1 vs 59.1 degrees, P<0.001), and CPT (63.3 vs 43.8 degrees, P=0.002). Using linear regression analysis, cSVA of 4 cm corresponded to CCA of 53.2 degrees (r
2=0.5) and CPT of 48.5 degrees (r
2=0.4).

Conclusions:

CCA and CPT account for both cervical sagittal alignment and upper cervical compensation and can be utilized in assessment of cervical alignment.
Reliability and Clinical Utility of the CARDS Classification for Degenerative Spondylolisthesis
Authors: Sobol Garret L. , Hilibrand Alan , Davis Ashley , Millhouse Paul , Koerner John , Kepler Christopher , Schroeder Gregory D. , Krystal Jonathan D. , Olsson Erik C. , Rihn Jeffrey , Anderson David Greg , Vaccaro Alexander , Radcliff Kristen
Published: March 2018

Study Design:

Retrospective cohort study.

Objective:

The objective of this study is to determine the reliability and clinical utility of the of the proposed CARDS classification for degenerative spondylolisthesis.

Background:

The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system was recently proposed as an alternative to the Meyerding system for classifying degenerative spondylolisthesis (DS). Unlike Meyerding, CARDS considers other relevant radiographic findings such as disk space collapse and segmental kyphosis to stratify DS into 4 radiographically discreet types. Currently, no studies have been conducted to assess the clinical utility of the CARDS system.

Methods:

A total of 78 consecutive surgical patients with L4-L5 DS were rated as CARDS types A through D and Fleiss’ κ for interobserver agreement was calculated. Then, demographics as well as preoperative and postoperative outcome scores (ODI, SF-12 mental and physical, VAS) were collected. The Kruskal-Wallis test was used to detect significant differences amongst CARDS types. An unpaired t test was used to compare individual CARDS types with all other subtypes combined.

Results:

Grading showed: 4 type A, 19 type B, 45 type C, and 8 type D (k=0.63). There was a statistically significant difference in preoperative back pain (P=0.046) between groups. CARDS type D had the highest mean back pain scores (8.8) of all subtypes which was significantly higher than mean back pain for all other subtypes combined (P=0.016). CARDS D showed the largest degree of improvement in all outcome measures. There was a trend towards an increased improvement in ODI (P=0.074) and SF-12 MCS (P=0.095) in the CARDS D subtype relative to the rest of the cohort.

Conclusions:

The CARDS classification system represents a reliable method for classifying cases of DS. Our results indicate that kyphotic segmental alignment (CARDS D) may be a less common, yet clinically distinct subset of DS characterized by worse preoperative back pain. CARDS type D cases may also show a greater degree of improvement in multiple outcome measures following surgical intervention.
The Influence of Geography, Time, and Payer Type on the Utilization of Bone Morphogenetic Protein (BMP) Between 2005 and 2015
Authors: Virk Sohrab S. , Phillips Frank M. , Khan Safdar N.
Published: March 2018

Bone morphogenetic protein (BMP) is a critical compound for endochondral bone formation and is used as a bone graft substitute to promote spinal fusion and fracture healing. We sought to identify rate, type, and applications of use of BMP in spinal fusion surgery during 2005 to 2015. The Medicare 5% national sample (SAF5) database and the Humana Orthopaedics database (HORTHO) were searched for patients who underwent spinal fusion with BMP. Rate of use over time and influence of geographic region and payer type on utilization of BMP during 2005 to 2015 were analyzed. A total of 9879 and 12,598 patients were treated with BMP within the SAF5 database and HORTHO databases, respectively. There was a statistically significant variation in use of BMP among geographic regions. Rate of BMP usage for patients above 65 years old was 11.02 and 58.91 patients per 100,000 members for SAF5 and HORTHO databases, respectively (P<0.001). Rate of use of BMP did not vary significantly during 2005 to 2012 within the SAF5 database (P=0.153). There was a trend toward lower use of BMP in the HORTHO database between 2007 and 2015 (P=0.081). BMP use was higher for private pay than Medicare.
Explanatory Versus Pragmatic Trials
Authors: Merali Zamir , Wilson Jefferson R.
Published: March 2018

Randomized clinical trials often represent the highest level of clinical evidence available to evaluate the efficacy of an intervention in clinical medicine. Although the process of randomization serves to maximize internal validity, the external validity, or generalizability, of such studies depends on several factors determined at the design phase of the trial including eligibility criteria, study setting, and outcomes of interest. In general, explanatory trials are optimized to demonstrate the efficacy of an intervention in a highly selected patient group; however, findings from these studies may not be generalizable to the larger clinical problem. In contrast, pragmatic trials attempt to understand the real-world benefit of an intervention by incorporating design elements that allow for greater generalizability and clinical applicability of study results. In this article we describe the explanatory-pragmatic continuum for clinical trials in greater detail. Further, a well-accepted tool for grading trials on this continuum is described, and applied, to 2 recently published trials pertaining to the surgical management of lumbar degenerative spondylolisthesis.
The P-mJOA: A Patient-derived, Self-reported Outcome Instrument for Evaluating Cervical Myelopathy
Authors: Rhee John M. , Shi Weilong J. , Cyriac Mathew , Kim Jin Y. , Zhou Feifei , Easley Kirk A. , Patel Anuj
Published: March 2018

Study Design:

Prospective Cohort Study.

Objective:

The objective of this study is to evaluate and validate a patient-derived version of the modified Japanese Orthopaedic Association (the “P-mJOA”) that a patient can complete along with other patient-derived outcome measures.

Summary of Background Data:

The modified Japanese Orthopaedic Association (mJOA) is a validated instrument widely used in the assessment of cervical myelopathy; however, it is not a patient-derived outcome. If available and reliable, a patient-derived version of the mJOA (P-mJOA) could facilitate research because the data would be immediately available upon patient completion and also remove any potential physician bias. Currently, there is no patient-derived myelopathy survey with the widespread acceptance of the mJOA.

Methods:

The P-mJOA was created by very slightly modifying the verbiage of the mJOA to make it possible for a patient to complete the instrument while maintaining the questionnaire’s core structure. A total of 100 consecutive consenting patients with cervical myelopathy were enrolled. After the patient completed the P-mJOA, the mJOA was scored by a physician blinded to the P-mJOA result.

Results:

The P-mJOA and the mJOA had identical mean scores of 14.7 (mean difference±SD: 0.0±1.5; P=0.89). Several measures of reliability demonstrated agreement between the 2 surveys, including strong agreement with the intraclass correlation coefficient and Spearman ρ (both 0.83) and moderate to substantial agreement with weighted κ values (0.55 to 0.66). In addition, 67% of patients preferred to fill out the P-mJOA themselves, suggesting low patient burden.

Conclusions:

The P-mJOA provided identical mean scores to the mJOA in assessing myelopathy with moderate to strong agreement. Comprised of the same 4 questions as the mJOA but slightly reworded for patient comprehension, the P-mJOA also demonstrated low patient burden in completing the survey. We believe the P-mJOA is a promising tool in cervical myelopathy research with the benefits of a patient-derived outcome measure and low patient burden.

Level of Evidence:

Level II.
The Risks of Hepatitis C in Association With Cervical Spinal Surgery
Authors: Lavian Joshua D. , Murray Daniel P. , Hollern Douglas A. , Bloom Lee , Shah Neil V. , Gewolb Daniel , Segreto Frank A. , Powell Shahla , Messina James C. , Naziri Qais , Yoshihara Hiroyuki , Paulino Carl B. , Diebo Bassel G.
Published: March 2018

Study Design:

Retrospective review.

Objective:

To investigate rates of in-hospital postsurgical complications among hepatitis C-infected patients after cervical spinal surgery in comparison with uninfected patients and determine independent risk factors.

Summary of Background Data:

Studying hepatitis C virus (HCV) as a possible risk factor for cervical spine postoperative complications is prudent, given the high prevalence of cervical spondylosis and HCV in older patients. Spine literature is limited with respect to the impact of chronic HCV upon complications after surgery.

Materials and Methods:

Patients who underwent cervical spine surgery for cervical radiculopathy (CR) or cervical myelopathy (CM) from 2005 to 2013 were retrospectively reviewed using the Nationwide Inpatient Sample database. Patients were divided into CR and CM groups, with comparative subgroup analysis of HCV and no-HCV patients. Univariate analysis compared demographics and complications. Binary logistic stepwise regression modeling identified any independent outcome predictors (covariates: age, sex, Deyo score, and surgical approach).

Results:

In total, 227,310 patients (HCV: n=2542; no-HCV: n=224,764) were included. From 2005 to 2013, HCV infection prevalence among all cervical spinal fusion cases increased from 0.8% to 1.2%. HCV patients were more likely to be African American or Hispanic and have Medicare and/or Medicaid (all P<0.001). Overall complication rates among HCV patients with CR or CM increased, specifically related to device (CR: 3.1% vs. 1.9%; CM: 2.9% vs. 1.3%), hematoma/seroma (CR: 1.1% vs. 0.4%; CM: 1.8% vs. 0.8%), and sepsis (CR: 0.4% vs. 0.1%; CM: 1.1% vs. 0.5%) (all P≤0.001). Among CR and CM patients, HCV significantly predicted increased complication rates [odds ratio (OR): 1.268; OR: 1.194], hospital stay (OR: 1.738; OR: 1.861), and hospital charges (OR: 1.516; OR: 1.732; all P≤0.044).

Conclusions:

HCV patients undergoing cervical spinal surgery were found to have increased risks of postoperative complications and increased risk associated with surgical approach. These findings should augment preoperative risk stratification and counseling for HCV patients and their spine surgeons.

Level of Evidence:

Level III.
Cervical Total Disk Arthroplasty
Authors: Roberts Timothy T. , Filler Ryan J. , Savage Jason W. , Benzel Edward C.
Published: March 2018

In the United States, cervical total disk arthroplasty (TDA) is US Federal Drug Administration (FDA) approved for use in both 1 and 2-level constructions for cervical disk disease resulting in myelopathy and/or radiculopathy. TDA designs vary in form, function, material composition, and even performance in vivo. However, the therapeutic goals are the same: to remove the painful degenerative/damaged elements of the intervertebral discoligamenous joint complex, to preserve or restore the natural range of spinal motion, and to mitigate stresses on adjacent spinal segments, thereby theoretically limiting adjacent segment disease (ASDis). Cervical vertebrae exhibit complex, coupled motions that can be difficult to artificially replicate. Commonly available TDA designs include ball-and-socket rotation-only prostheses, ball-and-trough rotation and anterior-posterior translational prostheses, as well as unconstrained elastomeric disks that can rotate and translate freely in all directions. Each design has its respective advantages and disadvantages. At this time, available clinical evidence does not favor 1 design philosophy over another. The superiority of cervical TDA over the gold-standard anterior cervical discectomy and fusion is a subject of great controversy. Although most studies agree that cervical TDA is at least as effective as anterior cervical discectomy and fusion at reducing or eliminating preoperative pain and neurological symptoms, the clinical benefits of motion preservation— that is, reduced incidence of ASDis—are far less clear. Several short-to-mid-term studies suggest that disk arthroplasty reduces the radiographic incidence of adjacent segment degeneration; however, the degree to which this is clinically significant is disputed. At this time, TDA has not been clearly demonstrated to reduce symptomatic ASDis.
Strategies for the Prevention and Treatment of Surgical Site Infection in the Lumbar Spine
Authors: Butler Joseph S. , Wagner Scott C. , Morrissey Patrick B. , Kaye Ian D. , Sebastian Arjun S. , Schroeder Gregory D. , Radcliff Kristen , Vaccaro Alexander R.
Published: March 2018

Surgical site infection (SSI) following spine surgery can be devastating for both the patient and the surgeon. It leads to significant morbidity and associated health care costs, from readmissions, reoperations, and subsequent poor clinical outcomes. Complications associated with SSI following spine surgery include pseudarthrosis, neurological deterioration, sepsis, and death. Its management can be very challenging. The diagnosis of SSI involves the interpretation of combined clinical, laboratory, and occasionally radiologic findings. Most infections can be treated with an appropriate course of antibiotics and bracing if required. Surgical intervention is usually reserved for infections resistant to medical management, the need for open biopsy/culture, evolving spinal instability or deformity, and neurologic deficit or deterioration. A thorough knowledge of associated risk factors is required and patients should be stratified for risk preoperatively. The multifaceted approach of risk stratification, early diagnosis and effective treatment, is essential for successful prevention and effective treatment and crucial for a satisfactory outcome.
Using a Patient-Centered Approach to Identify Symptom Clusters Among Adolescents With Cancer
Authors: Wu Wei-Wen , Lin Kuan-Chia , Liang Shu-Yuan , Jou Shiann-Tarng
Published: March 2018

Background

Prior studies identifying symptom clusters used a symptom-centered approach to demonstrate the relationship among symptoms. Latent profile analysis (LPA) is a patient-centered approach that classifies individuals from a heterogeneous population into homogeneous subgroups, helping prioritize interventions to focus on clusters with the most severe symptom burden.

Objective

The aim of this study was to use LPA to determine the best-fit models and to identify phenotypes of severe symptom distress profiles for adolescents with cancer who are undergoing treatment and in survivorship.

Methods

We used estimated means generated by the LPA to predict the probability of an individual symptom occurring across on- and off-treatment groups for 200 adolescents with cancer.

Results

The 3-profile solution was considered the best fit to the data for both on- and off-treatment groups. Adolescents on treatment and classified into the severe profile were most likely to report distress in appetite, fatigue, appearance, nausea, and concentration. Adolescents off treatment and classified into the severe profile were most likely to report distress in fatigue, pain frequency, and concentration.

Conclusions

Latent profile analysis provided a cluster methodology that uncovered hidden profiles from observed symptoms. This made it possible to directly compare the phenotypes of severe profiles between different treatment statuses.

Implications for Practice

The co-occurring 13-item Symptom Distress Scale symptoms found in the severe symptom distress profiles could be used as items in a prespecified severe symptom distress cluster, helping evaluate a patient's risk of developing varying degrees of symptom distress.
Incident Reporting to Improve Patient Safety
Authors: O'Connell Karen J. , Shaw Kathy N. , Ruddy Richard M. , Mahajan Prashant V. , Lichenstein Richard , Olsen Cody S. , Funai Tomohiko , Blumberg Stephen , Chamberlain James M.
Published: March 2018

Objective

Medical errors threaten patient safety, especially in the pediatric emergency department (ED) where overcrowding, multiple handoffs, and workflow interruptions are common. Errors related to process variance involve situations that are not consistent with standard ED operations or routine patient care.

Setting/Participants

We performed a planned subanalysis of the Pediatric Emergency Care Applied Research Network incident reporting data classified as process variance events. Confidential deidentified incident reports (IRs) were collected and classified by 2 independent investigators. Events categorized as process variance were then subtyped for severity and contributing factors. Data were analyzed using descriptive statistics.

Outcome Measures

The study intention was to describe and measure reported medical errors related to process variance in 17 EDs in the Pediatric Emergency Care Applied Research Network from 2007 to 2008.

Results

Between July 2007 and June 2008, 2906 eligible reports were reviewed. Process variance events were identified in 15.4% (447/2906). The majority were related to patient flow (35.4%), handoff communication (17.2%), and patient identification errors (15.9%). Most staff involved included nurses (47.9%) and physicians (28%); trainees were infrequently reported. The majority of events did not result in harm (65.7%); 17.9% (80/447) of cases were classified as unsafe conditions but did not reach the patient. Temporary harm requiring further treatment or hospitalization was reported in 5.6% (25/447). No events resulted in permanent harm, near death, or death. Contributing factors included human factors (92.1%), in particular handoff communication, interpersonal skills, and compliance with established procedures, and system-level errors (18.1%), including unclear or unavailable policies and inadequate staffing levels.

Conclusions

Although process variance events accounted for approximately 1 in 6 reported safety events, very few led to patient harm. Because human and system-level factors contributed to most of these events, our data provide an insight into potential areas for further investigation and improvements to mitigate errors in the ED setting.
Posttraumatic High-Flow Nonischemic Priapism
Authors: Nalbant Ismail , Tuygun Can , Gücük Adnan , Conkbayir Isik , Oztürk Ufuk , Yilmaz Muhammed Sahin , İmamoglu Muhammed Abdurrahim
Published: March 2018

Priapism is an uncommon disorder, and nonischemic priapism is seen less frequently in children, generally after trauma. Although it seems to be an advantage that urgent intervention is not required because of no cavernous ischemia, it is likely to be misdiagnosed because of the asymptomatic potential. We aimed to present a case of posttraumatic nonischemic priapism.
Conjugated Hyperbilirubinemia in the Neonate and Young Infant
Authors: Weiss Anna K. , Vora Parag V.
Published: March 2018

Cholestatic jaundice in the first few weeks of life may herald potentially life-threatening pathology. It is therefore incumbent upon the pediatric practitioner to have a high index of suspicion for severe disease when investigating jaundice in a young infant. This article outlines the epidemiology, pathophysiology, differential diagnosis, and diagnostic workup for both the most common and the most severe causes of cholestasis in the neonatal period.
Wound Surface Area as a Risk Factor for Flap Complications among Patients with Open Fractures
Authors: Shea Phelan , O’Hara Nathan N. , Sprague Sheila A. , Bhandari Mohit , Petrisor Brad A. , Jeray Kyle J. , Zhan Min , Slobogean Gerard P. , Pensy Raymond A.
Published: March 2018

Background:

Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer.

Methods:

This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders.

Results:

Seventeen percent of the 112 patients required a flap-related reoperation. A wound size greater than 200 cm2 was not associated with reoperation in an unadjusted model (p = 0.64) or adjusting for Gustilo type (p = 0.70). The sample had an overall wound complication rate of 47.3 percent. Patients with a wound size of greater than 200 cm2 were three times more likely to experience wound complications (OR, 3.05; 95 percent CI, 1.08 to 8.62; p = 0.04) when adjusting for moderate to severe wound contamination and wound closure in the operating room.

Conclusion:

The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft-tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
Accurate assembly of minority viral haplotypes from next-generation sequencing through efficient noise reduction
Authors: Knyazev Sergey , Tsyvina Viachaslau , Shankar Anupama , Melnyk Andrew , Artyomenko Alexander , Malygina Tatiana , Porozov Yuri B. , Campbell Ellsworth M. , Mangul Serghei , Switzer William M. , Skums Pavel , Zelikovsky Alex
Published: March 2018

Rapidly evolving RNA viruses continuously produce minority haplotypes that can become dominant if they are drug-resistant or can better evade the immune system. Therefore, early detection and identification of minority viral haplotypes may help to promptly adjust the patient's treatment plan preventing potential disease complications. Minority haplotypes can be identified using next-generation sequencing (NGS), but sequencing noise hinders accurate identification. The elimination of sequencing noise is a non-trivial task that still remains open. Here we propose CliqueSNV based on extracting pairs of statistically linked mutations from noisy reads. This effectively reduces sequencing noise and enables identifying minority haplotypes with the frequency below the sequencing error rate. We comparatively assess the performance of CliqueSNV using an in vitro mixture of nine haplotypes that were derived from the mutation profile of an existing HIV patient. We show that CliqueSNV can accurately assemble viral haplotypes with frequencies as low as 0.1% and maintains consistent performance across short and long bases sequencing platforms.
The Structural Basis of IKs Ion-Channel Activation: Mechanistic Insights from Molecular Simulations
Authors: Ramasubramanian Smiruthi , Rudy Yoram
Published: March 2018

Relating ion-channel (iCh) structural dynamics to physiological function remains a challenge. Current experimental and computational techniques have limited ability to explore this relationship in atomistic detail over physiological timescales. A framework associating iCh structure to function is necessary for elucidating normal and disease mechanisms. We formulated a modeling schema that overcomes the limitations of current methods through applications of Artificial Intelligence Machine Learning (ML). Using this approach, we studied molecular processes that underlie human IKs voltage mediated gating. IKs malfunction underlies many debilitating and life-threatening diseases. Molecular components of IKs that underlie its electrophysiological function include KCNQ1 (pore forming tetramer) and KCNE1 (auxiliary subunit). Simulations, using the IKs structure-function model, reproduced experimentally recorded saturation of gating charge displacement at positive membrane voltages, two-step voltage sensor (VS) movement shown by fluorescence, iCh gating statistics, and current-voltage (I-V) relationship. New mechanistic insights include - (1) pore energy profile determines iCh subconductance (SC), (2) entire protein structure, not limited to the pore, contributes to pore energy and channel SC, (3) interactions with KCNE1 result in two distinct VS movements, causing gating charge saturation at positive membrane voltages and current activation delay, and (4) flexible coupling between VS and pore permits pore opening at lower VS positions, resulting in sequential gating. The new modeling approach is applicable to atomistic scale studies of other proteins on timescales of physiological function.