bluuebunny/crossref_metadata_2025 huggingface dataset:
Gene and Protein Expression Pattern of Cytokines in Disc Herniation Depend on Time of Symptoms
Authors: Bozsodi Arpad , Lazary Aron , Varga Peter
Published: May 2015

Introduction

Sciatica caused by lumbar disc herniation is a frequent clinical condition. The development of the radicular pain is explained by mechanical and biological (inflammatory) factors. Spontaneous pain relief in the first weeks is not uncommon, but a significant part of the patients have got persistent (and/or recurrent) disabling pain requiring surgical intervention. The biological background of the alteration in clinical symptoms is still unknown.

Objective

The aim of this study was to investigate the protein and the mRNA expression of different cytokines in human herniated disc tissues.

Methods

A total of 24 patients who underwent lumbar microdiscectomy were included into the study. Sequestered disc tissue was collected during the surgery and analyzed using a Human Cytokine Array Panel (R&D Systems) and TaqMan Gene Expression Assays to determine the protein ( n = 12) and mRNA expression ( n = 12) of different cytokines. Cytokine expression levels were analyzed in relation to the duration of the symptoms (acute: less than 6 weeks, chronic: more than 3 months). Nonparametric statistical tests were used to determine significant differences in protein/mRNA expression. A minimum of 1.5-fold difference and p < 0.05 was considered significant.

Results

IL-6, IL-8, and GRO-a were expressed significantly higher in acute disc herniations either in protein and mRNA levels. RANTES, IFN-g, and G-CSF proteins were found to be increased in chronic herniations and higher expression of RANTES and IFN-g were confirmed at mRNA level.

Conclusions

Cytokine profile in herniated disc tissue changes with time. It can be associated with an altered inflammation process and the consequent change of the clinical picture. New biological approach selectively modulating the inflammatory response can be one of the future developments in the nonsurgical management of intervertebral disc herniation.
Effect of Postoperative Surgical Drain Concentrations of Vancomycin on Human Osteoblast Activity
Authors: Sinclair Sarina , Lyman Kade S. , Annis Prokopis , Spiker Ryan , Brodke Darrel S. , Lawrence Brandon D.
Published: May 2015

Introduction

The addition of powdered vancomycin inside the surgical wound site has become a common practice in recent years to decrease the incidence of postoperative orthopedic infections. The effectiveness of vancomycin against bone infections has been well documented and it is commonly delivered locally during a variety of surgeries. While several studies have been conducted to review the effect of using this drug at the surgical site on infections, few studies have examined its impact on local bone cells at the cellular level. A wide range of antibiotic concentrations has been used within cell studies. The purpose of this pilot study was to examine the effect of vancomycin on osteoblasts at a concentration based on surgical drain samples following spinal fusion procedures using established in vitro techniques.

Materials and Methods

Postanesthesia care unit (PACU) drain samples were collected from 37 patients following spinal fusion procedures where powdered vancomycin was placed inside the surgical site. Vancomycin levels in the drain samples were measured using the inpatient laboratory and the hospital's standard operating procedures. A human osteoblast cell line was used to model osteoblasts in vitro. Cells were seeded in triplicate on tissue culture plates and fed the recommended base medium for 48 hours. After 48 hours (day 2), baseline data were collected and cell medium was changed to include vancomycin at a concentration of 0 or 1,000 µg/mL based on the PACU drain level results. After 3 days of exposure to vancomycin (day 5), cells were rinsed and cultured in plain base medium for three additional days (day 8). Cellular metabolic and osteogenic activity and was evaluated using well-established in vitro assays.

Results

The average vancomycin level present in the PACU drain samples was determined to be 1,253.67 µg/mL (STD = 0 701). This study found that the metabolic activity of the human osteoblasts appeared to be unaffected by the exposure to vancomycin. There was no significant difference in metabolic activity observed between the cells fed 0 and 1,000 µg/mL vancomycin at any time point. The addition of vancomycin did have an effect on the osteogenic activity, based on alkaline phosphatase (ALP) expression. Cells had lower ALP levels after 3 days of vancomycin exposure at the clinically relevant level ( p = 0.05). The vancomycin group continued to express lower levels of ALP after 3 days of recovery following removal of the drug ( p = 0.02).

Conclusion

This study is one of the first to test the cellular activity of human osteoblast cells after exposure to a clinically relevant concentration of vancomycin. The results suggest that the addition of vancomycin within the surgical wound to combat infection may result in a local antibiotic concentration level that can have an adverse impact on the cellular activity of local bone cells.
Clinical Impact Correlation of a Delphi-Based Proximal Junctional Kyphosis Severity Scale and HRQOL
Authors: Lau Darryl , Funao Haruki , Clark Aaron , Smith Justin , Bess Shay , Shaffrey Christopher , Schwab Frank , Lafage Virginie , Deviren Vedat , Hart Robert , Kebaish Khaled , Ames Christopher
Published: May 2015

Introduction

Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are adverse outcomes following adult spinal surgery (ASD) surgery. There is a lack of consensus regarding which patients (pts) require revision surgery. The Hart ISSG PJK severity scale correlates with the need for revision surgery. This study evaluates the Hart International Spine Study Group (ISSG) PJK severity scale and health-related quality of life (HRQOL) measures in pts with PJK.

Patients and Methods

All ASD pts with PJK and/or PJF who eventually underwent revision surgery were identified from two large academic medical centers. Pts were retrospectively assigned scores based on the Hart ISSG PJK severity scale: neurological status, focal pain, instrumentation problem, kyphosis severity/PLC integrity, UIV/UIV + 1 fracture, and level of UIV. Scores range from 0 to 15. Pre-PJK revision HRQOL measures included: Oswestry disability index (ODI), short-form 36 (SF-36), and Scoliosis Research Society questionnaire (SRS30). Scores were subcategorized into 0 to 2, 3 to 5, 6 to 8, 9 to 11, and 12 to 15, and differences in HRQOL outcomes were determined with linear regression. Correlation was assessed with a Pearson correlation coefficient.

Results

A total of 54 cases were included, out of which 31.5% were male, and the mean age was 64.9 years. The Hart ISSG PJK severity scale scores ranged from 4 to 15, with the median being 8. PJK/PJF occurred in the upper thoracic spine in 24.1% of the cases. 54.8% had fractures and 77.8% had instrumentation issues. Overall, 55.6% had neurological deficits, with 16.7% having weakness and/or myelopathy. All pts had preoperative pain (median VAS 9/10). While statistical significance on linear regression was not seen, there were obvious trends that correlated with the Hart ISSG PJK severity scale. Higher Hart ISSG PJK severity scale scores were associated with higher ODI ( p = 0.283, r = 0.350), lower SRS30 function ( p = 0.821, r = −0.323), and lower SRS mental ( p = 0.646, r = −0.592).

Conclusion

The Hart ISSG PJK severity scale has been shown to be predictive in the decision making of when patients require revision surgery. Based on the current study, it may also correlate with functional outcomes, specifically ODI and SRS30 components.
Better Patient Reported Outcome Measures: The NDI-8 and NDI-5 Assessed in 714 Patients
Authors: Brodke Darrel S. , Lawrence Brandon D. , Spiker Ryan , Neese Ashley , Hung Man
Published: May 2015

Introduction

Patient reported outcome measures (PROM) are now a mandatory part of the assessment of clinical results in comparative effectiveness research. The 10-item neck disability index (NDI) is the most commonly used disease specific PROM in studies of patients with cervical spinal disorders. It is well known, easy to administer and score (10 items—answers added together and multiplied by 2, to provide a score). Recent studies have shown significant deficiencies in the psychometrics of the standard NDI, including poor coverage (large floor effect), multivariance, and most concerning, extremely poor raw score to measure correlation—which means using the additive score is concerning, particularly with standard statistical testing. By excluding two questions, or five questions, an NDI-8 and NDI-5 can be constructed with much-improved psychometrics and decreased clinical burden, yet this has not been evaluated in a formal spine medical practice and is not used in clinical research. The goal of this study is to clarify the psychometric properties of the standard NDI-10, in comparison with the new NDI-8 and NDI-5, in search of an improved PROM for neck patients.

Material and Methods

Patient demographics and the NDI were collected on 714 patients with neck ± upper extremity pain. Using Rasch analysis, the NDI-10, -8, and -5 were assessed for psychometric properties, including overall item fit, variance, coverage, and raw score to measure correlation.

Results

Data were assessed from 714 consecutive patients (53% males, 86% whites) with average age being 55 years, seen at a university-based spine center. The NDI-5 and NDI-8 were highly correlated at 0.95, had excellent fit, similar to the NDI-10, and less variance than the NDI-10. Like the NDI-10, coverage for the NDI-8 and -5 were poor, with very high floor effects of 39.36 and 39.22% (compared with 35.5% in the NDI-10). Ceiling effects were acceptable for both measures. Most importantly, the raw score to measure correlation of the NDI-8 and NDI-5 are very high at 0.94 each, while the NDI-10 correlation was poor, at 0.02.

Conclusion

While the standard 10-item NDI is of questioned value, the NDI-5 and NDI-8 show improved psychometrics, in particular the raw score to measure correlation. With fewer items the NDI-5 decreases patient and clinic burden without significantly effecting coverage, and is therefore the preferred measure. Future work should be concerned with improving coverage with the addition of items at the extremes of disability, particularly low disability items.
Incidence, Impact, and Risk Factors of Adverse Events in Thoracic and Lumbar Spine Fractures: An Ambispective Cohort Analysis of 390 Patients
Authors: Glennie R. Andrew , Ailon Tamir , Dea Nic , Batke Juliet , Street John
Published: May 2015

Background Context

Adverse events (AEs) in thoracic and lumbar spine fractures are common but little is known about the type of AEs that are specific to this population. Further, very little is known about the incidence and clinical impact of these AEs on patients in the presence of traumatic spinal cord injury (TSCI) and whether they are treated operatively or nonoperatively.

Purpose

To determine the incidence of AEs in patients with thoracic or lumbar spine fractures treated both operatively and nonoperatively and determine their impact on length of stay (LOS). Secondly, determine the difference in incidence of AEs in both neurologically intact and compromised patients.

Study Design/Setting

Ambispective cohort study at a quaternary referral center.

Patient Sample

Patients admitted at our institution with thoracic or lumbar fractures from January 2009 to December 2013 were identified. Patients with full spine adverse events severity system data (SAVES) were included.

Outcome Measures

Number and type of AEs collected from SAVES were assessed. Impact of AE on acute LOS was also determined.

Materials and Methods

No funding was received or used in this study. Data on intra-, pre-, and postoperative AEs were prospectively collected using the SAVES data collection. Logistic regression was used to model the likelihood of experiencing at least one AE based on patient characteristics. The impact of the total number of AEs experienced by a patient and that of each of the most common AEs on LOS was determined using Poisson regression.

Results

A total of 390 patients were included in final analysis. Total, 276 patients (70.8%) were treated operatively. Overall 140 patients (36%) experienced neurological deficit as a result of their initial injury. AEs occurred in operatively treated patients 56% of the time and only 13% of the time in the nonoperative group. The presence of neurological deficit increased the risk of AEs especially in high thoracic (T1–T6) trauma increasing the odds of having an adverse event by 12.1 ( p < 0.0001). The most common AEs were urinary tract infections (UTIs) (19.7%), neuropathic pain (12.3%), pneumonias (11.8%), delirium (10.5%), and ileus (6.2%). LOS increased significantly with pneumonia ( p < 0.0001) and delirium ( p = 0.0001).

Conclusions

The presence of neurological injury and the need for operative fixation of thoracic or lumbar injuries leads to a greater risk of adverse events. Only pneumonia and delirium consistently increase LOS.
A 5 and 10-Year Follow-Up on Intradiscal Ozone Injection for Disc Herniation
Authors: Buric Josip , Rigobello Luca , Hooper David
Published: May 2015

Introduction

Disc herniation is the most common cause for spinal surgery and many clinicians employ epidural steroid injections with limited success. Intradiscal injection of ozone gas has been used as an alternative to epidural steroids and surgical discectomy. Early results are positive but long-term data are limited.

Patients and Methods

A total of 108 patients with confirmed contiguous disc herniation were treated with intradiscal injection of ozone in 2002 to 2003. Around 107 patients were available for telephone follow-up at 5 years; 60 patients were available for a similar telephone follow-up at 10 years. Patients were asked to describe their clinical outcome since the injection. Surgical events were documented. MRI images were reviewed to assess the reduction in disc herniation at 6 months.

Results

MRI films demonstrated a consistent reduction in the size of the disc herniation. A total of 79% of patients had a reduction in herniation volume and the average reduction was 56%. There were 19 patients that ultimately had surgery and 12 of them occurred in the first 6 months after injection. One of these 12 was due to surgery at another level. Two surgeries involved an interspinous spacer indicated by stenosis or DDD. All other surgeries were discectomies. Of the patients that avoided surgery 82% were improved at 5 years and 88% were improved at 10 years. Other than subsequent surgeries, no spine-related complications were experienced.

Conclusion

We conclude that ozone is safe and effective in approximately 75% of patients with disc herniation and the benefit is maintained through 10 years. This is a retrospective review and randomized trials are needed. Clinical Relevance: Intradiscal ozone injection may enable patients to address their pain without multiple epidural injections and surgery. The benefit of ozone is durable and does not preclude future surgical options. The risk reward profile for this treatment is favorable.
Results of Anterior Spinal Fusion in Spondylolisthesis with or without Interbody Fusion Device (CAGE)
Authors: Kumar Manoj , Dhanraj Prashanth , Shivanna Deepak
Published: May 2015

Introduction

Lumbar spine spondylolisthesis (LSS) has been surgically managed by interbody fusion using pedicle screw and rod fixation. Many surgeons advocate the use of an interbody fusion device (cage) to assist in fusion and increase the stability of the construct.

Objective

The aim of the study is to assess and compare the functional and radiological outcome of patients undergoing surgical fixation with or without interbody cage.

Materials and Methods

We performed a prospective nonrandomized study in adults aged 28 to 68 years with LSS. Enrolment was done between 2010 and 2012 at the Department of Orthopaedics and Department of Neurosurgery, Bangalore Medical College and Research Institute, Bangalore, India. Clinical follow-up at 6 weeks, 3, 6, and 12 months intervals regarding pain, fusion (AP, lateral and flexion—extension radiographs) and the functional outcome was evaluated by visual analog scale (VAS) pain rating, and Oswestry disability index (ODI), SF-36, modified Benzel Japanese Orthopaedic Association score.

Results

A total of 20 patients with LSS were enrolled. The mean age of patients at the time of surgery was 46.85 years (± 21.15). Mean follow-up duration 14 months (range, 12–24 months). Earliest union seen at 6 months follow-up in 30% of bone graft (BG) and 50% of cage group (CG). At end of 1 year 90% of BG and 100% of CG group showed radiological union. Average fusion rate were 10 and 8.5 months in BG and CG, respectively. Radicular improvements were seen in 70 and 90% of BG and CG, respectively. Functional outcome was significantly better at 3, 6 months, and 1 year in both the groups ( p < 0.001). Complications were seen in 60 and 20% cases of BG and CG, respectively. Patient satisfaction was 80 and 90% in BG and CG, respectively. All patients returned to preinjury status except one in BG group.

Conclusion

Addition of an interbody fusion device (cage) helps in greater stability, lower implant failure, higher fusion rate, and better functional outcome in surgically treated patient of lumbar Spondylolisthesis at follow-up, however no significant difference seen between two groups ( p < 0.3, 0.5, and 0.26).
Fusion Rate Difference between Sublaminar Wire and Screw Fixation in Type 2 Odontoid Traumatic Fractures
Authors: El Fiki Ahmed , Alaa Mohamed
Published: May 2015

Introduction

Traumatic odontoid fracture type 2 is not uncommon in cervical spine trauma. Different techniques of fusion are usually applied depending on many factors with the aim of acquiring bony fusion at C1–2 segment.

Material and Methods

Twenty patient of traumatic type 2 odontoid fractures were operated in our institute from December 2010 till march 2014. Sublaminar wiring was done in 10 cases and the rest were operated by C1–2 screw fixation. Clinical condition and bony fusion were evaluated at 3 and 6 months.

Results

Fourteen patients were with improving or stationary clinical state plus good fusion signs. While six patients developed either clinical deterioration or radiological failure of fusion. Among these six patients, four cases were fused by sublaminar wire and two patients were operated by screw and rod fixation. All cases with fusion failure were re operated again.

Conclusion

Screw system fixation for traumatic odontoid fracture type 2 take upper hand than sublaminar wiring regarding bony fusion and clinical condition but longer time follow-up and larger series are needed.
Civilian Gunshot Wound to the Spine: 87 Cases
Authors: Reis Marco Tulio , Zanini Rocha Guilherme , Malheiros José Augusto , Malheiros José Augusto , Gonçalves Diogo , Alves Belo Joao Tiago
Published: May 2015

Introduction

Penetrating spinal cord injury (SCI) by gunshot is relatively common in Brazil, and the literature available is scarce. This study aims to report the experience of a level I trauma center, exploring epidemiological data, clinical features, treatment, and outcomes of victims of gunshot wound to the spine.

Material and Methods

A retrospective study was performed and included all victims of gunshot wound to the spine at João XXIII Hospital from April 2011 to March 2014 (36-month period). The epidemiological profile, topography of the injury, neurological status, treatment, and in-hospital morbidity and mortality are reported. Statistical analysis was performed on Epi Info 7.0 with Fisher exact test. Correlation with the current literature was conducted.

Results

A total of 1,088 patients were admitted with blunt and penetrating spinal injury in the 36 months evaluated. A total of 87 cases were gunshot wounds (8% of the 1,088 cases). A majority of the patients were men (93.1%) and young (76.1% are under 30 years). Topographically, 48% affected the cervical spine, followed by 32% in the thoracic spine. The motor status had a dichotomous presentation, with complete neurological deficit (ASIA A, 58.6%) and no neurological deficit (ASIA E, 27.6%). Incomplete neurological deficits represented a small number of cases. The vertebral instability, defined as the presence of acute or delayed deformity, was unusual (three cases, 3.4%). Almost 50% ( n = 44) of the patients had isolated spinal trauma and the remaining presented with associated traumas. Thoracic trauma was the most prevalent, followed by abdominal and facial injury. Only 10 patients (11.5%) required surgical treatment: laminectomy with bullet removal in 7 cases and instrumented fixation in the remaining 3. Infection was present in five cases: four postoperative infections and one in a patient with nonoperative management. Surgical treatment was associated with a 50-fold increase risk of infection ( p = 0.0004). CSF fistula was observed in only one case after surgical treatment and because of the rarity of the event, a statistical analysis could not be performed. Overall mortality was 14.9% (13 patients) and was more common in patients with cervical lesions (10 patients). Associated trauma was present in 70% of the patients who died, but did not acquire statistical significance ( p = 0.1) with mortality risk.

Conclusion

Gunshot wound to the spine is common in our population, affecting especially young men, associated with neurological deficit in two-thirds of the patients. Instability is a rare event in these patients (3.4%) and surgical treatment was associated with a significant risk of infection.
Efficacy and Safety of Riluzole in Acute Spinal Cord Injury: Rationale and Design of AOSpine Phase III Multicenter Double Blinded Randomized Controlled Trial
Authors: Fehlings Michael , Kopjar Branko , Grossman Robert , Wilson Jefferson
Published: May 2015

Introduction

There is convincing evidence from the preclinical realm that the pharmacologic agent riluzole attenuates certain aspects of the secondary injury cascade leading to diminished neurological tissue destruction in animal spinal cord injury (SCI) models. The safety and pharmacokinetic profile of riluzole has been studied in a multicenter pilot study in 36 patients. Efficacy of riluzole in acute human SCI has not been established.

Material and Methods

This phase II/III multicenter double-blind randomized controlled trial will involve up to 35 sites. A total of 351 patients with acute C4–C8 SCI and ASIA Impairment Grade A, B, or C will be randomized 1:1 to riluzole and placebo. Primary outcome is the change in ASIA Total Motor Score between baseline and 180 days. Other measures include ASIA Upper Extremity Motor Score; ASIA Lower Extremity Motor Score; ASIA Sensory Score; ASIA Grade; Spinal Cord Independence Measure; SF-36v2; EQ-5D, and GRASSP. The statistical design utilizes two-stage sequential adaptive trial. A sample size of 316 patients (158 in each arm) will have 90% power to detect 9 points difference in the ASIA Motor Score at one-sided α = 0.025. To account for losses to follow-up of up to 10%, the study will enroll 351 patients.

Results

Within the phase 1 study, a matched cohort analysis was performed comparing complication rates and neurological outcomes between patients who received riluzole and non-riluzole-treated patients from a prospective SCI registry. Although the groups experienced similar rates of complications, riluzole-treated cervical SCI patients experienced an additional 15.5 points in AMS recovery at 90 days after injury as compared with non-riluzole-treated patients. Although the phase I study was underpowered to investigate the efficacy, the current phase II/III study is poised to definitively address this question. Patient enrollment for this trial began on October 1, 2013.

Conclusion

This is a pivotal study of riluzole in acute SCI.
Prognostic Significance of T Gene SNP s2305089 in Individuals with Spinal Column Chordoma
Authors: Varga Peter , Lo Sheng-Fu Larry , Puvanesarajah Varun , Fisher Charles , Rhines Laurence , Boriani Stefano , Lazary Aron , Wang Wei-Lien , Gambarotti Marco , Germscheid Niccole , Yip Stephen , Gokaslan Ziya , Bettegowda Chetan
Published: May 2015

Introduction

Chordoma is the most common primary spinal tumor with a median survival of 6 to 7 years, with high recurrence rates. Radical surgical resection remains the mainstay of treatment, with radiation often utilized to enhance local disease control. There are no approved chemotherapeutic agents for chordomas. Brachyury, coded by the T gene, has been implicated in the pathogenesis of chordomas and is highly expressed in most of these tumors. Recently, Pillay et al found that the single nucleotide polymorphism (SNP) rs2305089 in the T gene was associated with chordoma development. The variant A allele at rs2305089 results in a p.Gy177Asp change in Brachyury. Given the rarity of this disease, with an incidence of 0.08 per 100,000 individuals, determining the clinical significance of this SNP has been challenging.

Materials and Methods

This study included both prospective and retrospective data collected from five high-volume centers within Europe and North America. Data were collected between 1990 and 2013, through the AOSpine Knowledge Forum Tumor (AOSKFT) primary tumor database. Institutional approval was obtained before studying the tumor samples.

Results

In the overall cohort of 109 patients, survival at last follow-up (mean follow-up: 1,330 ± 1,475 days) was 69.7%. Seven (6.4%) patients had the GG genotype, while 66 (60.6%) and 36 (33.3%) patients had the AA and GA genotypes, respectively. In the 102 cases with the A variant, 75 (73.5%) were alive at the last follow-up compared with only 1 (14.3%) of the 7 patients with the GG genotype. Local recurrence rates were similar between the populations with the A variant and those without, with 40 (39.2%) patients with the A variant experiencing local recurrence compared with 2 (33.3%) patients without the A variant.

Conclusions

There is a trend toward worse survival in individuals with the GG genotype than with the AA or GA genotypes. To our knowledge, this is the first time the rs2305089 SNP has been considered in the prognosis and survival of individuals with chordoma.
The Influence of a Performance Improvement Program on MRI in Spinal Trauma
Authors: Kraus Michael , Mueller Marguerite , Schmitz Bernd , Gebhard Florian , Cunningham Michael
Published: May 2015

Introduction

Performance improvement (PI) programs are an educational tool to analyze clinical parameters taking the behavior and attitude of clinicians into account.1 The impact of this tool is not fully explored in orthopedic and trauma surgery. This educational research aimed to deliver an effective PI program to orthopedic trauma surgeons, neurosurgeons, and radiologists to improve communication and the use of MRI in spinal trauma.

Materials and Methods

Following a worldwide web session on MRI in spinal injuries to identify the clinical need for an educational intervention, a three-step PI process was defined and implemented over a 6-month period in a hospital department. Opportunities for improvement were identified by applying a 10-item quality checklist to 26 cases. Then a focused educational intervention was delivered to address identified gaps, and a set of 22 post-education cases was compared.

Results

A total of 26 cases collected before the educational intervention showed several areas for potential improvement. In only 5 of the 26 cases, a specific trauma mechanism or a possible inflammatory or malignant illness was mentioned by the surgeon, where such information may lead to a change in MRI sequence planning. In 23 cases, the radiologist did not believe that the communication led to a change of plan, although sequences other than usual were performed. The educational intervention outlined the data and suggested actions. Comparing the information transfer of the pre- and postinterventional data there was a significant improvement following the intervention ( p = 0.0013). Following the intervention, the communication between surgeons and radiologists significantly influenced the sequences ( p = 0.0152).

Conclusion

There are specific aspects that may be improved concerning communication between the surgeon and the radiologist. Our PI program was able to demonstrate a significant influence on the behavior and attitude of surgeons and radiologists. In the future, the impact on patient-related outcome parameters has to demonstrate the clinical influence of PI programs in the care of spine patients. References Martin C, Rüetschi U, Cunningham M. Design and implementation of performance improvement programs for orthopedic trauma surgeons. Presented at: AMEE Conference; 2013
Comparison of Intraoperative Stitched Fluoroscopic Images to Postoperative Standing Full Spine Radiographs
Authors: Sembrano Jonathan , Peterson Erica , Yson Sharon , Santos Edward Rainier , Polly David
Published: May 2015

Introduction

Spinal deformity surgery requires assessment of correction achieved intraoperatively. Long cassette X-rays have been used in the past. Recent advances include availability of 3D scanners (e.g., O-arm). These are also able to take 2D images which can be stitched together to simulate full length X-rays. The process of “stitching” can be performed quickly and may potentially save time compared with conventional X-ray film developing. This is the first study to look at correlation between stitched O-arm fluoroscopic images and postoperative standing X-rays.

Methods

Patients who underwent fusion of ≥ 3 levels for coronal/sagittal deformity and who had intraoperative stitched O-arm images were identified. The intraoperative images and postoperative full-spine X-rays were reviewed. Coronal and sagittal curves and balance were measured by and averaged between two independent observers. Correlation between intra- and postoperative parameters was tested by computation of Pearson coefficient.

Results

Between March 2011 and June 2013, 80 patients met the inclusion criteria. Mean age was 27 years (range, 6–85 years). Correlation between intraoperative stitched images and postoperative full-length films was very strong for focal curve measurements at the operative levels (major curve Cobb r = 0.90, lordosis/kyphosis across instrumented levels r = 0.74, T5–T12 kyphosis r = 0.88). However, global balance parameters and regional lordosis were found to either have poor correlation (shoulder–pelvis balance 0.41, L1–S1 lordosis 0.62) or were not measurable on the stitched images (T1–pelvic angle).

Conclusion

Intraoperative AP and lateral stitched O-arm images correlated strongly with postoperative full-spine standing X-rays for focal angular measurements, such as major curve coronal Cobb angles, instrumented level lordosis, and mid-thoracic (T5–T12) kyphosis. However, global balance parameters, such as shoulder–pelvis balance and T1–pelvic angle, cannot be reliably measured on stitched images. This may be either because of differences between prone and upright positioning, image quality, technique of stitching, or the inability to include the entire spine and pelvis in the images.
Laminoplasty versus Laminectomy and Fusion to Treat Cervical Spondylotic Myelopathy: Outcomes of the Prospective Multicenter AOSpine International CSM Study
Authors: Fehlings Michael , Kopjar Branko , Kale Shashank , Defino Helton , Barbagallo Giuseppe , Bartels Ronald , Zhou Qiang , Arnold Paul , Zileli Mehmet , Tan Gamaliel , Moraes Osmar , Yukawa Yasutsugu , Alvarado Manuel , Scerrati Massimo , Toyone Tomoaki , Tanaka Masato , Bolger Ciaran , Ibrahim Ahmed , Tetreault Lindsay
Published: May 2015

Introduction

Recent studies conducted in North America have demonstrated the benefits of surgical treatment for symptomatic CSM. However, differences in pathology, comorbidities, treatment approaches, and cultural response to treatment may affect the generalizability of these findings at the global level.

Patients and Methods

Patients receiving surgery for clinically symptomatic CSM were enrolled in a prospective multicenter, cohort study which is continuing to accrue patients at 16 sites in Europe, Asia, and North and South America. Patients included were a part of a larger ongoing prospective observational study that has enrolled 492 patients with CSM involving 16 clinical sites in Europe, Asia, and North and South America. Of those, 108 received laminectomy and fusion, and 66 received laminoplasty. The choice of surgical approach was at the discretion of the surgeon. Outcome measures were mJOA, the Nurick scale, NDI, and the SF36 PCS and MCS component scores.

Results

Average age was 60.2 years (SD 10.8), 29.8% were female. Patients treated with laminectomy and fusion had more levels operated (5.0 vs. 4.4, p < 0.01), shorter length of stay (7.7 vs. 15.7 days, p < 0.01), and less severe neurologic impairment measured by mJOA (12.6 vs. 11.2, p < 0.01). There were no differences in age, baseline NDI, SF36v2 PCS, and SF36v2 MCS. At 12-month follow-up, there were no differences in neurologic and functional outcomes for laminoplasty compared with laminectomy and fusion; mJOA (3.0 and 2.3, respectively, p = 0.15). Moreover, there were no differences in NDI (13.3 and 12.0, respectively, p = 0.71), SF-36v2 PCS (8.5 and 7.7, respectively, p = 0.66), and SF-36v2 MCS (7.9 and 6.9, respectively, p = 0.56).

Conclusion

Patients undergoing laminectomy and fusion and laminoplasty surgery for CSM show similar improvements in generic and disease-specific outcome measures allowing for baseline differences in clinical presentation between the two groups of patients. Longer-term follow-up will be required to determine whether any differences in outcome between the two forms of treatment emerge.
Change in Pelvic Sagittal Parameters with Growth in Children with Adolescent Scoliosis
Authors: Songur Murat , Choi John , Cheung Kenneth M. C.
Published: May 2015

Introduction

Commonly measured spinopelvic parameters (pelvic incidence, sacral slope, and pelvic tilt) have an effect on global sagittal balance of the spine. It was shown previously by cross-sectional studies that pelvic incidence increases with growth in children. But this change was not demonstrated in longitudinal radiological follow-up studies. In this study, we aimed to investigate the changes in spinopelvic parameters with growth in surgically treated AIS patients.

Methods

Whole body lateral radiographs eligible for spinopelvic measurements with radiological follow-up before and after skeletal maturity of AIS patients treated surgically were evaluated. First evaluations are made on preoperative radiographs of AIS patients (Risser O or 1). Second evaluations were made on postoperative radiographs taken after skeletal maturity (Risser 5). On whole body lateral radiographs pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), lumbar lordosis between L1 cranial endplate and S1 endplate (LL), and thoracic kyphosis between cranial endplate of T5 and caudal endplate of T12 (TK) were performed using Centricity DICOM software (General Electric). Measurements were made by two observers. Intra- and interobserver reliabilities were also evaluated by repeat measurements. Intra- and interobserver reliabilities for measurements were evaluated by intraclass correlation (ICC).

Results

A total of 171 surgically treated cases for AIS were reviewed. Of them, 33 cases had radiological follow-up data before and after skeletal maturity with lateral X-rays eligible for spinopelvic parameters measurement. Mean interval between evaluations was 7.49 years. Intra- and interobserver reliabilities for measurements were accepted as “good” with ICC values between 0.951 and 0.989. A significant increase in PI and SS was observed before and after skeletal maturity (46.32 ± 11.61 vs. 52.14 ± 11.69 degrees and 38.14 ± 7.57 vs. 43.19 ± 7.46 degrees, respectively). Increase in LL was also statistically significant and correlated with PI (53.38 ± 9.53 vs. 61.92 ± 10.48 degrees). Changes in TK and PT were not significant.

Conclusions

Results were concordant with previous cross-sectional and anthropometric studies regarding increase in pelvic incidence by growth. It is also concluded that overall lumbar lordosis is influenced by pelvic incidence both before and after skeletal maturity. As thoracic kyphosis is mainly influenced by instrumentation, no significant difference and relation with spinopelvic parameters were encountered. As reported previously, sagittal profile changes are well tolerated in adolescents, there was no major change in PT. But concerning long fusions, change in pelvic incidence and sacral slope can have a substantial effect on long sagittal profile of surgical candidates.
Responsiveness of Different Validated Patient Reported Outcome Measurements in Cervical Spine Care
Authors: Klemencsics Istvan , Lazary Aron , Bozsodi Arpad , Szollosi Balazs , Varga Peter
Published: May 2015

Introduction

The importance of use of patient-reported outcome measurements (PROMs) in spine care has been previously widely reported, especially for lumbar conditions. One of the main clinicometric properties of a PROM is the responsiveness showing its discriminative ability between good and poor global treatment outcomes. Very limited data about the responsiveness of different cervical PROMs have been published so far. The aim of the study was to analyze the responsiveness of three validated cervical PROMs on a prospective clinical cohort.

Material and Methods

A total of 100 patients with degenerative cervical spinal disorders were recruited into the study. The patients filled out the cross-culturally adapted Hungarian versions of the Neck Disability Index (NDI), the Neck Pain and Disability Scale (NPAD), and the Core Outcome Measures Index for neck (COMI). Test–retest method was applied to assess the validity and reliability dimensions of the questionnaires. Patients completed the questionnaires 3 months after the surgical or nonsurgical treatment. Two different five-point Likert scales on global treatment outcome were used to determine the “good” and “poor” results. The receiver operating characteristics (ROC) method was used to evaluate the discriminative ability of the given change score relative to the outcome (c-index). SPSS 20.0 statistical program package was used for the analyses where p < 0.05 was considered significant.

Results

Correlation of the PROMs with pain was very good (r = 0.65, 0.73, and 0.79 for NDI, NPAD, and COMI, respectively). Intraclass correlation coefficient for the reliability measurement was high for all the three PROMs (ICC = 0.90, 0.85, and 0.89 for NDI, NPAD, and COMI, respectively) and the other clinicometric parameters showed good reliability and validity of the three PROMs in the test–retest phase of the study. For the question about the success of the applied treatment, the c-index was 0.66, 0.76, and 0.65 for NDI, NPAD, and COMI, respectively. When patients replied about the health of their cervical spine, the c-index proved to be 0.74, 0.85, and 0.68 for NDI, NPAD, and COMI, respectively.

Conclusion

Hungarian versions of NDI, NPAD, and COMI proved to be valid and reliable condition-specific measurements. The discriminative ability between “good” and “poor” global treatment outcome of the three PROMs was good, especially for the NPAD which performed significantly better in the responsiveness dimension than the other two PROMs. Based on our results, we can conclude that the use of condition-specific PROMs in cervical spine care is desirable but the performance of the PROMs can be different in certain clinicometric dimensions. Nevertheless, further studies considering the potential differences in different conditions and treatments are needed.
Role of MRI Features as a Prognostic Index in Cervical Spondilogenetic Myelopathy
Authors: Iodice Savino , Zelletta Nicola , Cecchini Giulio , Di Benedetto Mariagrazia , Cirrottola Giovanni , De Tommasi Antonio
Published: May 2015

Introduction

The importance of a correct preoperative radiological diagnosis in patients with cervical myelopathy has been widely demonstrated. Indeed, few studies still exist about the correlation between postoperative radiographic and clinical modifications.

Materials and Methods

The authors present a prospective study of 54 patients with cervical spondilogenetic myelopathy, who underwent surgery for corpectomy and anterior fusion with mesh in a period between January 2005 and August 2013. Images of cervical RMN were studied pre-and postoperatively and attention has been focused on alterations of intramedullary signal on T1- and T2-weighted sequences. Pre-and postoperative changes were correlated with clinical data (obtained by means of a Nurick scales and JOA classification—modified by Benzel). In relation to cervical RM-based studies, patients were divided into 3 groups: (A) no intramedullary signal alteration; (B) alterations in T2-weighted sequences; (C) alterations of the signal in both T1- and T2-weighted sequences.

Results

In all patients, decompression of the cervical spinal cord has been demonstrated by extension of the anteroposterior diameter of the spinal canal and by increase in the thickness of the subarachnoid space. In group A patients, no intramedullary signal changes were highlighted postoperatively. Patients in group B showed improvement on the base of hyperintensity disappearance on T2-weighted MRI, correlating with an improvement in the clinical quadro. Patients of group C have not been showing changes in the intramedullary MRI signal despite spinal cord decompression.

Conclusions

Signal alterations in T1 are an unfavorable prognostic index and proved to be irreversible. They correlate with a lack of clinical improvement of the patient. Patients in group B are those with the greatest clinical benefit after surgery and in whom clinical improvement correlates clearly with the radiological outcome.
Severity of Dysphagia after Anterior Cervical Surgery
Authors: Zaater Ahmed
Published: May 2015

Introduction

Several studies show a relatively high incidence of dysphagia following anterior cervical decompression and fusion (ACDF). Most of these studies are retrospective and lack a control group. This is a prospective study to show the incidence and severity of dysphagia after ACDF using lumbar decompression patients as a control group, and to show factors associated with increased postoperative dysphagia.

Materials and Methods

We prospectively followed patients undergoing ACDF single or double level ( n = 43) and posterior lumbar decompression ( n = 58) (control group). Patient data were recorded. We assess dysphagia using special questionnaire preoperatively and during the 2-week, 6-week, and 12-week postoperative visits. We found no significant differences between the patients who had cervical and lumbar surgery with regard to patient age, body mass index, or the preoperative incidence and severity of dysphagia.

Results

Postoperative dysphagia was reported in 75% of the patients having cervical spine surgery at 2-week follow-up. This incidence decreased to 10% at 12-week follow-up. The cervical group has higher incidence and severity of dysphagia at 2- and 6-week follow-up with a trend toward greater dysphagia at 12-week follow-up. The risk of developing dysphagia was not related to the body mass index, sex, location of surgery, or the number of surgical levels. We observed that operative time was correlated with the severity of postoperative dysphagia.

Conclusion

Dysphagia after anterior cervical spine surgery is a common early finding. However, dysphagia decreases over time, it decreases significantly by 12 weeks.
Subsequent Cervical Disc Herniation following Single-Level ACDF
Authors: Jeon Ikchan , Cho Yongeun , Chin Dongkyu
Published: May 2015

Introduction

Subsequent herniated cervical disc (HCD) and revision anterior cervical discectomy and fusion (ACDF) is not an uncommon disease and procedure. And we, as a spinal surgeon, have some difficulties in decision-making, because of the airway, esophagus, and vocal cord problems. Adjacent segment disease is well known as the pathologic process, in which the changes in the other segment may occur at the cranial or caudal segment. In this study, we discuss about the subsequent HCD which requires surgical treatment following single-level ACDF.

Materials and Methods

From 2006 to 2012, 27 Korean patients, who were operated for subsequent HCD following previous ACDF, were enrolled. The subsequent HCD was detected not only in adjacent segments just around fused spine but also in the skipped segments. A total of 23 patients were approached anteriorly (22 revision ACDF and 1 anterior foraminotomy) and 4 patients were approached posteriorly for posterior keyhole surgery. All 23 patients with anterior approach were evaluated for vocal cord palsy before anterior revision surgery. We retrospectively reviewed and analyzed the pre- and postoperative data.

Results

The subsequent HCD significantly occurred on the caudal segment in patients with C3–4 and C4–5 fused patients and on the cranial segment in C6–7 and C7–T1 fused patients ( p = 0.045). In C5–6 fused patients, the subsequent HCD occurred similarly, both caudally and cranially (5 cranially, 6 caudally). The use of plate in primary ACDF has no significant effect on either the caudal or the cranial segment ( p = 0.168). The direction of approach in primary ACDF (right vs. left) was mainly on contralateral side to the patient's symptom ( p = 0.007), whereas there was no laterality of approach in the revision ACDF according to the symptom and previous ACDF ( p = 0.767). Vocal cord palsy developed only in one patient with anterior keyhole surgery, who had been approached right in primary ACDF and left in revision surgery and there was right-sided vocal cord damage.

Conclusion

Revision ACDF was the major surgical method for subsequent HCD. There was no relationship between the laterality of the approach according to the previous operation and development of vocal cord palsy. The vocal cord palsy was detected in a significantly lower incidence (4.3%, 1/23) compared with the results of other studies. The subsequent HCD had a tendency of developing in the caudal segments in C3–4, 4–5 fused patients and in cranial segment in C6–7, C7–T1 fused patients. In C5–6 fused patients, the subsequent HCD occurred both caudally and cranially.
Changes in Lumbosacral Radiographic Parameters after Minimally Invasive Lumbar Interbody Fusion
Authors: Vialle Emiliano , Vialle Luiz Roberto , Carneiro Abel , Colina Orlando
Published: May 2015

Introduction

Modern techniques have allowed for less aggressive surgeries and faster postoperative recovery. This study aims to evaluate changes in lumbosacral parameters after minimally invasive lumbar interbody fusion. The secondary aim was to evaluate whether interbody cage shape (crescent or rectangular shape) would influence the results.

Method

This is a retrospective analysis of 70 patients who underwent one or two-level lumbar interbody fusion through a minimally invasive posterolateral approach. This included midline preservation and unilateral facetectomy. Pre- and postoperative (3–6 months postoperatively) radiographs were used for measuring lumbar lordosis (LL), segmental lordosis at the level of interbody fusion (SL), and sacral slope (SS). Further analyses divided the patients into Roussouly lumbar subgroups.

Results

LL was significantly reduced after surgery (59:39 degrees, p = 0.001) as well as the SS (33.8:31.2 degrees, p = 0.05). SL did not change significantly (11.4:11.06, p = 0.85). There were no significant differences when comparing patients who received crescent-shaped cage ( n = 27) and rectangular-shaped cage ( n = 43). Hypolordotic patients (Roussouly types 1 and 2) had radiographic improvement in comparison to normo and hyperlordotic groups (types 3 and 4).

Conclusion

Minimally invasive lumbar interbody fusion caused reduction in lumbosacral parameters. Hypolordotic patients showed improvement in radiographic measurements, in comparison to normo and hyperlordotic ones.