Search

Background Although venous thromboembolism (VTE) is a potentially serious and life-threatening complication, there is no widely accepted protocol to guide VTE prophylaxis in adult degenerative spinal surgery, and pharmacologic overtreatment may result in hemorrhagic complications. Previously, we published the VTE Prophylaxis Risk/Benefit Score, an evidence-based algorithm that balances the risk and consequences of thrombotic versus hemorrhagic complications by taking consideration of patient-related risks, procedure-related risks, and the risk of neurological compromise to guide VTE prophylaxis. To objective of this study was to validate the VTE Prophylaxis Risk/Benefit Score. Methods From January 1, 2016, to December 31, 2017, VTE Prophylaxis Risk/Benefit Scores and corresponding prophylaxes were prospectively assigned. When indicated, chemoprophylaxis was dosed 24 to 36 hours postoperatively to allow for adequate surgical hemostasis. Patients were retrospectively evaluated for immediate and short-term complications. The Fisher exact test compared incidence of complications by VTE prophylaxis. Multinomial logistic regression modeled the probability of complication by prophylaxis type, demographics, and comorbidities. Significance was set at P Results Of the 266 patients who met inclusion criteria, 79.3% were given mechanical prophylaxis alone and 20.7% were given combined mechanical and chemical prophylaxis. Complications including VTE (0.38%), delayed wound healing or infection (2.26%), and hematoma (0.75%) were observed at rates similar to or lower than previously published studies with increased utilization of chemoprophylaxis. Use of chemoprophylaxis and continuation of perioperative aspirin were significantly associated with the development of a hemorrhagic complication. No patient developed persistent neurologic deficit from hematoma or pulmonary embolism. Conclusions The VTE Prophylaxis Risk/Benefit Score comprehensively considers the risk of thrombotic, wound, and bleeding complications and is an effective tool for determining appropriate thromboprophylaxis in adult degenerative spinal surgery. Level of Evidence 3.

Study design Patellar tendon reflexes were elicited among patients who had had a unilateral total knee replacement, those planned for unilateral total knee replacement, and a cohort of controlled patients. Patellar tendon reflex (PTR) response was measured with surface electromyography. Objective The aim of this study was to determine if total knee arthroplasty significantly alters the PTR. Summary of background data As part of the clinical evaluation of the spine, extremity reflexes are provoked. Reflex variation between right and left extremities can be a pathological finding in disease of the spine. It has been noted that in patients who have undergone total knee arthroplasty (TKA), the PTR is diminished on the operative side compared with the contralateral nonoperative side. PTR is part of the clinical exam when evaluating a patient for lumbar radiculopathy. Methods The right and left patellar tendon reflex intensities were measured by quadriceps surface electromyography in 3 groups of patients. Group 1 consisted of 21 patients with unilateral TKA who were at least 6 months postoperative. Group 2 consisted of 18 patients with unilateral severe knee arthritis indicated for TKA. Group 3, serving as the control group, included 20 patients with no evidence of knee arthritis in either knee. The average reflex response for each group was recorded and comparisons were then made between each group. Results Patients who have undergone unilateral TKA have a PTR on average of 55.1% of their contralateral uninvolved side. This is statistically significant when compared with reflexes in patients who are planned for unilateral total knee arthroplasty, 96.03% (P = 0.001) and when compared with patients without evidence for knee arthritis, 102.2% (P Conclusion The results of this case control study show that TKAs do significantly diminish PTRs when compared with a contralateral uninvolved knee in the same patient. Level of evidence 3.

The incidence of intraoperative complications during cervical spine surgery is low; however, if they do occur, intraoperative complications have the potential to cause considerable morbidity and mortality. Spine surgeons should be familiar with methods to minimize intraoperative complications. If they do occur, surgeons must be prepared to immediately treat each potential complication to reduce any associated morbidity.

Background context The posterior ligamentous complex (PLC) is thought to contribute significantly to the stability of thoracolumbar spine. Obvious translation or dislocation of an interspace clearly denotes injury to the PLC. A recent survey of the Spine Trauma Study Group indicated that plain radiographic findings, if present, are most helpful in determining PLC injury. However, confusion exists when plain radiography shows injury to the anterior spinal column without significant kyphosis or widening of the posterior interspinous space. Purpose The objective of this study is to identify imaging parameters that may suggest a disruption of the posterior ligamentous complex of the thoracolumbar spine in the setting of normal-appearing plain radiographs. This study was performed, in part, as a pilot study to determine critical imaging parameters to be included in a future prospective, randomized, multicenter study. Study design/setting Survey analysis of the Spine Trauma Study Group. Patient sample None. Outcome measures Compilation and statistical analysis of survey results. Methods Based on a systematic review of the English literature from 1949 to present, we identified a series of traits not found on plain X-rays that were consistent with PLC injury. This included five imaging findings on either computed tomography (CT) scans or magnetic resonance imaging (MRI) and several physical examination features. These items were placed on a survey and sent to the members of the Spine Trauma Study Group. They were asked to rank the items from most important to least important in representing an injury to the PLC in the setting of normal-appearing plain radiographs. Results Thirty-three of 47 surveys were returned for final analysis. Thirty-nine percent (13/33) of the members ranked “disrupted PLC components (i.e., interspinous ligament, supraspinous ligament, ligamentum flavum) on T1 sagittal MRI” as the most important factor in determining disruption of PLC. When analyzed with a point-weighted system, “diastasis of the facet joints on CT” received the most points, indicating that this category was ranked high by the majority of the members of the group. The members were also given freedom to add other criteria that they believed were important in determining PLC integrity in the setting of normal-appearing plain radiograph. Of the other criteria suggested, one included a physical finding and the other a variant of MR sequencing. Conclusions In a setting of normal-appearing plain radiographs, PLC injury as displayed on T1-weighted MRI and diastasis of the facet joints on CT scan seem to be the most popular determinants of probable PLC injury among members of the Spine Trauma Study Group. Between MRI and CT scan, most members feel that various characteristics on MRI studies were more helpful.

Distinguishing between the normal gait of the elderly and pathologic gaits is often difficult. Pathologic gaits with neurologic causes include frontal gait, spastic hemiparetic gait, parkinsonian gait, cerebellar ataxic gait, and sensory ataxic gait. Pathologic gaits with combined neurologic and musculoskeletal causes include myelopathic gait, stooped gait of lumbar spinal stenosis, and steppage gait. Pathologic gaits with musculoskeletal causes include antalgic gait, coxalgic gait, Trendelenburg gait, knee hyperextension gait, and other gaits caused by inadequate joint mobility. A working knowledge of the characteristics of these gaits and a systematic approach to observational gait examination can help identify the causes of abnormal gait. Patients with abnormal gait can benefit from the treatment of the primary cause of the disorder as well as by general fall-prevention interventions. Treatable causes of gait disturbance are found in a substantial proportion of patients and include normal-pressure hydrocephalus, vitamin B(12) deficiency, Parkinson's disease, alcoholism, medication toxicity, cervical spondylotic myelopathy, lumbar spinal stenosis, joint contractures, and painful disorders of the lower extremity.

Venous thromboembolic embolism (VTE) is a potentially serious and life-threatening complication in spine surgery. However, VTE incidence and prophylaxis in spine surgery remains controversial. Current recommendations for VTE prophylaxis address "spine surgery" as a single broad category and mainly consider patient factors when determining risk. We performed a literature review to determine the varying VTE and bleeding risks within spine surgery to develop an individualized prophylactic algorithm. Our review suggests that the current guidelines on VTE prophylaxis for spine surgery from NASS and ACCP are suboptimal. Consideration of (1) patient-related VTE risks, (2) procedure-related VTE risks, and (3) the risk of neurological compromise from bleeding complications will more appropriately balance safety and effectiveness when choosing a VTE prophylaxis method. To better individualize VTE prophylaxis, we have developed the VTE Prophylaxis Risk/Benefit Score that considers this currently available best evidence to arrive at a recommendation for the most appropriate form of VTE prophylaxis. This algorithm informs the surgeon to help make a more nuanced and individualized determination of prophylaxis.

Study design A retrospective review of neurophysiologic alerts during anterior cervical surgery. Objectives To examine incidence and types of neurophysiologic alerts and their correlation with new postoperative neurologic deficits after anterior cervical discectomy or corpectomy procedures. Summary of background data Although multimodality neurophysiologic monitoring has been shown to predict iatrogenic neurologic injuries in scoliosis surgeries, their role in degenerative or trauma-related anterior cervical spine surgery is still unclear. Materials and methods We retrospectively reviewed 1,445 patients who underwent anterior cervical discectomy or corpectomy and arthrodesis with neurophysiologic monitoring that included transcranial electrical motor-evoked potentials (tceMEP), somatosensory-evoked potentials (SSEP), and spontaneous electromyography (EMG). Intraoperative alerts were analyzed for type, perceived cause, actions taken to reverse or minimize the possible spinal cord injury, and any new postoperative neurologic deficits. Results There were 267 (18.4%) procedures that had either minor (spontaneous, sustained EMG) or major (tceMEP/SSEP amplitude reduction) alerts. Patients who underwent corpectomies had 28% increased risk of having a major neurophysiologic alert compared with those who had discectomies. Diagnosis of cervical spondylotic myelopathy or trauma increased the risk of having a major neurophysiologic alert 30% and 76%, respectively, compared with cervical radiculopathy. Eight surgeries were aborted due to persistent tceMEP/SSEP amplitude loss, but none resulted in new postoperative neurologic deficits. Two patients had halo-vest applied due to early termination of surgery. One of these patients ultimately could not receive definitive surgical stabilization. Discussion and conclusion Diagnosis of cervical spondylotic myelopathy or trauma and cervical corpectomy procedures increase the risk for having major intraoperative alerts. In case of persistent tceMEP/SSEP amplitude loss, consider delaying potentially harmful interventions, such as premature termination of the procedure or methylprednisolone infusion, until a new neurologic deficit is verified with an awake-clinical examination.

Study design Prospective study of 5 spine surgeons rating 71 clinical cases of thoracolumbar spinal injuries using the Thoracolumbar Injury Severity Score (TLISS) and then re-rating the cases in a different order 1 month later. Objective To determine the reliability of the TLISS system. Summary of background data The TLISS is a recently introduced classification system for thoracolumbar spinal column injures designed to simplify injury classification and facilitate treatment decision making. Before being widely adopted, the reliability of the TLISS must be studied. Methods A total of 71 cases of thoracolumbar spinal trauma were distributed on CD-ROM to 5 attending spine surgeons, including clinical/radiographic data, details of the TLISS, and a scoring sheet in which cases would be scored using the system. The surgeons were later assigned the task with the cases reordered. Intraobserver and interobserver reliability was calculated for TLISS components, total score, and surgeon's treatment decision using the Cohen unweighted kappa coefficients and Spearman rank-order correlation. Results Interrater reliability assessed by generalized kappa coefficients was 0.33 +/- 0.03 for injury mechanism, 0.91 +/- 0.02 for neurologic status, 0.35 +/- 0.03 for posterior ligamentous complex status, 0.29 +/- 0.02 for TLISS total, and 0.52 +/- 0.03 for treatment recommendation. Respective results using the Spearman correlation were 0.35 +/- 0.04, 0.94 +/- 0.01, 0.48 +/- 0.04, 0.65 +/- 0.03, and 0.51 +/- 0.04. Surgeons agreed with the TLISS recommendation 96.4% of the time. Intrarater kappa coefficients were 0.57 +/- 0.04 for injury mechanism, 0.93 +/- 0.02 for neurologic status, 0.48 +/- 0.04 for posterior ligamentous complex status, 0.46 +/- 0.03 for TLISS total, and 0.62 +/- 0.04 for treatment recommendation. Respective results using the Spearman correlation were 0.70 +/- 0.04, 0.95 +/- 0.02, 0.59 +/- 0.05, 0.77 +/- 0.04, and 0.59 +/- 0.05. Conclusions The TLISS has good reliability and compares favorably to other contemporary thoracolumbar fracture classification systems.

Aging spine is prone to osteoporotic fractures that can cause considerable morbidity due to pain and deformity. Most osteoporotic vertebral compression fractures will respond to non-operative therapy that includes pain medications and bracing. For those who are resistant to conservative therapy, vertebroplasty or kyphoplasty can be a viable option. Most recent studies show 88%-96% satisfaction in pain reduction with vertebroplasty. Several studies have also shown similar satisfaction with kyphoplasty. Because these procedures are relatively new, however, indications, long-term effects, and intra-operative and peri-operative complications are not yet fully understood. Reported complications from both vertebroplasty and kyphoplasty are low, but can include increased pain, radiculopathy, spinal cord compression, pulmonary embolism, infection, and rib fractures. In this review, we summarize the current understanding of anatomy, biomechanics, indications, complications, techniques, and new technologies of vertebroplasty and kyphoplasty.

STUDY DESIGN A critical review of available and emerging nucleus pulposus replacement implants. OBJECTIVES To review the biomechanics, design, and clinical data of currently available and developing nucleus pulposus replacement technologies. SUMMARY OF BACKGROUND DATA The interest in minimally invasive treatment of degenerative disc disease has grown as the technology for intervertebral motion-sparing devices continues to improve. Replacement of nucleus pulposus without anular obliteration represents a tempting alternative to spinal fusion procedures. The aim in nucleus pulposus replacement is to slow adjacent level degeneration, restore normal loads to the diseased level, and restore segmental spinal biomechanics. METHODS A literature review of currently available biomaterials, biomechanics, and available preclinical and clinical data on nucleus pulposus replacement implants. RESULTS New synthetic biomaterials have recently been developed to closely mimic native biomechanics during compressive loading cycles of the intervertebral disc. This, in conjunction with improved understanding of global spine biomechanics, has allowed the development of novel nucleus replacement implants. These implants are currently at different stages of preclinical and clinical investigations. CONCLUSIONS Although some of the newly designed prosthesis have shown some promising results in preclinical studies, rigorous short- and long-term clinical evaluations will be critical in evaluating their true efficacy.

Objective To assess the general use of all non-steroidal anti-inflammatory drugs (NSAID) and their relation to upper gastrointestinal bleeding in view of National Institute for Clinical Excellence guidelines published in July 2001 in the UK. Methods Cross sectional study on all patients who were referred for endoscopy for suspected upper gastrointestinal bleeding in six hospitals in Yorkshire region of the UK. Results One hundred and sixty three patients presented for endoscopy for suspected upper gastrointestinal bleeding, 43 patients were taking at least one ulcerogenic drug, and 120 were not. The mean age difference between these two groups was eight years (p Conclusions Elderly patients are being inappropriately prescribed conventional NSAIDs. NSAIDs with or without aspirin use are still associated with a significant risk of upper gastrointestinal bleeding in the era of cyclo-oxygenase 2 selective agents. Substitution with cyclo-oxygenase 2 selective NSAIDs is not without risk of upper gastrointestinal bleeding.

STUDY DESIGN A retrospective chart and radiographic review of 122 pedicle screws placed with computerized stereotactic image-guidance into posterolateral fusion masses. OBJECTIVES To determine the accuracy rate of computerized stereotactic image-guided pedicle screw placement in previously fused lumbar spines. SUMMARY OF BACKGROUND DATA Placement of pedicle screws into a previously fused lumbar spine is challenging. The normal anatomic landmarks used to determine the starting point and trajectory of the screws have either been removed or are obscured by the fusion mass. Computerized frameless stereotaxis provides precise intraoperative real time multiplanar image-guidance and may be valuable in this clinical situation. METHODS Computerized frameless stereotactic image-guidance was used to place pedicle screws into 78 consecutive patients with prior lumbar spine fusions. Postoperative computed tomography was available on 35 patients (231 screws). One hundred and twenty-two screws were placed into fusion masses. Pedicle cortical perforations were characterized by the direction (medial, inferior, lateral, or superior) and magnitude (in 2-mm increments) of perforation. RESULTS Five (4.1%) of the 122 pedicle screws placed into previously fused levels were found to have unintentional cortical violations. There were 1 superior (

STUDY DESIGN This is a retrospective review of the epidemiology of contraindications to lumbar total disc replacement (TDR). OBJECTIVE To define the prevalence of contraindications to lumbar total disc replacement in a cohort of patients undergoing lumbar surgery in the senior author's (F.P.C.) practice. SUMMARY OF BACKGROUND DATA No published reports have documented the prevalence of contraindications to lumbar total disc replacement. METHODS We performed a retrospective review of 100 consecutive patients who had lumbar surgery by one surgeon between September and December 2002. Procedures performed and contraindications to TDR were recorded. Contraindications to TDR included central or lateral recess stenosis, facet arthrosis, spondylolysis or spondylolisthesis, herniated nucleus pulposus with radiculopathy, scoliosis, osteoporosis, and postsurgical pseudarthrosis or deficiency of posterior elements. Patients were divided into fusion and nonfusion groups. The percentage of patients without contraindications to TDR was calculated. RESULTS Of 100 patients, 56 had fusions and 44 had nonfusion surgery. In the fusion group, 56 of 56 patients had contraindications to TDR. In the nonfusion group, 11% (5 of 44) were candidates for TDR. Overall, 5% of patients in this series were candidates for TDR. The average number of contraindications to TDR was 2.48 (range, 0-5). CONCLUSIONS Predictions that TDR will replace fusion are premature. A small percentage (5%) of the patients currently indicated for lumbar surgery at our institution have no contraindications to TDR. Future growth in TDR implantation will result from the indication of patients for surgery who would not be indicated today or from the elimination of current contraindications.

Approximately 35% of adolescents experience back pain. In athletic adolescents, spondylolysis is the most common offending cause. With growing numbers of adolescents participating in sports with higher levels of intensity, spondylolysis is becoming an increasingly common clinical problem.A recent report demonstrated the benign natural history of asymptomatic spondylolysis. However, long-term follow-up studies of patients who experience painful spondylolysis as adolescents remain unavailable. Modern imaging modalities have led to earlier diagnosis with greater accuracy. Conservative management with bracing continues to be a mainstay of treatment. In patients who are not helped by conservative therapy, recent studies have demonstrated the satisfactory long-term results of surgical repair.The long-term sequelae of symptomatic spondylolysis and unhealed pars defects require investigation. MRI promises to be a valuable tool for diagnosis and clinical stratification, but further studies are necessary to demonstrate its clinical utility.