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BACKGROUND CONTEXT Fibromyalgia is associated with poor outcomes in patients undergoing various orthopedic procedures. No prior study has evaluated if this cohort has worse outcomes following spine surgery. PURPOSE The purpose of this study is to identify 90-day postoperative complications in patients with a history of fibromyalgia undergoing one- to two- level spine fusion. STUDY DESIGN/SETTING Retrospective database review. PATIENT SAMPLE The Pearl Diver database (Pearl Diver Technologies, West Conshohocken, PA, USA) identified all patients undergoing one- to two- level spine from 2005 to 2014, from the Medicare provider. All patients with a history of fibromyalgia were also identified. Our consisted of two groups: patients with and without a history of fibromyalgia undergoing primary one- to two- level spine fusion. OUTCOME MEASURES A total of 90-day medical complications were assessed including length of stay, readmission rates, and total cost of care. METHODS All patients in the database undergoing primary one- to two- level spine fusion were identified, in addition to all patients with a history of fibromyalgia 90days prior to their index procedure and having a diagnosis on the same day. This cohort served as our study group. Patients without a diagnosis of fibromyalgia undergoing one- to two- level spine fusion served as our control group. Patients from both cohorts were randomly matched based on age, gender, and comorbidities. Both groups were longitudinally followed for 90days to assess medical complications, readmission rates and total cost of care. RESULTS Fibromyalgia patients had a greater total odds of postoperative complications within the first 90 days (OR: 2.05, p CONCLUSIONS Patients with fibromyalgia are at greater odds for postoperative complications 90days following surgery. Additionally, fibromyalgia patients are more likely to be readmitted to the hospital within the first 90days. Due to the complications caused by fibromyalgia, patients with this condition undergoing one- to two- level spine fusion incur a greater total cost of care on the day of the surgery and 90days after.

Lumbar spine fusion rates have increased significantly over the past couple of decades. Spinal fusion procedures are performed for fractures, degenerative conditions, and deformity. The outcomes of these procedures are affected by many factors—both patient and surgeon specific. Therefore, the proper

INTRODUCTION: Intertransverse posterolateral fusion along with instrumentation is a common technique used for spinal fusion. Iliac crest bone graft (ICBG) offers good fusion success rates with a low risk for disease transmission but is, however, linked with certain morbidity. In an effort to eliminate or reduce the amount of iliac graft needed, bone substitutes including demineralized bone matrix (DBM) have been developed. This study evaluates a novel DBM (Accell Connexus((R))) used in one or two-level instrumented posterolateral lumbar fusion. MATERIALS AND METHODS: A total of 59 consecutive patients were studied as two groups. Group 1 consisted of 33 patients having Accell Connexus((R)) used to augment either ICBG or local decompression material. Group 2 consisted of 26 consecutive patients, operated prior to the introduction of this novel DBM, having either ICBG alone or local decompression material. Fusion was assessed by two independent observers, blinded to graft material, using standardized criteria found in the literature. All adverse events were recorded prospectively. RESULTS: The results show no statistically significant differences between the two groups in fusion rates, complications, surgery duration, ODI, or pain on VAS. Logistical regression showed no relation between fusion and age, smoking status or comorbidities. Furthermore, no adverse events related to the use of the novel DBM were observed. CONCLUSION: The results from this study demonstrate that the novel DBM presented performs equally as well as that of autologous bone, be it either ICBG or a local decompression material, and can therefore be used as a graft extender.

Implants of carbon fiber composite have been widely used in orthopedic and spinal surgeries. However, studies using carbon fiber-reinforced cages demonstrate frequent appearance of fibrous layer interposed between the implant and the surrounding bone. The aim of the present study was to test the possibility of coating a biocompatible metal layer on top of the carbon fiber material, to improve its biological performance. Tantalum was chosen because of its bone compatibility, based on our previous studies. A novel spinal fusion cage was fabricated by applying a thin tantalum coating on the surface of carbon-carbon composite material through chemical vapor deposition. Mechanical and biological performance was tested in vitro and in vivo. Compress strength was found to be 4.9 kN (SD, 0.2). Fatigue test with 500,000 cycles was passed. In vitro radiological evaluation demonstrated good compatibility with X-ray and CT scan examinations. In vivo test employed eight pigs weighing 50 kg each. Instrumented lumbar spine fusion of L3/4 and L4/5 with these cages was performed on each pig. After 3 months, excellent bone integration property was demonstrated by direct contact of the cage with the host bone and newly formed bone. No inflammatory cells were found around the implant. Cages packed with two different graft materials (autograft and COLLOSS) achieved the same new bone formation. The present study proved that coating tantalum on top of the carbon-based implant is feasible, and good bone integration could be achieved.

Objective: The Rapid Recovery program is an evidence-based structured approach to optimize patient care. In recent years, Rapid Recovery has been successfully established as care concept in hip, knee and shoulder arthroplasty already. The aim was now to apply this treatment approach to the care of patients[for full text, please go to the a.m. URL], 66. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC)

OBJECT Failure of fusion after a transforaminal lumbar interbody fusion (TLIF) procedure is a challenging problem that can lead to ongoing low-back pain, dependence on pain medication, and inability to return to work. B2A is a synthetic peptide that has proven efficacy in achieving fusion in animal models and may have a better safety profile than bone morphogenetic protein. The authors undertook this study to evaluate the safety and efficacy of B2A peptide–enhanced ceramic granules (Prefix) in comparison with autogenous iliac crest bone graft (ICBG, control) in patients undergoing single-level TLIF. METHODS Twenty-four patients with single-level degenerative disorders of the lumbar spine at L2–S1 requiring TLIF were enrolled between 2009 and 2010. They were randomly assigned to 3 groups: a control group (treated with ICBG, n = 9), a Prefix 150 group (treated with Prefix 150 μg/cm3 granules, n = 8), and a Prefix 750 group (treated with Prefix 750 μg/cm3 granules, n = 7). Outcome measures included the Oswestry Disability Index (ODI), visual analog pain scale, and radiographic fusion as assessed by CT and dynamic flexion/extension lumbar plain radiographs. RESULTS At 12 months after surgery, the radiographic fusion rate was 100% in the Prefix 750 group, 78% in the control group, and 50% in the Prefix 150 group, although the difference was not statistically significant (p = 0.08). At 6 weeks the mean ODI score was 41.0 for the control group, 27.7 for the Prefix 750 group, and 32.2 for the Prefix 150 group, whereas at 12 months the mean ODI was 24.4 for control, 31.1 for Prefix 750, and 29.7 for Prefix 150 groups. Complications were evenly distributed among the groups. CONCLUSIONS Prefix appears to provide a safe alternative to autogenous ICBG. Prefix 750 appears to show superior radiographic fusion when compared with autograft at 12 months after TLIF, although no statistically significant difference was demonstrated in this small study. Prefix and control groups both appeared to demonstrate comparable improvements to ODI at 12 months.

This study determines whether recombinant human bone morphogenetic protein-2 (rhBMP-2) (12 mg at the rate of 1.5 mg/mL) delivered on an absorbable collagen sponge with an added bulking agent can increase posterolateral lumbar spine fusion success rates and decrease time for fusion with autogenous bone grafts.A prospective, single institution, clinical case-matched, radiographic, cohort study was undertaken. A total of 52 patients underwent posterolateral lumbar arthrodesis with pedicle screw instrumentation. The experimental group (n=41) underwent placement of Iliac crest bone graft (ICBG) with InFUSE (12 mg/level at the rate of 1.5 mg/mL). The control group (n=11) consisted of sex-matched patients, consecutively collected over the same time period with an instrumented posterolateral arthrodesis and ICBG placed in the intertransverse space.Thin-cut (2 mm) axial, coronal, and sagittal reconstructions were blindly evaluated for evidence of bridging bone and cortication of the fusion mass by 3 separate reviewers. Fusions were graded and an overall score was given to the quality of the fusion mass.Fifty patients (ICBG alone n=11; ICBG/rhBMP-2 n=39) were available for CT evaluation at 2-year follow-up. An overall 97% (68/70 levels; Definite+Probably Fused) fusion rate in the rhBMP-2 group was achieved as compared to the 77% fusion rate (17/22 levels) in the ICBG alone group (P0.05). In the rhBMP-2 group, 92% of the patients (36/39 patients) received an overall excellent subjective fusion rating as compared to 27% (3/11) in the control group (P0.05). There was no computed tomographic evidence of soft-tissue ossification, dural ossification, or laminar bone regrowth in any patient.The adjunctive use of rhBMP-2 and ICBG seems to be safe and results in significantly larger and more consistent posterolateral fusion masses.

STUDY DESIGN: A prospective case controlled study to compare the clinical and radiographic performance of Healos soaked in bone marrow aspirate (BMA) to iliac crest autograft when used in lumbar spinal fusion. OBJECTIVE: To evaluate the null hypothesis: Healos used with BMA is not an effective alternative to iliac crest autograft in lumbar spine fusions. SUMMARY OF BACKGROUND DATA: Healos (a Type 1 collagen/hydroxyapatite matrix) is osteoconductive and when soaked for at least 20 minutes in BMA becomes osteoinductive. It is nontoxic and straightforward to use, avoiding the morbidity of autograft harvest. Animal studies and early clinical series in humans have suggested that Healos and BMA are an effective substitute for autograft in certain circumstances. METHODS: From July 2000, Healos and BMA were used as the graft material, instead of autograft harvested from the iliac crest, in all patients undergoing lumbar spinal fusion. Clinical outcome measures used were the Low Back Outcome Score (LBOS), a Patient Satisfaction Score, and the Prolo Economic Score (after Schnee). Standing anteroposterior and lateral radiographs were taken at 12- and 24-month follow-up visits. The first 50 cases in this consecutive series were age, sex, and operative intervention matched to historical controls who underwent surgery between 1997 and 2000 and in whom autograft from the iliac crest had been used as the graft material. Surgical outcome data in these patients had also been gathered prospectively. An independent radiologist, blinded to the graft material, using standard plain radiograph criteria for fusion, examined all the radiographs. An independent surgeon assessed clinical outcomes. RESULTS: For posterolateral lumbar fusions, there were equivalent radiologic fusion rates for the 2 groups with no significant difference in the subjective and objective clinical outcomes. The radiologic fusions rate was significantly lower when Healos had been used for lumbar interbody fusions. Clinical outcomes for both groups were similar. There were no lasting complications associated with Healos use compared with a 14%; persisting donor site complication rate in the autograft patients. CONCLUSION: The null hypothesis is only partially correct. Healos and BMA are not inferior to autologous iliac crest bone as a graft material in posterolateral lumbar spine fusions but are radiographically ineffective in lumbar interbody fusions.

Anterior approaches to the lumbar spine are of great interest due to the ability to implant fusion constructs without interference from neural structures. Conventional anterior open approaches are however unappealing due to the potential for serious complications, including bowel and vascular injury. Lateral approaches have improved the risk profile, truly approaching the goal of minimally invasive. This chapter reviews the current open and minimally invasive approaches and introduces the newest fluoroscopic and computed tomographic image-guided advanced techniques for anterior lumbar spine fusion.

Posterior lumbar fusion (PIF) is considered one of the choices to be considered when traumatic, degenerative, or neoplastic diseases occur, generating spine instability. During the last 5 years, because of dramatic improvement in CT-guided techniques using a percutaneous approach, as well as new materials adopted by industries, minimal invasive spine surgery (MISS) performing PIF procedures with soft tissues incision smaller than 10 mm only and fully CT-guided approach becomes a reality. The possibility to perform the procedure directly into the CT scan room, adopting the widespread C-arm + CT combination technique, increases optimal results significantly reducing general PIF drawbacks, as radiation exposure for the patient and physicians, incorrect screw position, time duration of the procedure, and possible complications. Recently, new percutaneous approaches have been proposed to perform direct posterior facet joint fixation (FF), using trans-facet screws (TFF), introduced through the articular facets, or intra-facet fusion (IFF), with intra-articular implants. Both systems have been proved to obtain biomechanical stability equivalent to conventional PIF on finite elements analysis and for this reason are more and more used in those patients with local microinstability responsible for chronic low back pain, unresponsive to the conventional facet joint radioablation.

Background: Spine surgery has been transformed significantly by the growth of minimally invasive surgery (MIS) procedures. Easily marketable to patients as less invasive with smaller incisions, MIS is often perceived as superior to traditional open spine surgery. The highest quality evidence comparing MIS with open spine surgery was examined. Methods: A systematic review of randomized controlled trials (RCTs) involving MIS versus open spine surgery was performed using the Entrez gateway of the PubMed database for articles published in English up to December 28, 2015. RCTs and systematic reviews of RCTs of MIS versus open spine surgery were evaluated for three particular entities: Cervical disc herniation, lumbar disc herniation, and posterior lumbar fusion. Results: A total of 17 RCTs were identified, along with six systematic reviews. For cervical disc herniation, MIS provided no difference in overall function, arm pain relief, or long-term neck pain. In lumbar disc herniation, MIS was inferior in providing leg/low back pain relief, rehospitalization rates, quality of life improvement, and exposed the surgeon to >10 times more radiation in return for shorter hospital stay and less surgical site infection. In posterior lumbar fusion, MIS transforaminal lumbar interbody fusion (TLIF) had significantly reduced 2-year societal cost, fewer medical complications, reduced time to return to work, and improved short-term Oswestry Disability Index scores at the cost of higher revision rates, higher readmission rates, and more than twice the amount of intraoperative fluoroscopy. Conclusion: The highest levels of evidence do not support MIS over open surgery for cervical or lumbar disc herniation. However, MIS TLIF demonstrates advantages along with higher revision/readmission rates. Regardless of patient indication, MIS exposes the surgeon to significantly more radiation; it is unclear how this impacts patients. These results should optimize informed decision-making regarding MIS versus open spine surgery, particularly in the current advertising climate greatly favoring MIS.

Study Design. Reviews were conducted. Objectives. To review the biology of spine fusion healing, and to outline several fundamental principles required for the selection of a bone graft substitute. Summary of Background Data. More than 200,000 spine fusions are performed each year in the United States. The success of this procedure is limited by morbidity from iliac crest bone graft harvest and a nonunion rate that ranges from 10% to 40%. In recent years, there has been an increased understanding of the biology of spine fusion healing. In addition, there has been a focus on finding suitable substitutes for autogenous iliac crest bone graft to promote spine fusion. The selection of a specific bone graft substitute can be a daunting task for the surgeon. Methods. The available literature was reviewed and combined with the author’s personal experience. Results. A basic understanding of the biology of healing in different types of spine fusions and the differences between different categories of bone graft substitutes can help surgeons organize the graft selection process. Conclusions. In general, purely osteoconductive substitutes are less effective in adult posterolateral spine fusions, but may be suitable in the anterior spine when it is rigidly immobilized. Osteoinductive substitutes are more likely to be successful as extenders, enhancers, or substi

Background: Laparoscopic lumbar spine fusion has been recently described. The aim of this study is to evaluate the safety and efficacy of this procedure for single- and multiple-level degenerative disc disease. Methods: Twenty-four consecutive laparoscopic interbody lumbar fusions were evaluated prospectively (18 single-level were compared with 6 multiple-level procedures). Results of the laparoscopic multiple-level procedures were further compared with 12 open multiple-level operations. Results: Twenty procedures were completed laparoscopically. The conversions were related to iliac vein lacerations (3 cases) and a mesenteric tear. Single-level cases had lower morbidity (22% versus 83%), shorter hospital stay (2 versus 10 days), and higher fusion rate (88% versus 50%) than multiple-level procedures. Overall results in the latter group were worse than in the matched open group. Conclusions: Laparoscopic single-level fusion (L5-S1) is safe and carries the benefits of minimal access surgery. Morbidity after multiple level approach is high, and this procedure cannot be advocated at this time.

STUDY DESIGN A posterolateral lumbar arthrodesis animal model using coralline hydroxyapatite as a bone graft substitute. OBJECTIVE To determine the effectiveness of coralline hydroxyapatite as a bone graft substitute for lumbar spine fusion when used with bone marrow, autogenous bone graft, or an osteoinductive bone protein extract. SUMMARY OF BACKGROUND DATA Coralline hydroxyapatite is commonly used as a bone graft substitute in metaphysial defects but its use in a more challenging healing environment such as the posterolateral spine remains controversial. There are no published animal studies in which the use of coralline hydroxyapatite has been evaluated in a posterolateral lumbar arthrodesis model. METHODS Single-level posterolateral lumbar arthrodesis was performed at L5-L6 in 48 adult New Zealand White rabbits. Rabbits were assigned to one of three groups based on the graft material they received: 3.0 mL coralline hydroxyapatite 1.5 mL plus bone marrow; 1.5 mL coralline hydroxyapatite plus 1.5 mL autogenous iliac crest bone; and, 3.0 mL coralline hydroxyapatite plus 500 micrograms bovine-derived osteoinductive bone protein extract on each side. Rabbits were killed after 2, 5, or 10 weeks, and the spines were excised and evaluated by manual palpation, radiographs, tensile biomechanical testing, and nondecalcified histology. RESULTS Fusions were assessed by manual palpation at 5 weeks for comparisons among the three groups of graft materials. The coralline hydroxyapatite used with bone marrow produced no solid fusions (0/14). When combined with an equal amount of autogenous iliac crest bone, coralline hydroxyapatite resulted in solid fusion in 50% (7/14) of the rabbits (P < 0.05). When combined with the osteoinductive growth factor extract, the coralline hydroxyapatite resulted in solid fusion in 100% (11/11) of the rabbits (P < 0.05). The fusion masses in the growth factor group were significantly stronger (1.8 +/- 0.2 vs. 1.3 +/- 0.1; P = 0.02) and stiffer (1.5 +/- 0.2 vs. 1.2 +/- 0.1, P = 0.04) based on tensile testing to failure when normalized to the adjacent unfused level. CONCLUSION These data indicate that coralline hydroxyapatite with bone marrow was not an acceptable bone graft substitute for posterolateral spine fusion. When combined with autogenous iliac crest bone graft-coralline hydroxyapatite served as a graft extender yielding results comparable to those obtained with autograft alone. Coralline hydroxyapatite served as an excellent carrier for the bovine osteoinductive bone protein extract yielding superior results to those obtained with autograft or bone marrow.

Combining our experience at the Barrow Neurological Institute with a review of the literature, we have defined the indications for fusion of the lumbar spine based on diagnostic categories. Clear indications for fusion include two-or three-column injuries produced by trauma, tumor, or infection; postoperative instability; and isthmic spondylolisthesis. Relative indications include degenerative spondylolisthesis, radiographically proven dynamic instability with pain or neurological findings, adult scoliosis, and mechanical back pain. Fusion is rarely indicated in the setting of routine microdiscectomy; abnormal radiographs without appropriate findings (eg, degenerative disc disease); facet joint syndrome; failed back surgery; or stable spinal stenosis.

STUDY DESIGN Retrospective chart review. OBJECTIVE To describe the adverse outcomes associated with the use of rhBMP-2 in thoracolumbar and lumbar fusions. SUMMARY OF BACKGROUND DATA rhBMP-2 has been increasingly used in spinal fusions over the past decade. Early studies reported that the use of rhBMP-2 is associated with decreased operative time, blood loss, and pain scores, as well as improved fusion rates. Recent investigations have shown rhBMP-2 to be associated with various complications occurring at incidences ranging from 0% to 100%. METHODS Using the institutional electronic medical records, we retrospectively reviewed all patients between January 2002 and September 2010 that underwent thoracolumbar and lumbar spine fusion with BMP. Patient demographics, operative, and outcome/complication information was collected. RESULTS A total of 547 patient charts were reviewed with a mean follow-up time of 17 months. Mean age was 58 years. Forty-one percent of patients had undergone previous spine surgery. Thirty-nine percent of patients had a PLIF/TLIF, 29% underwent a PLF, and 20% an ALIF. No relevant differences in the patient characteristics and complications were identified between the various surgical approaches. For all approaches, having undergone a previous spine surgery was associated with increased incidence of radiculitis, reoperation, and pseudoarthrosis (P=0.005, 0.0008, 0.05, respectively) as compared with those without previous spine surgery. Being a current smoker at the time of operation was associated with increased rate of radiculitis (P=0.03) as compared with nonsmokers. CONCLUSIONS The use of rhBMP-2, in this study, had an incidence of radiculitis, pseudoarthrosis, and reoperation that was similar to the rates in historical controls without rhBMP-2. Complications do not differ by surgical approach, but are more likely in current smokers and those undergoing revision surgery. A prospective study is warranted to further delineate the adverse event profile of rhBMP-2 and the variables that are likely to affect it (ie, type of surgery, carrier, and dose).

Objective: To examine the characteristics of postoperative fentanyl effect-site concentrations during intravenous analgesia in patients requiring or not requiring a fentanyl bolus and in patients with or without postoperative nausea and vomiting (PONV). Design: Retrospective observational study. Setting: University-affiliated general hospital. Patients: Sixty patients who underwent posterior lumbar spine fusion. Main outcome measures: The authors simulated the fentanyl effect-site concentration for 48 postoperative hours and compared it between patients who did and did not require a fentanyl bolus and between patients who did and did not experience PONV. Results: At the end of anesthesia, the fentanyl effect-site concentration was similar between 37 (61.7 percent) patients requiring and 23 (38.3 percent) patients not requiring a postoperative fentanyl bolus (p = 0.97). Within the first 12 postoperative hours, the concentration decreased in both groups (p < 0.01). The fentanyl effect-site concentration was higher in patients requiring a postoperative fentanyl bolus (within 12 hours, 1.4 ± 0.32 ng/mL vs 0.89 ± 0.35 ng/mL; between 12 and 48 hours, 0.94 ± 0.19 ng/mL vs 0.57 ± 0.09 ng/mL) (p < 0.05). PONV occurred in 22 (36.6 percent) patients, but more so in women (68.2 percent; p < 0.01); PONV was similar between patients requiring and not requiring a fentanyl bolus (p = 0.78). Between the 12th and 48th postoperative hours, fentanyl effect-site concentrations were higher in patients with PONV (0.61 ± 0.10 ng/mL vs 0.57 ± 0.10 ng/mL, p = 0.03). Conclusions: Patients needing a postoperative fentanyl bolus require a higher fentanyl effect-site concentration possibly because of individual variations, and PONV depends on the postoperative fentanyl effect-site concentration.

The advantages of the minimally invasive percutaneous approach to the lumbar intervertebral space were learned from percutaneous decompressions. Discoscopy, introduced in 1982, brought the endoscopic dimension to the intervertebral space. Percutaneous external pedicular fixation was adopted in 1988 for segmental stabilization in combination with percutaneous endoscopic preparation of the vertebral plates. The technique of percutaneous endoscopic interbody fusion, standardized since 1988, is presented and discussed with the outcome of a series of 50 patients with a mean follow up of 29 months.

Retrospective cohort study of the prospective collected American College of Surgeons National Surgical Quality Improvement Program database. The aim of the study was to identify predictive factors for the need of discharging patients to a facility other than home after lumbar spine fusion surgery. Lumbar spine fusion surgery is a common surgical procedure used to treat a variety of lumbar spine conditions. A great number of patients fail to go home after surgery and require admission to a rehabilitation center. Predictive factors for discharging patients to a facility other than home after lumbar fusion surgery do not exist in the literature. A total of 15,092 patients undergoing lumbar spine fusion were dichotomized based on discharge destination to patients who were discharged home (N = 12,339) and others who were discharged to a facility other than home (N = 2753). Outcomes included patient demographics, comorbidities, and clinical characteristics. A multivariate logistic regression was used to identify whether outcomes studied were predictive factors for discharging patients to a facility other than home after lumbar fusion surgery. Majority of patients were discharged home after lumbar fusion surgery (81.76%), with only some discharged to a facility other than home (18.24%). Multivariate analysis identified age, female sex, comorbidities (diabetes, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and obesity), minor and major complications, hospital length of stay, operative time at least 259 minutes, and multilevel surgery as significant predictive factors of discharging patients to a facility other than home after lumbar fusion surgery. The identified predictive factors can help the health system in developing an algorithm for early recognition of patients requiring postoperative admission to a facility other than home and possibly decreasing their hospital length of stay. This can significantly decrease the hospital costs for such patients. Level of Evidence: 3

Objectives: The Minimum Clinical Important Difference (MCID) was initially intended to provide outcome measures that would be more clinically meaningful than measurements based simply on mean improvement in some outcomes. Indeed, a basic concept behind the MCID was that statistically significant differences in measures did not necessarily reflect clinically meaningful benefits. Methods: This study provides a review of the literature suggesting that the MCID metric is not being applied and interpreted in practice in a manner that realizes its potential. The MCID has often been used as a means of delineating whether patients are “feeling better.” This does not, though, necessarily indicate that they are “doing better” in terms of physical or socioeconomic functioning. Results: The imperfect correlation between “feeling” and “doing” better makes it difficult to interpret the clinical implications of articles using MCID measures, particularly in the lumbar spine fusion literature. Alternative and more scientifically rigorous approaches to the MCID are presented. Discussion: A call is made for a more comprehensive approach to synthesize a nearly decade’s worth of clinical research that has still not yielded consensus concerning the best MCID approach to objectively document lumbar spine fusion patients’ outcomes.

Objective To study the role of drains in lumbar spine fusions. Methods The charts of 402 patients who underwent lumbar decompression and fusion (LDF) were retrospectively reviewed. Patients were classified per International Classification of Diseases, 9th Edition (ICD-9) procedure code as 81.07 (lateral fusion, 74.9%) and 81.08 (posterior fusion, 25.1%). The investigators studied the prevalence of drain use in lumbar fusion procedures and the impact of drain use on postoperative fever, wound infection, posthemorrhagic anemia, blood transfusion, and hospital cost. Results No significant differences in wound infection rates were noted between patients with and without drains (3.5% vs 2.6%, P = 0.627). The difference in postoperative fever rates between patients with and without drains (63.2% vs 52.6%, P = 0.05) was of borderline significance. Posthemorrhagic anemia was statistically more common in patients with drains (23.5% vs 7.7%, P = 0.000). Allogeneic blood transfusion was also statistically more common in the drained group (23.9% vs 6.8%, P = 0.000). Postoperative hemoglobin levels were lower in patients with drains who underwent one-level (9.5 g/dL vs 11.3 g/dL) or two-level (9.3 g/dL vs 10.2 g/dL) spine fusions. In this series in which drains were liberally used, no patient had to return to the operating room because of postoperative hematoma. An increased rate of allogeneic blood transfusion was noticed with posthemorrhagic anemia and drain use. The rate of allogeneic blood transfusion increased from 5.6% in patients without drains or posthemorrhagic anemia to 38.8% in patients with drains and posthemorrhagic anemia as a secondary diagnosis. The use of drains was associated with statistically insignificant increases in length of stay and cost in posterior procedures. Drain use was associated with shorter length of stay and hospital charges in lateral fusions of three or more levels. Conclusions Drain use did not increase the risk of wound infection in patients undergoing LDF, but it had some impact on the prevalence of postoperative fever. Drain use was significantly associated with posthemorrhagic anemia and allogeneic blood transfusion. Drain use did not have a significant economic impact on hospital length of stay and charges except in lateral procedures involving three or more levels.

Surgical Principles The use of a memory alloy implant is a special adjunct to anterior lumbar spine fusion. Primary stabilization is achieved by means of an interbody memory implant made of nickel-titanium (Figure 1). The implant is anchored thanks to a specific memory effect of the alloy [1–4]: Following warming of the inserted implant to at least 45°C, it expands in height, thus wedging itself into a stable position between the two vertebrae (Figures 2a and 2b). Fusion is achieved by applying autologous iliac crest bone into and around the implant.

OBJETIVO: determinar la eficacia y la seguridad del uso de morfina intratecal, en bajas dosis, en pacientes sometidos a cirugía de instrumentación y artrodesis lumbar. MÉTODOS: estudio prospectivo, randomizado, ciego y controlado. Fueron utilizados dos grupos de pacientes: Grupo Estudio, que recibió morfina intratecal al final de su cirugía, y Grupo Control que sólo recibió el protocolo de analgesia estándar. RESULTADOS: se encontraron diferencias significativas en la escala visual análoga (EVA) entre los dos grupos a las 12 horas postoperatorias. La EVA en reposo promedio del Grupo Estudio fue de 2,15 cm y el del Grupo Control, 5 cm (p=0,013). En actividad, el Grupo Estudio presentó una EVA promedio de 4,36 cm, y el Grupo Control 6,9 cm (p=0,029). No se encontraron diferencias en relación a las complicaciones entre los dos grupos. CONCLUSIÓN: el uso de morfina intratecal, en bajas dosis, es seguro y efectivo en el control del dolor en las primeras 12 horas postoperatorias en cirugía de artrodesis lumbar. OBJETIVO: determinar a eficácia e a seguridade do uso da morfina intratecal, em baixas doses, em pacientes submetidos à cirurgia de instrumentação e artrodese lombar. MÉTODOS: estudo prospectivo, randomizado, cego e controlado. Foram utilizados dois grupos de pacientes: Grupo Estudo, que recebeu morfina intratecal no final da cirurgia e o Grupo Controle, que recebeu somente o protocolo de analgesia padrão. RESULTADOS: foram encontradas diferenças significativas na escala visual analógica (EVA) entre os dois grupos às 12 horas pós-operatórias. A EVA em repouso, em média, do Grupo Estudo foi de 2,15 cm e do Grupo Controle, 5 cm (p=0,013). Durante atividade, o Grupo Estudo apresentou uma EVA de aproximadamente 4,36 cm e no Grupo Controle, 6,9 cm (p=0,029). Não foram encontradas diferenças com relação às complicações entre os dois grupos. CONCLUSÃO: o uso de morfina intratecal, em baixas doses, foi seguro e efetivo no controle da dor nas primeiras 12 horas pós-operatórias na cirurgia de artrodese lombar. OBJECTIVE: to determine the efficacy and safety of low-dose intrathecal morphine use in lumbar instrumented arthrodesis. METHODS: prospective, randomized, blind and controlled study, comparing two groups of patients, with and without the administration of intrathecal morphine at the end of surgery. RESULTS: statistically significant differences were found in the visual analogue score (VAS) between the two groups, 12 hours after surgery. Average VAS (at rest) in the Study Group was 2.15 cm versus 5 cm in the Control Group (p=0.013). In activity, average, VAS in the Study Group was 4.36 cm and in the Control Group, 6.9 cm (p=0.029). No differences were found when comparing complication rates. CONCLUSION: the use of low-dose intrathecal morphine in instrumented lumbar arthrodesis, for postoperative pain management, is safe and effective.

The technique of hypotensive epidural anesthesia for lumbar spine fusion is described. The major benefit is reduced blood loss. The other is early emergence from general anesthesia and the option for postoperative thoracic epidural analgesia. This technique requires skill at thoracic epidural anesthesia in patients with deformed spines, facility at performing hemodynamic monitoring, and a preparedness to closely monitor patients intraoperatively to optimize their physiology.