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Background: Health status is an important predictor of patient outcomes. Consequently, identifying patient predictors of health status is essential. In musculoskeletal orthopaedic care, the majority of work examining the association between patient characteristics and health status has been undertaken among hip/knee cohorts. We investigate these associations comparing findings across four musculoskeletal cohorts (hip/knee; foot/ankle; neck/back; elbow/shoulder)., Methods: Patients seeking elective musculoskeletal orthopaedic care were recruited prior to consultation. Questionnaires captured health domain status (bodily pain, physical functioning, and mental and general health) and covariates: demographics; socioeconomic characteristics; and comorbidity. Scores were compared across cohorts. Two path regression analyses were undertaken. First, domain scores were simultaneously examined as dependent variables in the overall sample. Subsequently, the model was assessed stratified by cohort., Results: 1,948 patients: 454 neck/back, 767 hip/knee, 378 shoulder/elbow, 349 foot/ankle. From stratified analyses, significant variability in covariate effects was observed. Worse bodily pain scores were associated with increasing age and female sex among hip/knee, low income among foot/ankle, and overweight/obese for foot/ankle and hip/knee. Worse mental health scores were associated with low income across cohorts except elbow/shoulder, low education within neck/back, and compared to Whites, Blacks had significantly worse scores among foot/ankle, better scores among hip/knee. Worse general health scores were observed for Asians among hip/knee, Blacks among foot/ankle, and South-Asians among elbow/shoulder and neck/back., Conclusion: The substantial heterogeneity across musculoskeletal cohorts suggests that patient- and cohort-specific approaches to patient counsel and care may be more effective for achieving optimal health and outcomes.

Background Context: Besides their clinical impact, the economic impact of health care-related adverse events (AEs) is significant. Although a number of studies have attempted to estimate the economic impact of AEs, few have directly linked costs to clinician-reported event severity., Purpose: To estimate the economic impact in terms of the incremental cost and length of stay (LOS), attributable to different severity grades of AEs that occurred during perioperative spinal surgery., Study Design: Health economic evaluation of data from a prospective observational study from the perspective of an academic hospital., Patient Sample: Consecutive patients at a single, tertiary-quaternary care institution who have undergone inpatient spinal surgery., Outcome Measures: The cost and LOS impacts with respect to the severity of the AEs., Methods: We analyzed 4 years of patient discharges between January 1, 2007 and December 31, 2010. The Spine Adverse Events Severity instrument was completed by the surgical team at discharge. Clinical impacts of the AEs were graded as I (requires no/minimal treatment), II (requires treatment and is not likely to cause long-term [>6 months] sequelae), III (requires treatment and is most likely to cause long-term sequelae), and IV (death). A total of 1,815 records were linked with the patient-level costing information. We matched each AE case with four control cases based on their propensity score for the risk of experiencing an AE, regressed against case characteristics. We estimated an incremental cost and LOS for each severity grade by calculating the differences in means across cases and controls. We conducted a sensitivity analysis by estimating the alternate models using generalized linear model (GLM) regression with a gamma log link., Results: Adverse events were reported in 316 (17.4%) cases, with 126 of these patients (40.2%) experiencing multiple events. The incremental cost/LOS for each severity grade are as follows: I=$4,224 (p=.0351)/3.63 days (p=.0001); II=$23,500 (p<.0001)/14.03 days (p<.0001); III=$147,285 (p=.0036)/74.50 days (p=.0018); and IV=$121,366 (p=.0323)/46.44 days (p=.0036). The total cost in millions/LOS (days) associated with each grade over the 4-year study period are as follows: I=$0.66 million/569.9 days; II=$2.96 million/1,767.8 days; III=$4.27 million/2,160.5 days; and IV=$0.49 million/185.8 days. Our sensitivity analysis produced comparable overall results using alternate modeling techniques. Overall, AEs contributed an estimated $8.38 million (16.0% of the total costs for all patients in the sample) in incremental costs and 4,684 additional bed days over the 4-year study period., Conclusions: In this surgical spine cohort, AEs accounted for 16% of the total cost of in-hospital care. Higher severity AEs were progressively more costly on a per-case basis; however, the more frequent lower severity events (ie, Grade I and II) also had a substantial aggregate cost (43%). These results suggest that a strong business case exists for patient safety strategies focused not only on severe AEs but also on the reduction of lower severity events that may be more amenable to prevention efforts., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: To examine health care services use after a magnetic resonance imaging (MRI) scan of the lumbosacral or cervical spine ordered by a primary care physician., Summary of Background Data: The use of MRI of the spine in the primary care setting is increasing, yet little is known about the relationship between MRI scan findings and subsequent patterns of health care utilization., Methods: Linkage of records from an audit of outpatient MRI scans of the spine performed in Ontario, Canada, to administrative databases., Results: Of the 647 patients who had a lumbosacral spine MRI scan ordered by a primary care physician, 288 (44.5%) were seen in consultation by an orthopedic surgeon or neurosurgeon, and 42 (6.5%) received spine surgery during 3 years of follow-up. Of the 373 patients who had a cervical spine MRI scan ordered by a primary care physician, 164 (44.0%) were seen in consultation by an orthopedic surgeon or neurosurgeon, and none had spine surgery during 3 years of follow-up. Patients with severe disc herniation (likelihood ratio, 5.62, 95% confidence interval, 2.64-12.00) or severe spinal stenosis (likelihood ratio, 2.34; 95% confidence interval, 1.13-4.85) on lumbosacral spine MRI were more likely to undergo subsequent surgery. However, many patients with these MRI abnormalities did not receive surgery, and the absence of these MRI findings did not significantly lower the likelihood of subsequent surgery., Conclusion: Patients receiving MRI scans of the spine in the primary care setting are frequently referred for surgical assessment and most do not receive subsequent surgery. MRI scan results do not discriminate very well between those who will and will not undergo surgery, suggesting that alternative models for the assessment of patients with spinal complaints in primary care should be explored, particularly in jurisdictions with long wait times for elective spinal surgery consultation.

Purpose: Knowledge of what influences patients' willingness to undergo elective orthopedic surgery is vital to the patient shared decision-making process. We sought to document the prevalence and identify the predictors of unwillingness to undergo surgery among a cohort of hip/knee, foot/ankle, neck/back, and hip/knee patients., Patients and Methods: Patient demographics and information on patient health status, perceptions of risk and success of surgery, and willingness to undergo surgery were collected. Sequential logistic regression models were used to investigate the influence of the captured variables on willingness to undergo surgery., Results: Overall, 392 (20%) of 1946 participants reported being unwilling to undergo or unsure about undergoing ("unwilling/unsure") surgery if it was offered to them. From adjusted analyses, low income and non-White ethnicity were associated with a greater likelihood of being unwilling/unsure. Compared with hip/knee patients, neck/back patients were more likely to report being unwilling/unsure (odds ratio: 1.90 [95% confidence interval: 1.36, 265]); no differences were found between the remaining anatomical groups. However, when perceptions of risk and success were additionally considered, the influence for the neck/back cohort was significantly attenuated. Foot/ankle and elbow/shoulder patients were found to be significantly less likely to report unwillingness when perceptions were considered., Conclusion: In addition to demographic/economic influences, perceptions of surgical risk and success play a critical role in patients' willingness to undergo surgery.

Background: Demand for surgery to treat osteoarthritis (OA) of the hip, knee and spine has risen dramatically. Whereas total hip (THA) and total knee arthroplasty (TKA) have been widely accepted as cost-effective, spine surgeries (decompression, decompression with fusion) to treat degenerative conditions remain underfunded compared with other surgeries., Methods: An incremental cost-utility analysis comparing decompression and decompression with fusion to THA and TKA, from the perspective of the provincial health insurance system, was based on an observational matched-cohort study of prospectively collected outcomes and retrospectively collected costs. Patient outcomes were measured using short-form (SF)-36 surveys over a 2-year follow-up period. Utility was modelled over the lifetime, and quality-adjusted life years (QALYs) were determined. We calculated the incremental cost per QALY gained by estimating mean incremental lifetime costs and QALYs of surgery compared with medical management of each diagnosis group after discounting costs and QALYs at 3%. Sensitivity analyses were also conducted., Results: The lifetime incremental cost:utility ratios (ICURs) discounted at 3% were $5321 per QALY for THA, $11,275 per QALY for TKA, $2307 per QALY for spinal decompression and $7153 per QALY for spinal decompression with fusion. The sensitivity analyses did not alter the ranking of the lifetime ICURs., Conclusion: In appropriately selected patients with leg-dominant symptoms secondary to focal lumbar spinal stenosis who have failed medical management, the lifetime ICUR for surgical treatment of.

Commentary on: Lee MJ, Konodi MA, Cizik AM, et al. Risk factors for medical complication after spine surgery: a multivariate analysis of 1,591 patients. Spine J 2012;12:197-206 (in this issue)., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background Context: The most common surgical treatment of symptomatic degenerative lumbar spondylolisthesis (DLS) is decompression and instrumented fusion. However, contemporary, midline-sparing, microdecompressive techniques have shown good results for selected patients with stable Grade 1 DLS. Growing concerns over the rising cost and rates of spinal fusion warrant both clinical and economic comparative effectiveness research in this common spinal diagnosis., Purpose: To determine the relative cost-utility of decompression with and without concomitant instrumented fusion for selected patients with DLS., Study Design/setting: Comparative cost-effectiveness study., Patient Sample: Probabilities and utilities were estimated from an observational cohort study and the current literature. Costing information was obtained from our institution (microcase costing data/patient) and the literature. Probabilities considered were perioperative and general mortality, probability of clinical improvement and clinical worsening, and reoperation., Outcome Measures: The primary outcome was the incremental cost/utility ratio (ICUR) expressed as the differential cost per relative gain in quality-adjusted life-year (QALY)., Methods: A Markov model with 10-year follow-up was developed. The analyses were carried out from the hospital's perspective. Sensitivity analysis was used to test the robustness of the model., Results: The cost-utility of decompression with fusion and decompression alone at 10 years postintervention was $3,281/QALY and $1,040/QALY, respectively. Compared with decompression alone, decompression plus instrumented fusion was associated with an improvement in quality of life at a cost of $185,878 per QALY in the base-case analysis. The ICUR was invariant to changes in clinical effectiveness of decompression alone, percentage of inpatient decompressions, and varying cost or QALY discounting rates. The ICUR was sensitive to change in QALY and cost structure changes., Conclusions: For a select subgroup of patients with DLS (leg-dominant pain with a stable Grade 1 spondylolisthesis), decompression without fusion is significantly more cost effective than instrumented fusion and provides an opportunity for increased service delivery and/or cost savings for this growing population., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background Context: To date, most reports on the incidence of adverse events (AEs) in spine surgery have been retrospective and dependent on data abstraction from hospital-based administrative databases. To our knowledge, there have been no previous rigorously performed prospective analysis of all AEs occurring in the entire population of patients presenting to an academic quaternary referral center., Purpose: To determine the mortality and true incidence and severity of morbidity (major and minor, medical and surgical) in adults undergoing complex spinal surgery, both trauma and elective, in a quaternary referral center. To examine the influence of the introduction of a dedicated weekly multidisciplinary rounds, and a formal abstraction tool, on the recording of this prospective perioperative morbidity data. To examine the validity and inter- and intraobserver reliability of a dedicated Spine AdVerse Events Severity system, version 2 (SAVES V2) AE abstraction tool., Study Design: Ours is an academic quaternary referral center serving a population of 4.5 million people. Beginning in April 2008, a spine-specific AE-recording instrument, entitled SAVES V2, was introduced at our center for reporting, categorization, and classification of AEs. The use of this system remains an ongoing prospective study., Patient Sample: All adult patients admitted to the spine service of a quaternary referral center for a 12-month period., Outcome Measures: A validity and an inter- and intraobserver reliability examination of the SAVES V2 system, as used at our institution. Morbidity and inhospital deaths, unplanned second surgeries during index admission, wound infections requiring reoperation, and readmissions during the same calendar year. We also examined in detail all intraoperative and nonsurgical postoperative AEs, as well as hospital length of stay (LOS)., Methods: Data on all patients undergoing surgery over a 12-month period were prospectively collected using a perioperative morbidity abstraction tool at weekly dedicated mortality and morbidity rounds. This tool allows identification of each specific AE and grades the severity. Before the introduction of this system, and using the hospital inpatient database, our documented perioperative morbidity rate (major and minor, medical and surgical) was 23%. Diagnosis, operative data, hospital data, major and minor complications both medical and surgical, and deaths were recorded., Results: One hundred percent of all patients discharged from the unit had complete data available for analysis. Nine hundred forty-two patients with an age range of 16 to 90 years (mean, 54 years; mode, 38 years) were identified. There were 552 males and 390 females. Around 58.5% of patients had undergone elective surgery. Thirty percent of patients were American Spinal Injury Association class D or worse on admission. The average LOS was 13.5 days (range, 1-221 days). Eight hundred twenty-two (87%) patients had at least one documented complication. Thirty-nine percent of these adversely affected hospital LOS. There were 14 mortalities during the study period. The rate of intraoperative surgical complication was 10.5% (4.5% incidental durotomy and 1.9% hardware malposition requiring revision and 2.2% blood loss >2 L). The incidence of postoperative complication was 73.5% (wound complications, 13.5%; delerium, 8%; pneumonia, 7%; neuropathic pain, 5%; dysphagia, 4.5%; and neurological deterioration, 3%)., Conclusions: Major spinal surgery in the adult is associated with a high incidence of intra- and postoperative complications. We identified a very high rate of previously unrecognized postoperative complications, which adversely affect LOS. Without strict adherence to a prospective data collection system, the true complexity of this surgery may be greatly underestimated., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Advanced imaging technologies such as computed tomography (CT) and magnetic resonance imaging (MRI) are highly sensitive, but often non-specific, diagnostic tools. Despite this, CT and MRI are overutilized in degenerative spinal disorder diagnosis. From the perspective of the Ministry of Health, we evaluated against usual care the cost-effectiveness of a hypothetical triage program for non-emergent spinal disorders that reduces unnecessary imaging uses., Methods: Diagnostic and surgical data were prospectively collected on 2,046 outpatients who received consultation with the senior surgical author at Toronto Western Hospital, University Health Network, between September 2005 and April 2008. Using these data, we modelled an evidence-based diagnostic triage program wherein spine-focused clinical assessments and plain X-ray imaging would be applied prior to CT and MRI. Incremental costs were the incurred expenses from additional consultations and plain X-rays less the cost savings from the eliminated CT and MRI scans, expressed in 2009 Canadian dollars. Outcomes were expressed as the number of surgical candidates identified per MRI used in diagnosis, reflecting the efficiency of diagnostic imaging., Results: The triage program incurred $109,720 from additional consultations and plain X-rays and saved $2,117,697 from eliminated CT and MRI scans, resulting in net cost savings of $2,007,977 for the 31 months of the study period, or $777,282 per year. In usual care, 0.328~0.418 surgical candidates were identified per MRI whereas in the triage program, 0.736~0.885 surgical candidates were identified per MRI, resulting in over a twofold improvement in MRI efficiency. The triage program was therefore dominating. Applying to high-volume spine surgeons in Ontario, we estimated that the implementation of the triage program would save the province $24,234,929 per year., Interpretation: Based on the assumptions made in our modelling, eliminating unnecessary imaging in spinal disorder diagnosis can save healthcare significant resources.

Background Context: The results of single-center studies have shown that surgical intervention for lumbar spinal stenosis yielded comparable health-related quality of life (HRQoL) improvement to total joint arthroplasty (TJA). Whether these results are generalizable to routine clinical practice in Canada is unknown., Purpose: The primary purpose of this equivalence study was to compare the relative improvement in physical HRQoL after surgery for focal lumbar spinal stenosis (FLSS) compared with TJA for hip and knee osteoarthritis (OA) across six Canadian centers., Study Design/setting: A Canadian multicenter ambispective cohort study., Patient Sample: A cohort of 371 primary one- to two-level spinal decompression (n=214 with instrumented fusion) for FLSS (n=179 with degenerative lumbar spondylolisthesis [DLS]) was compared with a cohort of primary total hip (n=156) and knee (n=208) arthroplasty for OA., Outcome Measures: The primary outcome was the change in preoperative to 2-year postoperative 36-Item Short Form Health Survey Physical Component Summary (PCS) score as reflected by the number of patients reaching minimal clinically important difference (MCID) and substantial clinical benefit (SCB)., Methods: Univariate analyses were conducted to identify baseline differences and factors that were significantly related to outcomes at 2 years. Multivariable regression modeling was used as our primary analysis to compare outcomes between groups., Results: The mean age (years) and percent females for the spine, hip, and knee groups were 63.3/58.5, 66.0/46.9, and 65.8/64.3, respectively. All three groups experienced significant improvement of baseline PCS (p<.001). Multivariate analyses, adjusting for baseline differences (age, gender, baseline Mental Component Summary score, baseline PCS), demonstrated no significant differences in PCS outcome between spinal surgery and arthroplasty (combined hip and knee cohorts) patients with an odds ratio of 0.80 (95% confidence interval [CI], 0.57-1.11; p=.17) and 0.79 (95% CI, 0.58-1.09; p=.15) for achieving MCID or SCB, respectively. In subgroup analysis, spine and knee outcomes were not significantly different, with hip arthroplasty superior to both (p<.0001)., Conclusions: Significant improvement in physical HRQoL after surgical treatment of FLSS (including DLS) is consistently achieved nationally. Our overall results demonstrate that a comparable number of patients can expect to achieve MCID and SCB 2 years after surgical intervention for FLSS and total knee arthroplasty., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Over the last few decades medical research and development has come to depend more heavily on the financial support of industry. However, there is concern that financial relations between the medical community and medical industry could unduly influence medical research and therefore patient care. Our objective was to determine whether conflict of interest owing to authors'/investigators' financial affiliation with industry associated with their academic research has been identified in the surgical literature. In particular, we sought to answer the following questions: What is the extent of such conflict of interest? Does conflict of interest bias the results of academic surgical research in favour of industry? What are the potential causes of this proindustry bias?, Methods: We conducted a systematic review of the literature in May 2008 using the OVID SP search engine of MEDLINE, EMBASE, CINAHL, the Cochrane Database of Systematic Reviews, DARE and Health Technology Assessment. Quantitative studies that included a methods section and reported on conflict of interest as a result of industry funding in surgery-related research specifically were included in our analysis., Results: The search identified 190 studies that met our criteria. Author/investigator conflict of interest owing to financial affiliation with industry associated with their academic research is well documented in the surgical literature. Six studies demonstrated that authors with such conflicts of interest were significantly more likely to report a positive outcome than authors without industry funding, which demonstrates a proindustry bias. Two studies found that the proindustry bias could not be explained by variations in study quality or sample size., Conclusion: The conflict of interest that exists when surgical research is sponsored by industry is a genuine concern.

Objective: To assess the concerns of adult patients with spine-related complaints during the period between referral to and consultation with a spine surgeon., Design: Prospective survey., Setting: Toronto, Ont., Participants: A total of 338 consecutive, nonemergent patients before consultation with a single spine surgeon over a 5-month period., Main Outcome Measures: Patient concerns, effect of referral to a spine surgeon, and effect of waiting to see a spine surgeon., Results: The issues patients reported to be most concerning were ongoing pain (45.6% rated this as most concerning), loss of function (23.4%), need for surgery (12.1%), and permanence of the condition (9.6%). Regression analysis demonstrated that older age was an independent predictor of increased level of concern regarding pain (P=.01) and disability (P=.04). Forty-seven percent of all patients listed the need for surgery among their top 3 concerns. Mere referral to a spine surgeon (P=.03) was an independent predictor of increased concern regarding the need for surgery. Sex, diagnosis, surgical candidacy, and actual wait time were not predictive of increased concerns. Patients reported family physicians to be their most influential information source regarding spinal conditions., Conclusion: Timely provision of more specific information regarding the benign and non-surgical nature of most degenerative spinal conditions might substantially reduce patients' exaggerated concerns regarding the probability of surgery for a considerable number of patients referred to spine surgeons.

Background: The utility and cost of minimally invasive surgical (MIS) fusion remain controversial. The primary objective of this study was to compare the direct economic impact of 1- and 2-level fusion for grade I or II degenerative or isthmic spondylolisthesis via an MIS technique compared with conventional open posterior decompression and fusion., Methods: A retrospective cohort study was performed by use of prospective data from 78 consecutive patients (37 with MIS technique by 1 surgeon and 41 with open technique by 3 surgeons). Independent review of demographic, intraoperative, and acute postoperative data was performed. Oswestry disability index (ODI) and Short Form 36 (SF-36) values were prospectively collected preoperatively and at 1 year postoperatively. Cost-utility analysis was performed by use of in-hospital micro-costing data (operating room, nursing, imaging, laboratories, pharmacy, and allied health cost) and change in health utility index (SF-6D) at 1 year., Results: The groups were comparable in terms of age, sex, preoperative hemoglobin, comorbidities, and body mass index. Groups significantly differed (P < .01) regarding baseline ODI and SF-6D scores, as well as number of 2-level fusions (MIS, 12; open, 20) and number of interbody cages (MIS, 45; open, 14). Blood loss (200 mL vs 798 mL), transfusions (0% vs 17%), and length of stay (LOS) (6.1 days vs 8.4 days) were significantly (P < .01) lower in the MIS group. Complications were also fewer in the MIS group (4 vs 12, P < .02). The mean cost of an open fusion was 1.28 times greater than that of an MIS fusion (P = .001). Both groups had significant improvement in 1-year outcome. The changes in ODI and SF-6D scores were not statistically different between groups. Multivariate regression analysis showed that LOS and number of levels fused were independent predictors of cost. Age and MIS were the only predictors of LOS. Baseline outcomes and MIS were predictors of 1-year outcome., Conclusion: MIS posterior fusion for spondylolisthesis does reduce blood loss, transfusion requirements, and LOS. Both techniques provided substantial clinical improvements at 1 year. The cost utility of the MIS technique was considered comparable to that of the open technique., Level of Evidence: Level III.

Study Design: Multicenter ambispective cohort analysis., Objective: The purpose of this study is to determine whether applying Enneking's principles to surgical management of primary bone tumors of the spine significant decreases local recurrence and/or mortality., Summary of Background Data: Oncologic management of primary tumors of spine has historically been inconsistent, controversial, and open to individual interpretation., Methods: A multicenter ambispective cohort analysis from 4 tertiary care spine referral centers was done. Patients were analyzed in 2 cohorts, "Enneking Appropriate" (EA), surgical margin as recommended by Enneking, and "Enneking Inappropriate" (EI), surgical margin not recommended by Enneking. Benign tumors were not included in mortality analysis., Results: Two cohorts represented an analytic dataset with 147 patients, 86 male, average age 46 years (range: 10-83). Median follow-up was 4 (2-7) years in the EA and 6 (5.5-15.5) years in the EI. Seventy-one patients suffered at least 1 local recurrence during the study, 57 of 77 in the EI group and 14 of 70 in the EA group. EI surgical approach caused higher risk of first local recurrence (P < 0.0001). There were 48 deaths in total; 29 in the EI group and 19 in the EA. There was a strong correlation between the first local recurrence and mortality with an odds ratio of 4.69, (P < 0.0001). EI surgical approach resulted in a higher risk of mortality with a hazard ratio of 3.10, (P = 0.0485) compared to EA approach., Conclusion: Surgery results in a significant reduction in local recurrence when primary bone tumors of the spine are resected with EA margins. Local recurrence has a high concordance with mortality in resection of these tumors. A significant decrease in mortality occurs when EA surgery is used.

Objective: To compare the prevalence of spinal abnormalities found on magnetic resonance imaging (MRI) in symptomatic surgical candidates and non-surgical patients., Design: Retrospective cohort study., Setting: A single academic spine surgery practice in Toronto, Ont., Participants: A total of 1586 symptomatic patients referred during a 32-month period; based on chart review, patients were classified as surgical candidates (n=722), non-surgical patients (n=690), or indeterminate regarding surgical candidacy (n=174)., Main Outcome Measures: Prevalence rates of different spinal abnormalities between the 2 cohorts, including type, severity, and number of levels of abnormalities detected on lumbar MRI., Results: The total number of abnormalities did not differ between the 2 groups (P=.26). The non-surgical group exhibited more degenerative disk disease (P<.01), while surgical candidates had a higher prevalence of spinal stenosis and spondylolisthesis (P<.01). In multivariate analysis, age (adjusted odds ratio [AOR] per 10-year increase 3.33, 95% confidence interval [CI] 3.32 to 3.33), disk herniation (AOR 1.49, 95% CI 1.16 to 1.89), spinal stenosis (AOR 1.61, 95% CI 1.26 to 2.05), and spondylolisthesis (AOR 2.83, 95% CI 2.08 to 3.88) were independent predictors of surgical candidacy., Conclusion: These results might enable physicians without specialty training in spinal disorders to more effectively use MRI reports when deciding on referral to surgical or non-surgical specialists. In jurisdictions with long wait times for elective spinal surgery consultation, a more directed referral is one of many steps necessary to improve patient access and management.

Variability exists in the management of cervical spinal injuries. The goal of this study was to assess the effect of training specialty (orthopedic surgery vs neurosurgery) on management of cervical dislocations. Twenty-nine spine surgeons reviewed 10 cases of cervical dislocation injuries. For each of the 10 cases, the surgeons evaluated 3 clinical scenarios, which included a neurologically intact patient, a patient with an incomplete spinal cord injury (SCI), and a patient with complete SCI. Surgeons determined whether a unilateral or bilateral facet dislocation was present and whether pretreatment magnetic resonance imaging (MRI) or immediate closed reduction was indicated. Management decisions were re-assessed after review of MRIs. While spine surgeons may agree on what they see on MRI and how they classify certain cervical injuries irrespective of training, significant differences of opinion continue to exist regarding the therapeutic implications of this information, specifically, whether to order a pretreatment MRI and how to manage the injury.

Background: The A-Mav (Medtronic, Sofamor Danek, Memphis, TN) is a well-established lumbar total disc arthroplasty device. The O-Mav (Medtronic) is a more recent innovation designed to minimize the potential vascular complications associated with A-Mav insertion at L4/5. No study has hitherto studied the relative accuracy or safety of the two techniques., Purpose: To compare the accuracy of lumbar disc arthroplasty placement by using the anterior technique (A-Mav) with the oblique (O-Mav) technique., Study Design: Technical report., Patient Sample: Fourteen patients., Outcome Measures: Implant placement accuracy on high-resolution computed tomography scan. Comparative morbidity, mortality, blood loss, and operating time were also assessed., Methods: Patients were considered for lumbar disc arthroplasty who had suffered chronic discogenic low back pain unresponsive to nonoperative management for at least 6 months. All patients were operated on at the L4/5 level. A-Mavs were inserted in 7 patients and O-Mavs in 7. Implant placement was analyzed postoperatively by using computer software on high-resolution computed tomography scan with respect to four parameters: (1) off-center malplacement, (2) axial rotational malplacement, (3) coronal tilt, and (4) vertebral body susbsidence. Comparative morbidity, mortality, blood loss, and operating time were also assessed., Results: Subsidence, off-center malplacement, and rotational malplacement were significantly increased in O-Mavs compared with A-Mavs (4.3+/-0.6 mm vs. 1.6+/-0.6 mm, p=.008; 3.1+/-0.4 mm vs. 1.3+/-0.4 mm, p=.006; 6.5 degrees +/-1.2 degrees vs. 3.8 degrees +/-0.4 degrees , p=.046). No significant differences were found between O-Mavs and A-Mavs in tilt, operating time, blood loss, or morbidity and mortality., Conclusions: O-Mav insertion appears to be complicated by significantly greater vertebral body subsidence and malplacement than A-Mav insertion. A-Mav insertion therefore appears to be more accurate and less complicated yet equally as safe as O-Mav insertion.

Background Context: In the last decade, the number of patients undergoing surgical treatment for lumbar spinal stenosis (LSS), particularly instrumented fusions, has significantly increased. The surgical procedures for LSS represent a significant cost to the health-care system and are a priority focus for most governments, insurers, hospital administrators, and spine care physicians., Purpose: The purpose of this study was to directly compare the relative improvement in self-reported quality of life after surgical intervention for matched groups of patients with primary hip or knee osteoarthritis (H-OA/K-OA) and focal lumbar spinal stenosis (FLSS)., Study Design/setting: Observational cohort study of prospectively collected outcomes., Patient Sample: Patients, following elective primary one- to two-level spinal decompression (n=90) with (n=28/90) or without fusion for FLSS, were compared with a matched (age, sex, and time of surgery) cohort of patients who had undergone elective total hip (n=90) or total knee (n=90) arthroplasty (total joint arthroplasty [TJA]) for primary osteoarthritis., Outcome Measures: Medical Outcomes Study Short Form-36 (SF-36)., Methods: Patents were obtained for prospective outcomes databases (TJA and spine). Inclusion and exclusion criteria were independently applied, and matching was performed in a blinded fashion. The primary outcome measure was the relative change between preoperative and 2-year postoperative SF-36 questionnaires. Data were analyzed with the t test and repeated measures analysis of variance (ANOVA)., Results: The three groups (FLSS/H-OA/K-OA) were equally matched with respect to mean age (64/63/65 years), sex (female/male, 51/39 for all groups), body mass index (BMI) (27/24/27), and American Society of Anesthesiologists (ASA) physical status (2/2/2). Comparison of preoperative SF-36 physical component summary (PCS) scores and mental component summary (MCS) scores between groups showed no statistical difference (PCS: FLSS=32.0, H-OA=30.2, K-OA=31.3 [p=.32, ANOVA]/MCS: FLSS=43.5, H-OA=45.0, K-OA=46.2 [p=.25, ANOVA]). Postoperatively, PCS improved significantly for all groups (1 year-PCS: FLSS=39.6, H-OA=44.5, K-OA=38.5 [p<.0001 for all groups]; 2 years-PCS: FLSS=38.6, H-OA=43.2, K-OA=37.1 [p<.0001 for all groups]). At both 1- and 2-year follow-ups, the PCS improvement between groups was greater for the H-OA group compared with the FLSS (p=.0037, p=.0073) and K-OA (p=.00016, p=.00053) groups. At the 1-year follow-up, MCS did not significantly increase for any group; however, 2 years postoperatively, MCS improved significantly for the FLSS and H-OA groups (2 years-MCS: FLSS=50.3, H-OA=50.9, K-OA=44.8 [p=.00021, p=.00079, p=.35]). At the 1-year follow-up, there was no statistical difference in MCS improvement between groups (p=.45, ANOVA). Two years postoperatively, the MCS for both the FLSS and H-OA groups was significantly greater than that for the K-OA group (p=.0014, p=.00055)., Conclusions: The results of this study show that surgical intervention for FLSS can obtain and maintain improvement in self-reported quality of life comparable to that of total hip and knee arthroplasty. This study provides data to support the need for prospective cost-effectiveness studies for the surgical management of appropriately selected patients suffering from FLSS.

It is a general principle with arthroplasty insertion that precise implant centering is critical for long term function and outcome. Whilst some authors have proclaimed that lumbar total disc arthroplasty (TDA) may be different, and that off -centre placement may be functionally well tolerated, these claims are premature: significantly worse clinical results have already been reported with poorly placed TDA at 2 years. Accurate TDA placement requires a precise and consistent definition of the desired coronal midline target (which is currently lacking), as well as a procedural mechanism to optimize placement at that target. We summarize our experience, as well as others', in achieving these two requirements. Long-term outcomes after lumbar TDA insertion should only be compared with results from fusion where TDAs have been implanted accurately.

Study Design: A retrospective outcomes study., Objective: The purposes of this study were 1) to identify plausible patient and interventional variables that influence the outcome of unilateral facet injuries and 2) to determine if patients return to normal general health status after unilateral facet injuries., Summary of Background Data: The management of unilateral subaxial cervical facet fractures and dislocations lacks agreement on treatment options and the variables that influence outcome., Methods: Injury data, radiographs, and outcomes (North American Spine Society Cervical Follow-up Questionnaire and Short Form-36) were collected from 9 centers and 13 surgeons, members of the Spine Trauma Study Group., Results: Causally motor vehicle accidents (49%) and sports (31%) predominated. The C6-C7 level accounted for 60% of injuries and C5-C6 represented 17%. The mean SF-36 PCS score of the operative patients with follow-up >18 months was 6.70 points higher than the mean of the nonoperative patients (P = 0.017). The SF-36 Bodily Pain mean of all patients was 67.2 (SD = 27.6), significantly lower (more pain) than the normative mean of 75.2 (SD = 23.7) (P = 0.014). Nonoperative patients also reported a mean Bodily Pain score of 63.0 (SD = 30.5) that was significantly worse than normative values (P = 0.031). Similarly, the NASS PD mean score for all patients was 84.8 (SD = 17.9), significantly lower than the normative mean of 89.1 (SD = 15.5) (P = 0.014)., Conclusion: To our knowledge this is the largest reported series of facet injuries to date and the only one using health-related quality of life instruments. Unilateral facet injuries of the subaxial cervical spine led to reported levels of pain and disability that are significantly worse than those of the healthy population. Although further study is required, we suggest that nonoperatively treated patients report worse outcomes than operatively treated patients, particularly at longer follow-up despite having a more benign fracture pattern. The presence of comorbidities, associated injuries, and advanced age adversely impact clinical outcomes.

Study Design: Cohort study., Objective: The purpose of this study was to develop and validate a series of novel assessment measures for use during a lumbar pedicle cannulation task., Summary of Background Data: There is increasing pressure being placed on the surgical community to develop appropriate assessment measures of technical skills as an indicator of surgical competence. To date, little research has been performed in this area in spinal surgery., Methods: Twelve novice and 7 expert spine surgeons cannulated a complete set of lumbar pedicles on a synthetic model. Electromagnetic markers were traced to record their dominant hand and arm movements while the forces applied to the model were measured using a small force plate. The amount of wrist motion, mean forces, peak forces, and task time were evaluated. Following task completion, angles of pedicle cannulation and the number and location of all breaches in the models were recorded., Results: Novice surgeons used less mean force (91 N vs. 115 N, P = 0.001) but required more time to perform each cannulation task (12.4 seconds vs. 8.2 seconds, P < 0.001). Cannulation by novices demonstrated a greater mean number of frank (far lateral) pedicle breaches (1.5 vs. 0 per individual, P = 0.002), but no differences in the angles of cannulation were seen (P = 0.988)., Conclusion: Four variables, 3 involving process measures and 1 an outcome measure, can be used to distinguish between novice and expert spine surgeons using a simple lumbar spine pedicle cannulation task, providing evidence of their construct validity. Knowledge of these differences may be useful in objective evaluation of surgical competence and providing precise feedback during the training of this skill, thereby enhancing learning.

Study Design: Original study., Objective: To compare the accuracy of radiograph (XR) estimates of lumbar total disc arthroplasty placement with high-resolution computed tomography (CT)., Summary of Background Data: Most lumbar disc arthroplasties are inserted and subsequently analyzed using anteroposterior and lateral XR: XR estimates are often correlated with clinical outcomes. No study has hitherto assessed the relative accuracy of XR estimates with CT., Methods: Patients (N = 36) had recently undergone uncomplicated lumbar total disc arthroplasty for unresponsive discogenic back pain. Interpedicular midline malplacement and vertebral body penetration (VBP) were estimated after surgery, by "blinded" independent review, using computer software on both nonrotated XR and high-resolution CT at the same clinic attendance., Results: Results were obtained in N = 36 patients. No significant differences were found between XR and CT in the mean +/- standard error estimation of either midline malplacement (1.7 +/- 0.2 mm vs. 1.8 +/- 0.2 mm, P = 0.86) or VBP (1.5 +/- 0.3 mm vs. 1.6 +/- 0.3 mm, P = 0.79). However, the correlation between XR and CT for midline malplacement appeared strong (r = 0.72, P < 0.001), whereas the correlation between XR and CT for VBP was poor (r = 0.23 P > 0.10). The standard deviation of XR-CT differences for VBP (2.2 mm) was almost twice that for midline malplacement (1.2 mm). XR-CT differences exceeded the 95% limit of agreement in 6% of midline placement estimates, and in 8% for VBP., Conclusion: Nonrotated XR permitted an accurate and valid estimate of midline malplacement relative to CT in most cases. However, the correlation was biased toward XR underestimation of CT-derived malplacement, and highly significant XR-CT differences occurred in 6% of estimates: early postoperative CT is therefore recommended to enhance the estimation of midline placement. XR-CT agreement for VBP was poor: CT is therefore indicated in all cases for this parameter. This is the first study to compare the accuracy of XR in estimating lumbar total disc arthroplasty placement with CT.

Study Design: Systematic review of literature and expert clinical opinions of the members of the Spine Trauma Study Group were combined to develop and refine this algorithm., Objective: To develop an evidence-based algorithm for surgical approaches to manage subaxial cervical injuries using a systematic review of the literature, expert opinion, and anticipated patient preferences., Summary of Background Data: There is lack of consensus in the management of subaxial cervical spine trauma, in part, because of the lack of a clinically relevant system for classifying these injuries. The newly developed Subaxial Injury Classification scoring system categorizes injury morphology into 3 broad groups, includes an assessment of the integrity of the discoligamentous soft tissue structures and the patient's neurologic status, and thus guides surgical or nonsurgical treatment. The choice of a specific surgical technique and approach is currently not evidence based, and this gap in knowledge is one which the current article seeks to address., Methods: A literature review followed by a consensus of experts approach was used to develop the algorithm and to ensure face and content validity., Results: An algorithm is presented to guide the choice of surgical approach in cervical subaxial burst fractures, distraction injuries, and translation or rotation injuries. The burst or compression injuries and distraction injuries are more likely to be treated with a single anterior approach, whereas the more severe translation or rotation injuries may more commonly be approached posteriorly or with combined anterior and posterior surgery., Conclusion: This algorithm; derived from the Subaxial Injury Classification scoring system, will assist surgeons in answering the 2 most common questions they face when managing subaxial cervical spine trauma: "Should I operate?" and "Which surgical approach should I select?"

Study Design: Technical report., Objective: To compare the accuracy of lumbar total disc arthroplasty placement using an image-guidance system (IGS) with conventional fluoroscopy., Summary of Background Data: Most disc arthroplasties are inserted and analyzed using fluoroscopy. One previous cadaveric study demonstrated beneficial, but insignificant, effects of IGS on total disc arthroplasty placement compared with conventional fluoroscopy., Methods: Patients were considered for lumbar total disc arthroplasty who had chronic discogenic low back pain unresponsive to nonoperative management for at least 6 months. Total disc arthroplasty was performed in n = 6 with IGS and in n = 14 without IGS. Implant placement was analyzed after surgery using computer software on high-resolution CT with respect to 3 parameters: 1) off-center mal-placement, 2) axial rotational mal-placement, and 3) coronal tilt., Results: Arthroplasties inserted with IGS were positioned with significantly greater accuracy than non-IGS arthroplasties with respect to all 3 parameters measured (off-center: 1.1 +/- 0.3 vs. 2.3 +/- 0.3 mm, P = 0.031; rotation: 88.8 degrees +/- 0.2 degrees vs. 87.1 degrees +/- 0.4 degrees; P = 0.0084; and tilt: 1.0 degrees +/- 0.5 degrees vs. 2.6 degrees +/- 0.3 degrees, P = 0.01). There was no significant difference in operating time between non-IGS controls (123 +/- 5 minutes) and IGS (139 +/- 10 minutes) groups (P = 0.129)., Conclusion: This is the first clinical study to demonstrate significantly improved accuracy of lumbar total disc arthroplasty placement on CT using IGS compared with conventional fluoroscopy. IGS should be considered for routine use with lumbar total disc arthroplasty insertion.

Objective: Posterior transpedicular fixation at the cervicothoracic junction (CTJ) is increasing in popularity. However, the clinical accuracy of pedicle screw placement at the CTJ has not been specifically assessed., Methods: Between January 2000 and July 2004, 60 consecutive patients underwent a variety of posterior spinal procedures necessitating pedicle screw placement at C7, T1, and T2. Thirty-two patients had cervicothoracic screws (3.5 to 4.5 mm) placed by an "open" technique (laminectomies or lamino-foraminotomies) and 28 patients with either a closed (before any decompression) 2-dimensional (n=19, fluoroscopy) or 3-dimensional (n=9, CT) computer-assisted technique. Screws were independently assessed for pedicle breach on postoperative CT and scored using a points-based classification system., Results: The total number of screws placed was 86, 63 and 45 in the open, closed-2-dimensional and closed-3-dimensional groups, respectively. Overall, 61(70.9%), 51(81%), and 40(89%) screws were completely within the pedicle. In the open group, the majority of pedicle breaches were more than 2 mm [n=3 (<2 mm), n=20 (2-4 mm), n=2 (>4 mm)]. Screw violation occurred laterally 11/25(44%), medially 3/25(12%), inferiorly 7/25(28%), and superiorly 4/25(16%). In the closed technique, all breaches were lateral. Seventeen screws (n=11-2-dimensional, n=5-3-dimensional) breached the pedicle by a margin of less than 2 mm and 1 screw (2-dimensional) by 2 to 4 mm. Pedicle screw accuracy was significantly improved with computer-assisted techniques. However, there was no significant difference between the 2-dimensional and 3-dimensional techniques. For all patients, there were no clinically significant screw misplacements, nor any need for screw revision., Conclusions: Computer-assisted surgery allows for more accurate placement of pedicle screws at the CTJ. Although a higher proportion of major pedicular breaches occurred in the "open lamina/lamino-foraminotomy" group, no screws required revision in either group.

Study Design: Prospective observational study., Objective: To assess the incidence and clinical consequence of intraoperative adverse events from a wide variety of spinal surgical procedures., Summary of Background Data: In this study, adverse events were defined as any unexpected or undesirable event(s) occurring as a result of spinal surgery. A complication was defined as a disease or disorder, which, as a consequence of a surgical procedure, will negatively affect the outcome of the patient. We hypothesized that most adverse events would not result in complications that would be normally flagged through traditional practice audit approaches. By defining the incidence and types of adverse events seen in a spine surgical practice, we hope to develop preventative approaches to enhance patient safety., Methods: All postoperative clinical sequelae (i.e., complications) were prospectively identified, classified as to type, and graded (0 [none] to IV [death]) in 700 consecutive patients who underwent spine surgery (excluding > 300-day surgery microdiscectomies) at a university center from January 2002 to June 2003. To confirm data accuracy and assess the clinical sequelae of any adverse events, the medical records of these 700 patients were reviewed., Results: The overall incidence of intraoperative adverse events was 14% (98/700). A total of 23 adverse events led to postoperative clinical sequelae for an overall intraoperative complication incidence of 3.2% (23/700). Specific adverse events included dural tears (n = 58), spinal instrumentation-related events (n = 12), blood loss exceeding 5000 mL (n = 10), anesthesia/medical (n = 4), suspected or actual vertebral artery injury (n = 3), approach-related events (n = 3), esophageal/pharyngeal injury (n = 2), and miscellaneous (n = 6)., Conclusions: Adverse events can frequently occur (14%) during spinal surgery, however, the majority (76.5%) are not associated with complications. Improved patient safety can only be maximized by independent practice audit and the development of prospective methods to record adverse event data so that enhanced, evidence-based, clinical protocols can be developed.

Study Design: Literature review and expert opinion., Objective: To provide an overview of the current concepts of minimally invasive surgical (MIS) techniques for the management of thoracolumbar (TL) spinal trauma., Summary of Background Data: Current surgical treatment of thoracolumbar trauma typically involves open placement of spinal instrumentation with fusion. Conventional open spinal exposures can be associated with significant muscle morbidity that can lead to subsequent paraspinal muscular atrophy, scarring, decreased extensor strength and endurance, as well as pain. This approach-related morbidity is the main impetus for application MIS techniques to spinal procedures including trauma., Methods: A review of the relevant English literature was performed., Results: The current rationale, clinical applications, outcomes, and limitation of MIS management of TL injuries are summarized., Conclusion: The application of MIS techniques to spinal trauma is theoretically sound. However, the indications and technology are currently in evolution. Although very limited information is available, the results of current MIS techniques for the management of TL trauma are encouraging.

Object: A new classification and treatment algorithm for thoracolumbar injuries was recently introduced by Vaccaro and colleagues in 2005. A thoracolumbar injury severity scale (TLISS) was proposed for grading and guiding treatment for these injuries. The scale is based on the following: 1) the mechanism of injury; 2) the integrity of the posterior ligamentous complex (PLC); and 3) the patient's neurological status. The reliability and validity of assessing injury mechanism and the integrity of the PLC was assessed., Methods: Forty-eight spine surgeons, consisting of neurosurgeons and orthopedic surgeons, reviewed 56 clinical thoracolumbar injury case histories. Each was classified and scored to determine treatment recommendations according to a novel classification system. After 3 months the case histories were reordered and the physicians repeated the exercise. Validity of this classification was good among reviewers; the vast majority (> 90%) agreed with the system's treatment recommendations. Surgeons were unclear as to a cogent description of PLC disruption and fracture mechanism., Conclusions: The TLISS demonstrated acceptable reliability in terms of intra- and interobserver agreement on the algorithm's treatment recommendations. Replacing injury mechanism with a description of injury morphology and better definition of PLC injury will improve inter- and intraobserver reliability of this injury classification system.

Study Design: Observational cohort study with computerized tomography (CT) analysis of in vivo pedicle screw placement., Objective: To evaluate the clinical accuracy of computer-assisted fluoroscopy for the placement of thoracic and lumbosacral (LS) pedicle screws., Summary of Background Data: Computer-assisted fluoroscopy is an adjunct for the placement of pedicle screws., Methods: Postoperative CT of 360 titanium pedicle screws (281 LS [L1-S1]; 79 thoracic [T2-T12]) were independently assessed. All screws were placed using the FluoroNav system (Medtronic Surgical Navigation Technologies, Louisville, CO). The relative position of the screw to the pedicle was graded as follows: A = completely in; B = <2 mm breach; C = 2-4 mm breach; and D = >4 mm breach. If an osseous breach occurred, the direction of the breach was further classified., Results: Eight-five percent of screws were completely contained within the pedicle. Fifty-five-pedicle breaches (25 medial; 30 lateral) occurred. Pedicle breaches were graded B in 13.1% (47 breaches), C in 1.9% (7), and D in 0.3% (1) of screws. Pedicle breach was significantly higher in the thoracic compared to the LS spine, 31.6% (25/79) and 10.6% (30/281), respectively (P < 0.0001). In the thoracic spine, 72% of pedicle breaches were lateral. In 49% of breaches, the screw diameter was larger than the pedicle diameter. None of the pedicle breaches were associated with neurologic or other clinical sequelae., Conclusions: The clinical pedicle breach rate in this study is comparable to those reported using conventional techniques with or without fluoroscopic assistance. FluoroNav appears to be a safe adjunct for the placement of thoracic and LS pedicle screws.