Patient Radiation Exposure Associated With the Use of Computer Navigation During Spinal Fusion.

BACKGROUND: Calibration of computer navigation for spinal fusion is most commonly conducted using either a preoperative computed tomography (CT) scan or intraoperative O-arm scanning. This study aimed to directly compare patient radiation exposure from intraoperative O-arm use for pedicle screw placement versus typical diagnostic lumbar spine CT studies. METHODS: A retrospective review of patients undergoing O-arm navigated lumbar spine fusion procedures was performed to record radiation exposure as the primary outcome, as well as surgical and demographic details. The same was done for a control group of patients undergoing lumbar spine CT scans. RESULTS: A total of 83 patients undergoing lumbar spine fusion with O-arm navigation were included, as well as 105 unique patients who underwent a lumbar spine CT. The 2 groups were similar in terms of average age (60.2 versus 60.5, P = .90), average height (170 cm versus 169 cm, P = .50), and average weight (92.6 kg versus 90.9 kg, P = .62). Dose-length product for O-arm navigated procedures was 798.3 mGy-cm and 924.2 mGy-cm for CT scans (P = .064). Subgroup analysis revealed 18 patients who had both an O-arm navigated surgery and a lumbar spine CT. In this group the average dose-length product for O-arm surgeries was 806.2 mGy-cm and 822.1 mGy-cm for CT scans (P = .92) CONCLUSION: This study revealed no statistically or clinically significant differences between patient radiation exposure for O-arm operative navigation compared to lumbar spine CT. CLINICAL RELEVANCE: Given the similarity in radiation exposure, surgeons should rely on other factors to guide decision making in regard to mode of imaging for navigation. Knowledge of this comparison and total radiation exposure will also be useful for patient education and shared decision making in regard to navigated procedures.

The Use of Spinal Cord Stimulation/Neuromodulation in the Management of Chronic Pain.

Chronic pain causes a tremendous burden on the society in terms of economic factors and social costs. Rates of spinal surgery, especially spinal fusion, have increased exponentially over the past decade. The opioid epidemic in the United States has been one response to the management of pain, but it has been fraught with numerous catastrophic-related adverse effects. Clinically, spinal cord stimulation (SCS)/neuromodulation has been used in the management of chronic pain (especially spine-related pain) for more than two decades. More recent advances in this field have led to new theories and approaches in which SCS can be used in the management of chronic spine-related pain with precision and efficacy while minimizing adverse effects commonly seen with other forms of chronic pain treatment (eg, narcotics, injections, ablations). Narcotic medications have adverse effects of habituation, nausea, constipation, and the like. Injections sometimes lack efficacy and can have only limited duration of efficacy. Also, they can have adverse effects of cerebrospinal fluid leak, infection, and so on. Ablations can be associated with burning discomfort, lack of efficacy, recurrent symptoms, and infection. High-frequency stimulation, burst stimulation, tonic stimulation with broader paddles, and new stimulation targets such as the dorsal root ganglion hold promise for improved pain management via neuromodulation moving forward. Although a significant rate of complications with SCS technology are well described, this can be a useful tool in the management of chronic spine-related pain.

Management of Sacroiliac Joint Pain.

Sacroiliac joint (SIJ)-based pain can be difficult to diagnose definitively through physical examination and conventional radiography. A fluoroscopically guided injection into the SIJ can be both diagnostic and therapeutic. The initial phase of treatment involves nonsurgical modalities such as activity modification, use of a sacroiliac (SI) belt, NSAIDs, and physical therapy. Prolotherapy and radiofrequency ablation may offer a potential benefit as therapeutic modalities, although limited data support their use as a primary treatment modality. Surgical treatment is indicated for patients with a positive response to an SI injection with >75% relief, failure of nonsurgical treatment, and continued or recurrent SIJ pain. Percutaneous SI arthrodesis may be recommended as a first-line surgical treatment because of its improved safety profile compared with open arthrodesis; however, in the case of revision surgery, nonunion, and aberrant anatomy, open arthrodesis should be performed.

Anatomic mapping and evaluation of the esophagus in relation to the cervical vertebral body.

The relationship of the esophagus to the cervical vertebral body (CVB), disc space and longus colli (LC) muscles, to our knowledge, has not been previously studied. The purpose of this study was to quantify the relationship of the esophagus to the CVB, disc space and LC. 30 patients were selected for a retrospective review of computed tomography (CT) scans. Measurements between the esophagus and the C5, C6, and C7 vertebral bodies as well as the C5/6 and C6/7 disc spaces were performed in the midline, 3 mm right and left of midline, and at the edge of the LC on both sides. The closest distance of the esophagus to the CVB and disc space occurs at the midline (range 1.02-1.31 mm at each level). The furthest distance occurred at the edge of the right LC (range 2.67-3.30 mm at each level). The mean distance from the edge of the right LC to the midline was significantly greater (P < 0.01) than mean distance from the edge of the left LC to the midline. No statistical significant differences were observed when comparing measurements at the individual vertebral bodies and disc spaces. The results of the study demonstrate that the esophagus lies in closest proximity to the CVB and disc space in the midline. A larger potential space exists between the esophagus and the CVB and disc space at the edge of the LC. These results may provide insight into a potential cause of post-operative dysphagia. Furthermore, it may help guide the future design of cervical plates to better utilize the potential space between the esophagus and the CVB and disc space at the edge of the LC.

Knee injury in patients experiencing a high-energy traumatic ipsilateral hip dislocation.

BACKGROUND: Traumatic hip dislocation results from the dissipation of a large amount of energy about the hip joint. Clinically, these forces often are first transmitted through the knee en route to the hip. It is therefore logical to look for coexistent ipsilateral knee injury in patients with a traumatic hip dislocation. METHODS: Over a one-year period, we prospectively evaluated the ipsilateral knee of all patients who had a traumatic hip dislocation on the basis of a standardized history, physical examination, and magnetic resonance imaging. RESULTS: Twenty-one (75%) of the twenty-eight knees were painful. Twenty-five (89%) of the twenty-eight knees had visible evidence of soft-tissue injury on inspection. Magnetic resonance imaging revealed evidence of some abnormality in twenty-five (93%) of twenty-seven knees, with effusion (37%), bone bruise (33%), and meniscal tear (30%) being the most common findings. CONCLUSIONS: The present study provides evidence of a high rate of associated ipsilateral knee injuries in patients with a traumatic hip dislocation. Bone bruises may provide a plausible explanation for persistent knee pain following a traumatic hip dislocation. The liberal use of magnetic resonance imaging is recommended for the evaluation of these patients in order to detect injuries that may not be discoverable on the basis of a history and physical examination alone.

Reproducibility and reliability of the anatomic axis of the lower extremity.

Two observers measured the tibiofemoral angle of 60 knees on hip-knee-ankle and anteroposterior (AP) knee radiographs and repeated the measurements 6 months later. Intraobserver reproducibility was moderate. Interobserver reliability was poor. These findings were the same irrespective of which radiograph was used during the measurement. Hence, although an AP knee radiograph was as reliable and reproducible as the hip-knee-ankle view, the radiographic tibiofemoral angle should not be considered a precise measurement.