Inpatient radiation exposure in patients with spinal trauma.

CONTEXT/OBJECTIVE: Radiation exposure from medical imaging is an important patient safety consideration; however, patient exposure guidelines and information on cumulative inpatient exposure are lacking. DESIGN/SETTING: Trauma patients undergo numerous imaging studies, and spinal imaging confers a high effective dose; therefore, we examined cumulative effective radiation dose in patients hospitalized with spinal trauma. We hypothesized that people with spinal cord injury (SCI) would have higher exposures than those with spine fractures due to injury severity. PARTICIPANTS/INTERVENTIONS: Retrospective data were compiled for all patients with spine injuries admitted to a level I trauma center over a 2-year period. OUTCOME MEASURES: Injury severity score (ISS) and cumulative radiation exposure were then determined for these patients, including 406 patients with spinal fractures and 59 patients with SCI. RESULTS: Cumulative effective dose was 45 millisieverts (mSv) in SCI patients, compared to 38 mSv in spinal fracture patients (P = 0.01). Exposure was higher in patients with an ISS over 16 (P = 0.001). Mean exposure in both groups far exceeded the European annual occupational exposure maximum of 20 mSv. More than one-third of patients with SCI exceeded the US occupational maximum of 50 mSv. CONCLUSION: Patients with SCI had significantly higher radiation exposure and ISS than those with spine fracture, but the effective dose was globally high. Dose did not correlate with injury severity for patients with SCI. While the benefits of imaging are clear, radiation exposure does involve risk and we urge practitioners to consider cumulative exposure when ordering diagnostic tests.

Maximum pain on visual analog scales in spinal disorders.

BACKGROUND CONTEXT: Determining pain intensity is largely dependent on the patient's report. PURPOSE: The objective of this study was to test the hypothesis that patients initially reporting a pain score of 10 out of 10 on the visual analog scale (VAS) would experience symptom improvement to a degree similar to patients reporting milder pain. STUDY DESIGN: This study is a retrospective chart review. PATIENT SAMPLE: A total of 6,779 patients seeking care for spinal disorders were included in the study. OUTCOME MEASURES: The outcome measures used in the study were pain scores on the VAS pain scale, smoking status, morbid depression, gender, and the presence of known secondary gain. MATERIALS AND METHODS: Patients with lumbar degenerative disk disease with or without spinal stenosis who reported a VAS pain score of 10 out of 10 were identified. Changes in reported VAS pain, patient age, smoking status, morbid depression, gender, and the presence of known secondary gain were examined. RESULTS: A total of 160 individuals (2.9%) reported a maximum pain score of 10 out of 10 on a VAS at their initial presentation. The patients had a median improvement of 3 points in reported VAS pain between the first visit and the last follow-up appointment. The odds to improve by at least 40% on the VAS were 1.500 (95% confidence interval 1.090-2.065) compared with patients reporting submaximal pain. The proportion of patients with identifiable secondary gain was higher (p=.001) than that of patients with submaximal pain. Patients whose pain scores improved dramatically (ie, at least 4 points on the VAS) tended to be older (p=.001), to less often have secondary gain from their disease (p=.007), and to have a negative current smoking status (p=.002). Patients whose pain remained 10 out of 10 during the course of treatment smoked more frequently (p=.016). CONCLUSIONS: Our analysis supports the need to consider the influence of secondary gain on the patients' reported VAS pain scores. Maximum pain seems to be a more acute phenomenon with some likelihood to significantly improve.

Does lumbar paraspinal muscle fatty degeneration correlate with aerobic index and Oswestry disability index?

BACKGROUND: We sought to analyze whether the amount of paraspinal fatty degeneration correlates with a patient's physical fitness, and to determine if these findings on lumbar magnetic resonance imaging (MRI) scans can help predict functional outcomes. METHODS: A retrospective review was performed on 172 patients. Inclusion criteria involved being seen by a spine surgeon for low back pain, having aerobic index (AI), body mass index (BMI), Oswestry disability index (ODI), and body fat percentage measured recently, and having had a recent lumbar MRI scan. The percentage of fatty muscle degeneration was graded by three reviewers using T2-weighted axial images at L3 and L5 using a newly proposed system that was validated independently. The system is graded as follows: Grade 1: 0-24%, Grade 2: 25-49%, Grade 3: 50-74%, and Grade 4: 75-100%. An independent t-test was used for comparisons. RESULTS: The average AI was 34.87, and the cohort was divided into two groups: above-average AI (89 patients) and below-average AI (83 patients). For all paraspinal fat measurements and body fat percentage, the difference between the above- and below-average AI groups was statistically significant (P < 0.05), with the least amount of paraspinal fatty degeneration and body fat in the greater AI group. Weight alone and BMI were not found to be significantly different between those with above-average AI when compared to those with below-average AI (P = 0.491 and P = 0.122, respectively). There was a trend for lower ODI scores in the above-average AI group (41.9 vs 46.1), but this did not reach statistical significance between the two groups (P = 0.075). For all patients it was shown that there was significantly less paraspinal fat at the L3 level as compared to L5 (P < 0.001). CONCLUSIONS: We were able to show that patients with a higher AI have lower body fat percentages and lower amounts of fatty degeneration in their lumbar paraspinal musculature. The amount of paraspinal fatty degeneration, therefore, correlates with physical fitness. Patients with higher AI also showed a trend toward having a lower ODI score.

Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal Care in Geriatric Patients.

INTRODUCTION: We examined rates of smoking cessation and the effect of smoking cessation on pain and disability scores in a geriatric patient population. METHODS: Prospectively maintained database records of 6779 patients treated for painful spinal disorders were examined. The mean duration of care was 8 months. Multivariate statistical analysis was performed with independent variables including smoking status, secondary gain status, gender, treatment type, depression, and age. RESULTS: Of the patients seeking care for painful spinal disorders, 8.9% over the age of 55 smoked compared with 23.9% of those under 55 years of age. Rates of smoking cessation did not differ for those older than 55 years (25.1%) and younger patients (26.1%). Current smokers in both age-groups reported greater pain than those who had never smoked in all pain ratings (P < .001). Mean improvement in reported pain over the course of treatment was significantly different in nonsmokers and current smokers in both age-groups (P < .001). Those who quit smoking during the course of care reported greater improvement in pain than those who continued to smoke. The mean improvement in pain ratings was clinically significant in patients in all 3 groups of nonsmokers whereas those who continued to smoke had no clinically significant improvement in reported pain. CONCLUSION: The results support the need for smoking cessation programs, given a strong association between improved patient-reported pain and smoking cessation. Fewer older patients smoke but they are equally likely to quit.

Comparison of image quality and radiation exposure from C-arm fluoroscopes when used for imaging the spine.

STUDY DESIGN: Cadaveric imaging study. OBJECTIVE: We sought to compare the fluoroscopic images produced by 4 different fluoroscopes for image quality and radiation exposure when used for imaging the spine. SUMMARY OF BACKGROUND DATA: There are no previous published studies comparing mobile C-arm machines commonly used in clinical practice for imaging the spine. METHODS: Anterior-posterior and lateral images of the cervical, thoracic, and lumbar spine were obtained from a cadaver placed supine on a radiolucent table. The fluoroscopy units used for the study included (1) GE OEC 9900 Elite (2010 model; General Electric Healthcare, Waukesha, WI), (2) Philips BV Pulsera (2009 model; Philips Healthcare, Andover, MA), (3) Philips BV Pulsera (2010 model; Philips Healthcare, Andover, MA), and (4) Siemens Arcadis Avantic (2010 model; Siemens Medical Solutions, Malvern, PA). The images were then downloaded, placed into a randomizer program, and evaluated by a group of spine surgeons and neuroradiologists independently. The reviewers, who were blinded to the fluoroscope the images were from, ranked them from best to worst using a numeric system. In addition, the images were rated according to a quality scale from 1 to 5, with 1 representing the best image quality. The radiation exposure level for the fluoroscopy units was also compared and was based on energy emission. RESULTS: According to the mean values for rank, the following order of best to worst was observed: (1) GE OEC > (2) Philips 2010 > (3) Philips 2009 > (4) Siemans. The exact same order was found when examining the image quality ratings. When comparing the radiation exposure level difference, it was observed that the OEC was the lowest, and there was a minimum 30% decrease in energy emission from the OEC versus the other C-arms studied. CONCLUSION: This is the first time that the spine image quality and radiation exposure of commonly used C-arm machines have been compared. The OEC was ranked the best, produced the best quality images, and had the least amount of radiation.

Randomized trial demonstrates that extended-release epidural morphine may provide safe pain control for lumbar surgery patients.

BACKGROUND: Safe and effective postoperative pain control remains an issue in complex spine surgery. Spinal narcotics have been used for decades but have not become commonplace because of safety or re-dosing concerns. An extended release epidural morphine (EREM) preparation has been used successfully in obstetric, abdominal, thoracic, and extremity surgery done with epidural anesthesia. This has not been studied in open spinal surgery. METHODS: Ninety-eight patients having complex posterior lumbar surgery were enrolled in a partially randomized clinical trial (PRCT) of low to moderate doses of EREM. Surgery included levels from L3 to S1 with procedures involving combinations of decompression, instrumented arthrodesis, and interbody grafting. The patients were randomized to receive either 10 or 15 mg of EREM through an epidural catheter placed under direct vision at the conclusion of surgery. Multiple safety measures were employed to prevent or detect respiratory depression. Postoperative pain scores, narcotic utilization, and adverse events were recorded. RESULTS: There were no significant differences between the two groups as to supplemental narcotic requirements, pain scores, or adverse events. There were no cases of respiratory depression. The epidural narcotic effect persisted from 3 to 36 hours after the injection. CONCLUSION: By utilizing appropriate safety measures, EREM can be used safely for postoperative pain control in lumbar surgery patients. As there was no apparent advantage to the use of 15 mg, the lower 10 mg dose should be used.

Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal Care.

BACKGROUND: Smoking is associated with low back pain, intervertebral disc disease, inferior patient outcomes following surgical interventions, and increased rates of postoperative complications. The purpose of the present study was to examine the effect of smoking and smoking cessation on pain and disability in patients with painful spinal disorders. METHODS: We examined a prospectively maintained database of records for 5333 patients with axial or radicular pain from a spinal disorder with regard to smoking history and the patient assessment of pain on four visual analog scales during the course of care. Confounding factors, including secondary gain, sex, age, and body mass index, were also examined. The mean duration of follow-up was eight months. Multivariate statistical analysis was performed with variables including smoking status, secondary gain status, sex, depression, and age as predictors of pain and disability. RESULTS: Compared with patients who had never smoked, patients who were current smokers reported significantly greater pain in all visual analog scale pain ratings (p < 0.001). The mean improvement in reported pain over the course of care was significantly different between nonsmokers and current smokers (p <0.001). Compared with patients who had continued to smoke, those who had quit smoking during the course of care reported significantly greater improvement in pain in visual analog scale pain ratings for worst (p = 0.013), current (p < 0.05), and average weekly pain (p = 0.024). The mean improvement in the visual analog scale pain ratings was clinically important in patients in all three groups of nonsmokers. As a group, those who had continued smoking during treatment had no clinically important improvement in reported pain. CONCLUSIONS: Given a strong association between improved patient-reported pain and smoking cessation, this study supports the need for smoking cessation programs for patients with a painful spinal disorder.