Biologics in spine arthrodesis.

Spine fusion is a tool used in the treatment of spine trauma, tumors, and degenerative disorders. Poor outcomes related to failure of fusion, however, have directed the interests of practitioners and scientists to spinal biologics that may impact fusion at the cellular level. These biologics are used to achieve successful arthrodesis in the treatment of symptomatic deformity or instability. Historically, autologous bone grafting, including iliac crest bong graft harvesting, had represented the gold standard in spinal arthrodesis. However, due to concerns over potential harvest site complications, supply limitations, and associated morbidity, surgeons have turned to other bone graft options known for their osteogenic, osteoinductive, and/or osteoconductive properties. Current bone graft selection includes autograft, allograft, demineralized bone matrix, ceramics, mesenchymal stem cells, and recombinant human bone morphogenetic protein. Each pose their respective advantages and disadvantages and are the focus of ongoing research investigating the safety and efficacy of their use in the setting of spinal fusion. Rh-BMP2 has been plagued by issues of widespread off-label use, controversial indications, and a wide range of adverse effects. The risks associated with high concentrations of exogenous growth factors have led to investigational efforts into nanotechnology and its application in spinal arthrodesis through the binding of endogenous growth factors. Bone graft selection remains critical to successful fusion and favorable patient outcomes, and orthopaedic surgeons must be educated on the utility and limitations of various biologics in the setting of spine arthrodesis.

Retrospective Analysis of Thoracolumbar Junction Injuries Using the Thoracolumbar Injury Severity and Classification Score, American Spinal Injury Association Class, Injury Severity Score, Age, Sex, and Length of Hospitalization.

STUDY DESIGN: Retrospective review of patient cohort. OBJECTIVE: Our goal was to assess the validity of the Thoracolumbar Injury Classification and Severity (TLICS) score system by comparing the TLICS system to prior management of thoracolumbar injuries at our institution between January 1, 2006 to March 31, 2011. SUMMARY OF BACKGROUND DATA: TLICS was introduced in 2005 to classify and assign treatment recommendations for injuries based on 3 axes: mechanism of injury, integrity of the posterior ligamentous complex, and neurological status. METHODS: We retrospectively obtained and analyzed patient data regarding thoracolumbar junction injuries at a major academic medical center servicing level I trauma. In addition, we compared the American Spinal Injury Association (ASIA) class at time of injury to last follow-up to determine if there was any change in neurological status after intervention. We also compared sex, injury severity score (ISS), length of hospitalization, and age between nonoperatively and operatively treated patients. RESULTS: Included in our study were 201 patients (70% male and 30% female). We found the TLICS system agreed with prior thoracolumbar junction injury management at our institution 98% of the time in nonoperatively treated patients and 78% of the time in operatively treated patients. Age, sex, and ISS were not statistically significant factors in patients who were treated operatively versus nonoperatively, however, there was a trend towards higher ISS in operatively treated patients. Average TLICS score between nonoperative and operative groups was 1.56 and 4.8, respectively, and was a statistically significant difference. There was no statistically significant difference in ASIA class improvement between operative and nonoperative treatment, however, this is likely because of having only 20 patients in this subcohort. Of note, about 50% of the 17 operatively treated patients had improvement in ASIA class. CONCLUSIONS: Our data suggest that TLICS is a valuable tool in a spine surgeon's armamentarium in treating thoracolumbar junction injuries. Some surgeons might be more likely to operate on thoracolumbar junction injuries that should be treated nonoperatively according to the TLICS score. As with all classification schemes, the TLICS system should be used in conjunction with sound clinical judgment.

Evaluation and treatment of spinal metastatic disease.

With the increased survival of oncologic patients, evaluation and management of patients with spinal metastasis is crucial to reducing morbidity and maximizing function. In this chapter, we present some guidelines for the initial systematic evaluation of patients with spinal lesions, as well as the risks, benefits, and alternatives to nonoperative and operative management of metastatic spinal disease, and the overall survival of these patients.

Validation of Patient Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Tests (CATs) in the Surgical Treatment of Lumbar Spinal Stenosis.

STUDY DESIGN: Prospective, cohort study. OBJECTIVE: Demonstrate validity of Patient reported outcomes measurement information system (PROMIS) physical function, pain interference, and pain behavior computer adaptive tests (CATs) in surgically treated lumbar stenosis patients. SUMMARY OF BACKGROUND DATA: There has been increasing attention given to patient reported outcomes associated with spinal interventions. Historical patient outcome measures have inadequate validation, demonstrate floor/ceiling effects, and infrequently used due to time constraints. PROMIS is an adaptive, responsive National Institutes of Health (NIH) assessment tool that measures patient-reported health status. METHODS: Ninety-eight consecutive patients were surgically treated for lumbar spinal stenosis and were assessed using PROMIS CATs, Oswestry disability index (ODI), Zurich Claudication Questionnaire (ZCQ), and Short-Form 12 (SF-12). Prior lumbar surgery, history of scoliosis, cancer, trauma, or infection were excluded. Completion time, preoperative assessment, 6 weeks and 3 months postoperative scores were collected. RESULTS: At baseline, 49%, 79%, and 81% of patients had PROMIS pain behavior (PB), pain interference (PI), and physical function (PF) scores greater than 1 standard deviation (SD) worse than the general population. 50.6% were categorized as severely disabled, crippled, or bed bound by ODI. PROMIS CATs demonstrated convergent validity through moderate to high correlations with legacy measures (r = 0.35-0.73). PROMIS CATs demonstrated known groups validity when stratified by ODI levels of disability. ODI improvements of at least 10 points on average had changes in PROMIS scores in the expected direction (PI = -12.98, PB = -9.74, PF = 7.53). PROMIS CATs demonstrated comparable responsiveness to change when evaluated against legacy measures. PROMIS PB and PI decreased 6.66 and 9.62 and PROMIS PF increased 6.8 points between baseline and 3-months post-op (P < 0.001). Completion time for the PROMIS CATs (2.6 min) compares favorably to ODI, ZCQ, and SF-12 scores (3.1, 3.6, and 3.0 min). CONCLUSION: PROMIS CATs demonstrate convergent validity, known groups validity, and responsiveness for surgically treated patients with lumbar stenosis to detect change over time and are more efficient than legacy instruments. LEVEL OF EVIDENCE: 2.

Posterior Cervical Foraminotomy: Indications, Technique, and Outcomes.

Cervical radiculopathy presents with upper extremity pain, decreased sensation, and decreased strength caused by irritation of specific nerve root(s). After failure of conservative management, surgical options include anterior cervical decompression and fusion, disk arthroplasty, and posterior cervical foraminotomy. In this review, we discuss indications, techniques, and outcomes of posterior cervical laminoforaminotomy.

The Morel-Lavallée lesion revisited: management in spinopelvic dissociation.

BACKGROUND CONTEXT: The Morel-Lavallée lesion occurs from a compression and shear force that usually separates the skin and subcutaneous tissue from the underlying muscular fascia. A dead space is created that becomes filled with blood, liquefied fat, and lymphatic fluid from the shearing of vasculature and lymphatics. If not treated appropriately, these lesions can become infected, cause tissue necrosis, or form chronic seromas. PURPOSE: To review appropriate identification and treatment of Morel-Lavallée lesions in spinopelvic dissociation patients. STUDY DESIGN: Uncontrolled case series. METHODS: Retrospective review of medical records. No funding was received in support of this study. The authors report no conflicts of interest. RESULTS: We present four cases of patients with traumatic spinopelvic dissociation. All had concomitant lumbosacral Morel-Lavallée lesions. All four trauma patients suffered traumatic spinopelvic dissociation with concomitant lumbosacral Morel-Lavallée lesions. Appropriate treatment included irrigation and debridement, drainage, antibiotics, and vacuum-assisted wound closure. CONCLUSIONS: Our series reflects an association of Morel-Lavallée lesion in spinopelvic dissociation trauma patients. Possibly, the rotatory injury that occurs at the spinopelvic junction creates a shear force to form the Morel-Lavallée lesion. When presented with a spinopelvic dissociation patient, one should be prepared to treat a Morel-Lavallée lesion.

Surgical stabilization of the spine in the osteoporotic patient.

Osteoporosis affects millions of US citizens, and millions more are at risk for developing the disease. Several operative techniques are available to the spine surgeon to provide care for those affected by osteoporosis. The types of osteoporosis, common surgical complications, medical optimization, and surgical techniques in the osteoporotic spine are reviewed, with an emphasis on preoperative planning.