Complications and Revisions After Spine Surgery in Patients With Skeletal Dysplasia: Have We Improved?

STUDY DESIGN: Retrospective case series. OBJECTIVE: To report contemporary rates of complications and subsequent surgery after spinal surgery in patients with skeletal dysplasia. METHODS: A case series of 25 consecutive patients who underwent spinal surgery between 2007 and 2017 were identified from a single institution's skeletal dysplasia registry. Patient demographics, medical history, surgical indication, complications, and subsequent surgeries (revisions, extension to adjacent levels, or for pathology at a non-contiguous level) were collected. Charlson comorbidity indices were calculated as a composite measure of overall health. RESULTS: Achondroplasia was the most common skeletal dysplasia (76%) followed by spondyloepiphyseal dysplasia (20%); 1 patient had diastrophic dysplasia (4%). Average patient age was 53.2 ± 14.7 years and most patients were in excellent cardiovascular health (88% Charlson Comorbidity Index 0-4). Mean follow up after the index procedure was 57.4 ± 39.2 months (range). Indications for surgery were mostly for neurologic symptoms. The most commonly performed surgery was a multilevel thoracolumbar decompression without fusion (57%). Complications included durotomy (36%), neurologic complication (12%), and infection requiring irrigation and debridement (8%). Nine patients (36%) underwent a subsequent surgery. Three patients (12%) underwent a procedure at a non-contiguous anatomic zone, 3 (12%) underwent a revision of the previous surgery, and another 3 (12%) required extension of their previous decompression or fusion. CONCLUSIONS: Surgical complication rates remain high after spine surgery in patients with skeletal dysplasia, likely attributable to inherent characteristics of the disease. Patients should be counseled on their risk for complication and subsequent surgery.

Particulated Autologous Chondral-Platelet-Rich Plasma Matrix Implantation (PACI) for Treatment of Full-Thickness Cartilage Osteochondral Defects.

Articular hyaline cartilage injuries can occur as a result of either traumatic of progressive degeneration. When the articular cartilage in a joint is damaged, it can cause joint pain and dysfunction, predisposing patients for the development of early-onset osteoarthritis. There are many restoration procedures available to treat these injuries, such as bone marrow-stimulation techniques, osteoarticular auto/allograft transplants, and autologous chondrocyte implantation. Each of these techniques has its own limitations, which led researchers to explore new regenerative and repair techniques to produce normal hyaline cartilage. The purpose of this Technical Note is to describe in detail the particulated autologous chondral-platelet-rich plasma matrix implantation (PACI) technique that could be used as a single-stage cartilage restoration procedure for treatment of full-thickness cartilage and osteochondral defects.

All-Arthroscopic Meniscal Allograft Transplantation Technique with Bone Plugs and Preloaded Sutures.

The meniscus is an essential structure for the knee functioning and survival. Meniscectomy is the most common surgical procedure in orthopaedic surgery. Following total or subtotal meniscectomy, meniscal allograft transplantation (MAT) should be considered in symptomatic active young patients. Several MAT techniques have been described in the literature as an attempt to restore normal knee kinematics and potentially decrease the risk of developing knee osteoarthritis. The purpose of this article is to describe in detail an efficient and reproducible all-arthroscopic MAT technique with bone plugs and preloaded sutures.

An institutional intervention to modify opioid prescribing practices after lumbar spine surgery.

OBJECTIVEPatients with lumbar spine pathology are at high risk for opioid misuse. Standardizing prescribing practices through an institutional intervention may reduce the overprescribing of opiates, leading to a decrease in the risk for opioid misuse and the number of pills available for diversion. Without quantitative data on the "minimum necessary quantity" of opioids appropriate for postdischarge prescriptions, the optimal method for changing existing prescribing practices is unknown. The purpose of this study was to determine whether mandatory provider education and prescribing guidelines could modify prescriber behavior and lead to a decreased amount of opioids prescribed at hospital discharge following lumbar spine surgery.METHODSQualified staff were required to attend a mandatory educational conference, and a consensus method among the spine service was used to publish qualitative prescribing guidelines. Prescription data for 2479 patients who had undergone lumbar spine surgery were captured and compared based on the timing of surgery. The preintervention group consisted of 1177 patients who had undergone spine surgery in the period before prescriber education and guidelines (March 1, 2016-November 1, 2016). The postintervention group consisted of 1302 patients who had undergone spine surgery after the dissemination of the guidelines (February 1, 2017-October 1, 2017). Surgeries were classified as decompression or fusion procedures. Patients who had undergone surgeries for infection and patients on long-acting opioids were excluded.RESULTSFor all lumbar spine surgeries (decompression and fusion), the mean amount of opioids prescribed at discharge was lower after the educational program and distribution of prescribing guidelines (629 ± 294 oral morphine equivalent [OME] preintervention vs 490 ± 245 OME postintervention, p < 0.001). The mean number of prescribed pills also decreased (81 ± 26 vs 66 ± 22, p < 0.001). Prescriptions for 81 or more tablets dropped from 65.5% to 25.5%. Tramadol was prescribed more frequently after prescriber education (9.9% vs 18.6%, p < 0.001). Refill rates within 6 weeks were higher after the institutional intervention (7.6% vs 12.4%, p < 0.07).CONCLUSIONSQualitative guidelines and prescriber education are effective in reducing the amount of opioids prescribed at discharge and encouraging the use of weaker opioids. Coupling provider education with prescribing guidelines is likely synergistic in achieving larger reductions. The sustainability of these changes is yet to be determined.

Disability status and dental pathology in multiple sclerosis patients.

OBJECTIVE: Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) leading to demyelination and neurodegeneration. The disease is plurifactorial, it being assumed that it is caused by an interaction between genes and the environment. Authors aimed to: (1) achieve better understanding of MS evolution; (2) identify, if any, significant associations between dental pathology and the clinical course of the disease in MS patients. METHOD: We performed a cross-sectional study on a group of 33 MS patients treated with immunomodulatory drugs (64% women and 36% men, with a mean age of 39.97 years). The data obtained from the medical records, through neurological assessment, oral and dental evaluation and the information collected by means of a questionnaire were grouped in: (1) items related to MS, (2) items related to dental health and (3) items regarding socio-demographic information. RESULTS: In our sample, disability status was significantly correlated to the number of relapses that occurred during the last year of disease and the total number of relapses. The immunomodulatory treatment significantly reduces the number of relapses in the first year of treatment, then the disease stabilizes. The disability level was highly dependent on the number of relapses that occurred in the most recent period of time. A percentage of 67.9% of the patients reported gingival bleeding. However, the bleeding was not significantly associated with the number of relapses from the last year, the degree of disability (EDSS) or type of immunomodulatory treatment. The only significant difference was identified between the EDSS scores and the presence/absence of dental amalgam fillings but the sample was too small to interpret this result. CONCLUSION: The study did not provide conclusive evidence regarding the association between amalgam restorations, periodontal disease and MS disability.

Eye tracking detects disconjugate eye movements associated with structural traumatic brain injury and concussion.

Disconjugate eye movements have been associated with traumatic brain injury since ancient times. Ocular motility dysfunction may be present in up to 90% of patients with concussion or blast injury. We developed an algorithm for eye tracking in which the Cartesian coordinates of the right and left pupils are tracked over 200 sec and compared to each other as a subject watches a short film clip moving inside an aperture on a computer screen. We prospectively eye tracked 64 normal healthy noninjured control subjects and compared findings to 75 trauma subjects with either a positive head computed tomography (CT) scan (n=13), negative head CT (n=39), or nonhead injury (n=23) to determine whether eye tracking would reveal the disconjugate gaze associated with both structural brain injury and concussion. Tracking metrics were then correlated to the clinical concussion measure Sport Concussion Assessment Tool 3 (SCAT3) in trauma patients. Five out of five measures of horizontal disconjugacy were increased in positive and negative head CT patients relative to noninjured control subjects. Only one of five vertical disconjugacy measures was significantly increased in brain-injured patients relative to controls. Linear regression analysis of all 75 trauma patients demonstrated that three metrics for horizontal disconjugacy negatively correlated with SCAT3 symptom severity score and positively correlated with total Standardized Assessment of Concussion score. Abnormal eye-tracking metrics improved over time toward baseline in brain-injured subjects observed in follow-up. Eye tracking may help quantify the severity of ocular motility disruption associated with concussion and structural brain injury.