Skipped versus consecutive pedicle screw constructs for correction of Lenke 1 curves.

PURPOSE: Thoracic pedicle screws provide superior curve correction to hook and wire constructs in adolescent idiopathic scoliosis, while increasing cost. The number of implants required for best correction and outcome has not yet been determined. METHODS: We retrospectively reviewed pre- and post-operative radiographs and self-reported outcome measures in an age- and curve-matched cohort of 40 patients with Lenke I AIS who underwent selective fusions between T3/4 and L1. Twenty patients were treated with thoracic pedicle screws at every level bilaterally (CON) and 20 patients with screws at every level on the concave side and skipped levels on the convex side of the curve (SKP). All patients had a minimum 2-year follow-up. Radiographs were assessed for coronal and sagittal curvatures, as well as thoracic torsion and vertebral rotation. Health-related quality of life was assessed using the SRS-22 instrument. Instrumentation cost data were collected for each case. RESULTS: Postoperative follow-up averaged 28 months for the CON group and 29 months for the SKP group. No statistically significant differences were found between groups with respect to age and pre- and post-operative radiographic parameters. Both constructs provided acceptable correction of the main thoracic curves (66.9 vs. 66.6 %, CON group and SKP group, respectively; p = 0.92), and spontaneous correction of the proximal thoracic (41.5 vs. 41.1 %; p = 0.92) and thoracolumbar/lumbar curves (54.8 vs. 54.3 %; p = 0.92). No significant difference was found in postoperative SRS-22 scores (96 vs. 94.3; p = 0.34). The CON group cost for instrumentation was significantly higher than the SKP group ($19,500 vs. $13,300; p = 0.002). There was no statistically significant difference in operating room times between groups. CONCLUSION: Both construct types provide excellent coronal correction and sagittal balance, with no significant differences in radiographic findings or clinical outcomes. A significant decrease in cost was found with use of skipped screw constructs.

The increased prevalence of cervical spondylosis in patients with adult thoracolumbar spinal deformity.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess the concomitance of cervical spondylosis and thoracolumbar spinal deformity. SUMMARY OF BACKGROUND DATA: Patients with degenerative cervical spine disease have higher rates of degeneration in the lumbar spine. In addition, degenerative cervical spine changes have been observed in adult patients with thoracolumbar spinal deformities. However, to the best of our knowledge, there have been no studies quantifying the association between cervical spondylosis and thoracolumbar spinal deformity in adult patients. METHODS: Patients seen by a spine surgeon or spine specialist at a single institution were assessed for cervical spondylosis and/or thoracolumbar spinal deformity using an administrative claims database. Spinal radiographic utilization and surgical intervention were used to infer severity of spinal disease. The relative prevalence of each spinal diagnosis was assessed in patients with and without the other diagnosis. RESULTS: A total of 47,560 patients were included in this study. Cervical spondylosis occurred in 13.1% overall, but was found in 31.0% of patients with thoracolumbar spinal deformity (OR=3.27, P<0.0001). Similarly, thoracolumbar spinal deformity was found in 10.7% of patients overall, but was increased at 23.5% in patients with cervical spondylosis (OR=3.26, P<0.0001). In addition, increasing severity of disease was associated with an increased likelihood of the other spinal diagnosis. Patients with both diagnoses were more likely to undergo both cervical (OR=3.23, P<0.0001) and thoracolumbar (OR=4.14, P<0.0001) spine fusion. CONCLUSIONS: Patients with cervical spondylosis or thoracolumbar spinal deformity had significantly higher rates of the other spinal diagnosis. This correlation was increased with increased severity of disease. Patients with both diagnoses were significantly more likely to have received a spine fusion. Further research is warranted to establish the cause of this correlation. Clinicians should use this information to both screen and counsel patients who present for cervical spondylosis or thoracolumbar spinal deformity.

Progressive Gorham disease of the forearm.

Gorham's-Stout disease is a rare but potentially debilitating disease consisting of massive bone osteolysis and bone resorption associated with vascular proliferation and increased osteoclastic activity. Although it can present in a wide variety of forms, it typically involves bones formed by intramembranous ossification such as the skull, pelvis, and scapula. It can occur spontaneously or after trauma. Most cases are monofocal and resolved spontaneously, although there are reports of multifocal and rapidly progressing disease. It typically presents as disuse muscle atrophy or pathologic fracture during the second through fourth decades of life, yet it has also been reported in childhood and in the elderly. The etiology of Gorham's disease remains to be fully elucidated. Gorham attributed the origin of the disease to uncontrolled proliferation of small vessels eating away bone tissue. Other authors attribute the cause of the disease to increased osteoclastic activity mediated by elevated cytokine levels and increased osteoclastic differentiation. Treatment is not established and focuses at stopping osteoclastic activity and angiogenic proliferation. Radiation therapy, chemotherapy, bone grafting, and antiresorptives medications have all been used with different degrees of success. In an effort to further characterize this elusive disease, we report on an unusual presentation of a patient with Gorham's disease of the radius spreading to the ulna and then the proximal humerus with a 13-year follow-up. To our knowledge this is the first report in the literature of a saltatory type of Gorham's disease spreading from bone to bone across a joint.

The validity of the OSA-18 among three groups of pediatric patients.

OBJECTIVE: To compare the signs and symptoms of obstructive sleep apnea syndrome in three groups of pediatric patients; solid organ transplant recipients, healthy children, and children with leukemia; in order to examine the effects of chronic illness on the obstructive sleep apnea-18-item questionnaire and to investigate its validity as a screening tool for obstructive sleep apnea in the pediatric solid organ transplant population. METHODS: In this cross-sectional study, there were two hundred and six subjects; 46 kidney transplant recipients, 59 liver transplant recipients, 34 patients with leukemia, and 67 healthy children. Adenotonsillar enlargement was assessed by using the obstructive sleep apnea-18-item questionnaire and by performing a focused physical examination of the oral and nasal cavity at the time of the child's routine visit in either the transplant clinic, outpatient oncology center, or general pediatric clinic. RESULTS: Comparison of questionnaire scores amongst the three groups showed significant differences between the healthy children and liver transplant recipients as well as those with leukemia. There was a significant difference in the physical examination scores of the children with leukemia as compared to the other groups. CONCLUSIONS: Adenotonsillar enlargement in pediatric transplant recipients can be an early indication of post-transplantation lymphoproliferative disorder. However, the prevalence of adenotonsillar enlargement in the transplant population does not appear to differ from that of the healthy population. Additionally, scores on the OSA-18 in the transplant population were confounded by chronic illness. Further prospective studies need to be performed to develop a screening tool to identify transplant recipients at risk for post-transplantation adenotonsillar lymphoma.

Hospital readmission rates after surgical treatment of primary and metastatic tumors of the spine.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: This study aimed to identify the rates and causes of unplanned hospital readmission at 30 days and 1 year after surgical treatment of primary and metastatic spinal tumors. SUMMARY OF BACKGROUND DATA: Primary spine tumors and non-spine tumors metastatic to the spine can represent complex problems for surgical treatment, but surgical intervention can provide significant patients with significant improvements in quality of life. However, recent emphasis on decreasing the cost of health care has led to a focus on quality measures such as hospital readmission rates. METHODS: At a large referral spine center between 2005 and 2011, 197 patients with primary (n = 33) or metastatic (n = 164) tumors of the spine were enrolled. Hospital readmissions within 1 year were reviewed. Kaplan-Meier analysis was performed to estimate unplanned hospital readmission rates, and risk factors were evaluated using a Cox proportional hazards model. RESULTS: Unplanned hospital readmission rates were 6.1% and 16.8% at 30 days for primary and metastatic tumors (P = 0.126), respectively, and 27.5% and 37.8% at 1 year (P = 0.262). Metastatic tumors with aggressive biology (i.e., lung, osteosarcoma, stomach, bladder, esophagus, pancreas) caused higher rates of readmission than other types of metastatic tumors. One-third of readmissions were due to recurrent disease, whereas 23.3% were due to surgical complications and 43.3% due to medical complications. Numerous medical comorbidities increased the risk of unplanned hospital readmission. CONCLUSION: Unplanned hospital readmissions after surgical intervention for spine tumors are common, and patients with aggressive metastatic tumors are at increased risk. In addition, comorbid medical problems are important risk factors that increase the chance that a patient will require hospital readmission within 1 year. LEVEL OF EVIDENCE: 3.

Hospital readmission after spine fusion for adult spinal deformity.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess the rate, causes, and risk factors of unplanned hospital readmission after spine fusion for the treatment of adult spinal deformity. SUMMARY OF BACKGROUND DATA: Hospital readmissions in the elderly are common, and with increasing emphasis on the quality of health care, readmission rates are used to assess hospital performance. Spine surgery has seen rapidly increased utilization during the past 2 decades. Surgical treatments of complex spinal deformity are known to have higher rates of complications than other types of spine surgery. However, there are no reports describing the rates and causes of hospital readmission after deformity surgery. METHODS: Patients were identified at a single institution from 2006 through 2011 that received a spine fusion for the treatment of adult spinal deformity. All hospital readmissions within 90 days of discharge were reviewed for cause. Unplanned readmission rates were calculated via Kaplan-Meier failure analysis. Rates were compared across patients receiving different lengths of spine fusion (short: 2-3 vertebra, medium: 4-8, long: 9 or more). Risk factors were assessed using a Cox proportional hazards multivariate model. RESULTS: Eight hundred thirty-six patients were enrolled (111 short, 402 medium, and 323 long fusions). The overall unplanned readmission rate was 8.4% at 30 days and 12.3% at 90 days. Patients with long spine fusion had higher rates of readmission than patients with medium or short length fusions. Surgical site infection accounted for 45.6% of readmissions. Risk factors for readmission include longer fusion length, higher patient severity of illness, and specific medical comorbidities. CONCLUSION: Unplanned hospital readmissions after spine fusion for adult spinal deformity are common, and are most often due to surgical site infection. Patient medical comorbidities are an important part of assessing risk and can be used by providers and patients to better assess individual risk prior to treatment.

Quality of information concerning cervical disc herniation on the Internet.

BACKGROUND CONTEXT: Many Americans seek and are influenced in their decision making by medical information on the Internet. Past studies have repeatedly found information on most medical Web sites to be deficient and of low quality. Physicians must remain aware of the quality and reliability of the information available on the Internet for patient education purposes. PURPOSE: To assess quality and authorship of Internet Web sites regarding a common cervical spine disorder, cervical disc herniation. STUDY DESIGN: The present study is a systematic quality assessment survey of Web sites concerning cervical disc herniation. METHODS: Fifty relevant and unique sites were identified. The five most popular search engines were used to identify 100 Web sites using the search term, "cervical disc herniation." Using a validated technique, three orthopedic surgeons independently generated content quality scores and accuracy scores, then integrated into a single final total summary score for each Web site. RESULTS: Four of the five identified top-scoring Web sites were found to be commercial and one was academic. Most of the Web sites were found to be physician sponsored, followed by academic and commercial. CONCLUSIONS: There is wide variability in Web site quality, with most of the Web sites failing to be sufficiently comprehensive and accurate. Physicians treating patients with cervical disc herniation must remain vigilant in guiding their patients to proper information on the Internet.

Uncontrolled hemorrhage in insulin-dependent diabetic rats.

OBJECTIVES: Diabetes mellitus (DM) is a known risk factor for higher morbidity and mortality after trauma. The authors tested the hypothesis that there is a difference in the response to uncontrolled hemorrhage between normal euglycemic rats and insulin-dependent diabetic rats. METHODS: Thirty-one adult male Sprague-Dawley rats were used in this study. Fifteen streptozocin (STZ)-injected rats became diabetic (DM+) 2 weeks after treatment. Sixteen rats served as nondiabetic controls (DM-). All rats were anesthetized with Althesin and their femoral arteries were catheterized via cutdown, allowing continuous monitoring of vital signs. Sixteen (eight DM-, eight DM+) rats underwent uncontrolled hemorrhage by 75% tail amputation. Fifteen (eight DM-, seven DM+) rats served as non-hemorrhage controls. The mean arterial pressure (MAP), lactate, and cumulative hemorrhage volume per 100 g were measured pre-hemorrhage and then every 15 minutes post-hemorrhage for 2 hours. Data were reported as mean +/- standard deviation. Interval data were analyzed by analysis of variance (two tails, alpha = 0.05). RESULTS: Pre-hemorrhage glucose was significantly higher (p < 0.001) in the DM+ (357.9 +/- 22.2 mg/dL) versus DM- (125.7 +/- 9.7 mg/dL) rats. At baseline, there was no significant difference in weight, MAP, or lactate between DM+ and DM- rats. Body-weight-adjusted mean cumulative hemorrhage volume was significantly greater (p < 0.04) in diabetic rats (2.52 +/- 0.15 cm(3)/100 g body weight) than the nondiabetic rats (1.86 +/- 0.25 cm(3)/100 g body weight). CONCLUSIONS: Compared to nondiabetic rats, diabetic rats suffered a greater blood loss after the same uncontrolled vascular injury.

The effect of ethanol on uncontrolled hemorrhage in a rodent model.

OBJECTIVES: Ethanol intoxication has hemodynamic and metabolic effects after hemorrhage according to studies using fixed-volume controlled blood loss models. The authors tested the null hypothesis that after uncontrolled hemorrhage there would be no difference in the hemodynamic responses between ethanol-intoxicated (EtOH+) and nonintoxicated (EtOH-) rats. METHODS: Forty Sprague-Dawley rats were anesthetized with althesin intraperitoneally. Twenty EtOH+ rats received a 3-g/kg dose of 20% ethanol intraperitoneally 60 minutes before hemorrhage. The EtOH- rats received an equivalent volume of normal saline intraperitoneally. The femoral artery was cannulated by cutdown to monitor the mean arterial blood pressure (MAP) and to obtain blood samples for lactate (LAC). Twenty rats (ten EtOH+ and ten EtOH-) underwent uncontrolled hemorrhage by 75% tail amputation. Twenty rats (ten EtOH+ and ten EtOH-) served as nonhemorrhage controls. The MAP, LAC, and cumulative hemorrhage volume were measured prehemorrhage and then every 15 minutes posthemorrhage for 120 minutes. Data were reported as mean +/- SEM. Group comparisons were analyzed by analysis of variance with repeated values and post hoc testing by Bonferroni (two tailed; alpha = 0.05). RESULTS: Initially, EtOH+ and EtOH- rats were evenly matched for LAC and MAP. The mean (+/-SD) baseline ethanol level was 170 (+/-68) mg/dL in EtOH+ rats. Cumulative hemorrhage volume was similar (p = 0.23) for the EtOH- (2.36 +/- 0.24 mL/100 g) and EtOH+ (1.87 +/- 0.32 mL/100 g) rats. No significant difference was noted in posthemorrhage MAP between EtOH- (68.6 +/- 6.8 mm Hg) and EtOH+ (69.3 +/- 7.2 mm Hg) rats (p = 1.00). The EtOH- group had a significantly higher LAC (4.94 +/- 1.07 mmol/L) than the EtOH+ group (2.27 +/- 0.59 mmol/L) (p < 0.03). CONCLUSIONS: Ethanol intoxication does not deleteriously affect the hemodynamic response to uncontrolled hemorrhage.