The Impact of Asymptomatic Human Immunodeficiency Virus-Positive Disease Status on Inpatient Complications Following Spine Surgery: A Propensity Score-Matched Analysis.

In the United States, nearly 1.2 million people > 12 years old have human immunodeficiency virus (HIV), which is associated with postoperative complications following orthopedic procedures. Little is known about how asymptomatic HIV (AHIV) patients fare postoperatively. This study compares complications after common spine surgeries between patients with and without AHIV. The Nationwide Inpatient Sample (NIS) was retrospectively reviewed from 2005-2013, identifying patients aged > 18 years who underwent 2-3-level anterior cervical discectomy and fusion (ACDF), ≥4-level thoracolumbar fusion (TLF), or 2-3-level lumbar fusion (LF). Patients with AHIV and without HIV were 1:1 propensity score-matched. Univariate analysis and multivariable binary logistic regression were performed to assess associations between HIV status and outcomes by cohort. 2-3-level ACDF (n = 594 total patients) and ≥4-level TLF (n = 86 total patients) cohorts demonstrated comparable length of stay (LOS), rates of wound-related, implant-related, medical, surgical, and overall complications between AHIV and controls. 2-3-level LF (n = 570 total patients) cohorts had comparable LOS, implant-related, medical, surgical, and overall complications. AHIV patients experienced higher postoperative respiratory complications (4.3% vs. 0.4%,). AHIV was not associated with higher risks of medical, surgical, or overall inpatient postoperative complications following most spine surgical procedures. The results suggest the postoperative course may be improved in patients with baseline control of HIV infection.

Anatomic consideration for standard and modified techniques of cervical lateral mass screw placement.

BACKGROUND CONTEXT: Posterior screw placement techniques have been previously described. Each technique differs with respect to starting point, lateral angulation and sagittal orientation. PURPOSE: To examine the potential for injury to critical anatomic structures, such as nerve roots and vertebral arteries, during posterior cervical screw placement and to determine safe screw placement. STUDY DESIGN/SETTING: An anatomic study was conducted to determine the optimal screw angulation for posterior cervical lateral mass screws. SPECIMEN SAMPLE: Ten fresh-frozen human cadaveric cervical spine specimens were used, consisting of four females and six males, ranging in age from 32 to 68 years. OUTCOME MEASURES: Angular measurements and distance from nerve root and vertebral arteries were measured with a single caliper and recorded. One millimeter of proximity to a vital structure was considered a violation of that structure. METHODS: Ten fresh-frozen human cadaveric cervical spine specimens were instrumented from C2 to C7 by a single surgeon. Kirschner wires (2.0 mm) were used to reproduce the Roy-Camille, Anderson and Magerl screw trajectories. The wire was drilled through each lateral mass, simulating overdrill error. Each technique was instrumented according to the original description and with additional modifications. The modification consisted of varying the angle of screw placement in the axial plane of the original description from 0 to 30 degrees. Distances to the closest neurovascular structures were averaged for all assays. RESULTS: The Magerl technique is safe at the standard position and modified positions of 20 degrees and 30 degrees from C3-C6. The Roy-Camille technique frequently violates neurovascular structures below C3, especially the nerve root with more lateral screw angulation. The standard technique is noted to have good bone purchase only at C2 and C3. The Anderson technique is safe at 20 degrees and 30 degrees modified positions from C3-C7. Posterior screw placement at the C7 vertebral level was safe only with a modified Anderson technique of 20 degrees and 30 degrees of lateral screw angulation. CONCLUSIONS: The present study indicates that there are significant differences of potential neurovascular injury, which is dependent on the technique used for screw entry, the level instrumented and the angle of screw trajectory in the parasagittal plane.

Surfing for scoliosis: the quality of information available on the Internet.

STUDY DESIGN: A cross section of Web sites accessible to the general public was surveyed. OBJECTIVE: To evaluate the quality and accuracy of information on scoliosis that a patient might access on the Internet. SUMMARY OF BACKGROUND DATA: The Internet is a rapidly expanding communications network with an estimated 765 million users worldwide by the year 2005. Medical information is one of the most common sources of inquires on the Web. More than 100 million Americans accessed the Internet for medical information in the year 2000. Undoubtedly, the use of the Internet for patient information needs will continue to expand as Internet access becomes more readily available. This expansion combined with the Internet's poorly regulated format can lead to problems in the quality of information available. Since the Internet operates on a global scale, implementing and enforcing standards have been difficult. The largely uncontrolled information can potentially negatively influence consumer health outcomes. METHODS: To identify potential sites, five search engines were selected and the word "scoliosis" was entered into each search engine. A total of 50 Web sites were chosen for review. Each Web site was evaluated according to the type of Web site, quality content, and informational accuracy by three board-certified academic orthopedic surgeons, fellowship trained in spinal surgery, who each has been in practice for a minimum of 8 years. Each Web site was categorized as academic, commercial, physician, nonphysician health professional, and unidentified. In addition, each Web site was evaluated according to scoliosis-specific content using a point value system of 32 disease-specific key words pertinent to the care of scoliosis on an ordinal scale. A list of these words is given. Point values were given for the use of key words related to disease summary, classifications, treatment options, and complications. The accuracy of the individual Web site was evaluated by each spine surgeon using a scale of 1 to 4. A score of 1 represents that the examiner agreed with less than 25% of the information while a score of 4 represents greater than 75% agreement. RESULTS: Of the total 50 Web sites evaluated, 44% were academic, 18% were physician based, 16% were commercial, 12% were unidentified, and 10% were nonphysician health professionals. The quality content score (maximum, 32 points) for academic sites was 12.6 +/- 3.8, physician sites 11.3 +/- 4.0, commercial sites 11 +/- 4.2, unidentified 7.6 +/- 3.9, and nonphysician health professional site 7.0 +/- 1.8. The accuracy score (maximum, 12 points) was 6.6 +/- 2.4 for academic sites, 6.3 +/- 3.0 for physician-professional sites, 6.0 +/- 2.7 for unidentified sites, 5.5 +/- 3.8 for nonphysician professional sites, and 5.0 +/- 1.5 for commercial Web sites. The academic Web sites had the highest mean scores in both quality and accuracy content scores. CONCLUSION: The information about scoliosis on the Internet is of limited quality and poor information value. Although the majority of the Web sites were academic, the content quality and accuracy scores were still poor. The lowest scoring Web sites were the nonphysician professionals and the unidentified sites, which were often message boards. Overall, the highest scoring Web site related to both quality and accuracy of information was www.srs.org. This Web site was designed by the Scoliosis Research Society. The public and the medical communities need to be aware of these existing limitations of the Internet. Based on our review, the physician must assume primary responsibility of educating and counseling their patients.

A multicenter study of the outcomes of the surgical treatment of adolescent idiopathic scoliosis using the Scoliosis Research Society (SRS) outcome instrument.

STUDY DESIGN: A multicenter study of the outcomes of the surgical treatment of adolescent idiopathic scoliosis using the Scoliosis Research Society Questionnaire (SRS 24). OBJECTIVE: To evaluate the patient based outcome of the surgical treatment of adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: A paucity of information exists with respect to patient measures of outcome regarding the surgical treatment of adolescent idiopathic scoliosis. To our knowledge, no prospective outcome study on this topic thus far exists. METHODS: Using the SRS 24 questionnaire, seven scoliosis centers agreed to prospectively assess outcome for surgically treated patients with adolescent idiopathic scoliosis. Data were collected before surgery and at 24 months after surgery. Data were analyzed using paired and independent samples t test for all seven SRS 24 questionnaire domains (Pain, General Self-Image, Postoperative Self-Image, Postoperative Function, Function From Back Condition, General Level of Activity, and Satisfaction) using Statistical Package for Social Science. The domains were analyzed with respect to the total cohort, gender, curve magnitude, and type of surgery using independent-samples t tests. RESULTS: A total of 242 patients were included in our analysis. A baseline preoperative pain level of 3.68 of 5 was found. This improved to 4.63 after surgery, representing an improvement of 0.95 points. Surgical intervention was associated with improving outcome when compared with preoperative status. Pain, General Self-Image, Function From Back Condition, and Level of Activity all demonstrated statistically significant improvement as compared with preoperative status (P < 0. 001). Overall, patients were highly satisfied with the results of surgery. CONCLUSION: Preoperative pain exists in our adolescent scoliosis population. Pain scores were improved in our study population at the 2-year postsurgical follow-up. Statistically significant improvements were likewise seen in the General Self-Image, Function From Back Condition, and Level of Activity domains. The present study demonstrates the ability of surgery to improve the outcome of patients afflicted with adolescent idiopathic scoliosis.

Factors involved in the decision to perform a selective versus nonselective fusion of Lenke 1B and 1C (King-Moe II) curves in adolescent idiopathic scoliosis.

STUDY DESIGN: A retrospective evaluation of 203 adolescent idiopathic scoliosis patients with Lenke 1B or 1C (King-Moe II) type curves. OBJECTIVES: To evaluate the incidence of inclusion of the lumbar curve in the treatment of this type of deformity as well as radiographic factors associated with lumbar curve fusion. SUMMARY OF BACKGROUND DATA: In patients with structural thoracic curves and compensatory lumbar curves, many authors have recommended fusing only the thoracic curve (selective thoracic fusion). Studies have shown that correction of the thoracic curve results in spontaneous correction of the unfused lumbar curve; however, in some cases, truncal decompensation develops. Though there have been various attempts to define more accurately what type of curve pattern should undergo selective fusion, controversy continues in this area. METHODS: Measurements were obtained from the preoperative standing posteroanterior and side-bending radiographs of 203 patients with Lenke Type 1B or 1C curves from five sites of the DePuy AcroMed Harms Study Group. Patients were divided into two groups depending on their most distal vertebra instrumented: the "selective thoracic fusion" group included patients who were fused to L1 or above and the "nonselective fusion" group included patients fused to L2 or below. A statistical comparison was conducted to identify variables associated with the choice for a nonselective fusion. RESULTS: The incidence of fusion of the lumbar curve ranged from 6% to 33% at the different patient care sites. Factors associated with nonselective fusion included larger preoperative lumbar curve magnitude (42 +/- 10 degrees vs. 37 +/- 7 degrees, P < 0.01), greater displacement of the lumbar apical vertebra from the central sacral vertical line, (3.1 +/- 1.4 cm vs. 2.2 +/- 0.8 cm, P < 0.01), and a smaller thoracic to lumbar curve magnitude ratio (1.31 +/- 0.29 vs. 1.44 +/- 0.30, P = 0.01). CONCLUSIONS: The characteristics of the compensatory "nonstructural" lumbar curve played a significant role in the surgical decision-making process and varied substantially among members of the study group. Side-bending correction of the lumbar curve to <25 degrees (defining these as Lenke 1, nonstructural lumbar curves) was not sufficientcriteria to perform a selective fusion in some of these cases. The substantial variation in the frequency of fusing the lumbar curve (6% to 33%) confirms that controversy remains about when surgeons feel the lumbar curve can be spared in Lenke 1B and 1C curves. Site-specific analysis revealed that the radiographic features significantly associated with a selective fusion varied according to the site at which the patient was treated. The rate of selective fusion was 92% for the 1B type curves compared to 68% for the 1C curves.