Elective Lumbar Spine Surgery in Depressed Patients: Is it Worth it?

BACKGROUND: The objective of this study is to compare surgical results (pain, function, and satisfaction) between a group of depressed patients and a nondepressed group who had been operated on for a degenerative lumbar condition. METHODS: Prospective observational study. Preoperative pain (lumbar and radicular visual analog scale [VAS]), function (Oswestry Disability Index [ODI]), and depression (Zung depression scale) data were collected in patients listed to be operated on for a lumbar degenerative condition. One year postoperatively, ODI and VAS data were collected again as well as a satisfaction question (are you satisfied with the surgical results? Yes/no). RESULTS: Ninety-seven patients were included in the study, 78 nondepressed patients (80.4%) and 19 depressed patients (19.6%). Preoperatively, depressed patients had more lumbar pain (P = .00) and more functional limitation (P = .01) than nondepressed patients. One year postoperatively, depressed patients had more radicular pain (P = .029) and more functional limitation (P = .03) than non-depressed patients. The overall improvement of pain and function was similar between both groups (not significant). Seventy percent of depressed patients and 80% of nondepressed patients were satisfied with the surgical outcome (P = .52) 1 year postoperatively. CONCLUSION: Depressed patients experience the same overall level of improvement as nondepressed patients, despite having more pain and functional limitation preoperatively and 1 year after elective lumbar spine surgery than nondepressed patients. The level of satisfaction does not differ significantly between the two groups. LEVEL OF EVIDENCE: 2.

Viability and long-term survival of short-segment posterior fixation in thoracolumbar burst fractures.

BACKGROUND CONTEXT: Short-segment pedicle screw instrumentation constructs for the treatment of thoracolumbar fractures gained popularity in the 1980s. The load-sharing classification (LSC) is a straightforward way to describe the extent of bony comminution, amount of fracture displacement, and amount of correction of kyphotic deformity in a spinal fracture. There are no studies evaluating the relevance of fracture comminution/traumatic kyphosis on the long-term radiologic outcome of burst fractures treated by short-segment instrumentation with screw insertion in the fractured level. PURPOSE: To evaluate the efficacy of the six-screw construct in the treatment of thoracolumbar junction burst fractures and the influence of the LSC score on the 2-year radiologic outcome. STUDY DESIGN: Case series of consecutive patients of a single university hospital. PATIENT SAMPLE: Consecutive patients from one university hospital with nonosteoporotic thoracolumbar burst fractures. OUTCOME MEASURES: Being a radiology-based study, the outcome measures are radiologic parameters (regional kyphosis [RK], local kyphosis, and thoracolumbar kyphosis [TLK]) that evaluate the degree and loss of correction. METHODS: Retrospective analysis of all consecutive patients with nonosteoporotic thoracolumbar burst fractures managed with a six-screw construct in a single university hospital, with more than 2 years' postoperative follow-up. RESULTS: Eighty-six patients met the inclusion criteria, and 72 (83.7%) with available data were ultimately included in the study. The sample included 53 men and 19 women, with a mean (standard deviation [SD]) age of 35.6 years (14.4 years) at the time of surgery. Mean LSC score was 6.3 (SD 1.6, range 3-9). Forty-four of 62 (70.9) fractures had a score greater than 6. Mean (SD) RK and TLK deteriorated significantly during the first 6 months of follow-up: 2.90° (4.54°) p=.005 and 2.78° (6.45°) p=.069, respectively. Surgical correction correlated significantly (r=0.521, p<.0001) with the time elapsed until surgery. Loss of surgical correction (postoperative to 6-month RK and TLK increase) correlated significantly with the LSC score (r=0.57, p=.004; r=0.51, p=.022, respectively). Further surgery because of correction loss was not required in any case. CONCLUSIONS: The six-screw construct is effective for treating thoracolumbar junction burst fractures. The medium-to-long-term loss of correction is affected by the amount of bony comminution of the fracture, objectified through the LSC score.

Poor outcomes and satisfaction in adolescent idiopathic scoliosis surgery: the relevance of the body mass index and self-image.

INTRODUCTION AND AIM: The purpose of this study was to evaluate patients with adolescent idiopathic scoliosis (AIS) to determine whether a low body mass index (BMI) influences surgery outcomes and satisfaction. METHODS: There were 39 patients in this prospective 3-year cohort study. The BMI, Cobb angle, the Body Shape Questionnaire 14 (BSQ-14), the Scoliosis Research Society Questionnaire 22 (SRS-22) and eight satisfaction questions results were obtained. Having a BMI greater than or less than 18 kg/m(2) was used as a determiner to allocate patients to groups. As a low BMI is related to the presence of a disturbance in body perception, patients were also dichotomized by using the BSQ-14. RESULTS: All scales were worse in both slimmer patients and the group with a body perception disorder. The group with a BMI <18 kg/m(2) obtained a total of 82.31 points in the SRS-22, and it was 93.45 points for the group with a BMI >18 kg/m(2) (p = 0.001). In terms of satisfaction, the percentage of patients that would undergo surgery again was 30.8 vs 69.2 % (p = 0.054). Patients with an alteration of physical perception obtained a total SRS-22 of 82.90 points versus 96.10 points in the control group (p < 0.001). No differences in terms of the Cobb correction (p = 0.29) or the percentage of correction (p = 0.841) were found in any case. CONCLUSION: The alteration of physical perception and a low BMI negatively affect the outcomes in AIS surgery, regardless of the curve magnitude and the percentage of correction. Considerable care should be taken in recommending surgical correction to these patients.

Industrially prefabricated cement spacers: do vancomycin- and gentamicin-impregnated spacers offer any advantage?

BACKGROUND: Industrially preformed antibiotic-loaded cement spacers are useful to facilitate the second stage of two-stage exchange arthroplasty for infected THAs and TKAs. However, whether gentamicin alone or a combination of antibiotics (such as vancomycin and gentamicin) is more effective is not known. QUESTIONS/PURPOSES: We therefore sought to compare industrially prefabricated spacers containing either gentamicin or gentamicin and vancomycin with respect to (1) infection control, (2) complications, and (3) quality of life, pain, and patient satisfaction. METHODS: We performed a review of 51 patients with chronic infections treated at one center using either gentamicin or vancomycin and gentamicin-prefabricated spacers. The former were used exclusively from January 2006 until May 2009, and the latter from June 2009 until July 2011, and there was no overlap. We collected data on demographics, immunologic status (McPherson classification), prosthetic joint infection location, type of prosthesis, microbiologic results, and time between stages. We evaluated the primary outcome of infection control or recurrence after at least 12 months followup. We also recorded complications. Each patient completed a quality-of-life survey, VAS, and a self-administered satisfaction scale. RESULTS: The overall infection control rate was 83% after a mean followup of 35 months (range, 12.4-64.7 months). There were no differences between gentamicin and vancomycin and gentamicin spacers in terms of infection eradication (80 % versus 85 %, respectively; p = 0.73), nor in terms of complications, quality of life, pain, or satisfaction scores. CONCLUSIONS: Prefabricated, antibiotic-loaded cement spacers has been proven effective for infection control in TKAs and THAs but with the numbers available, we did not find any differences between a gentamicin or vancomycin and gentamicin-prefabricated spacer, and therefore, we are unable to validate the superiority of the combination of vancomycin and gentamicin over gentamicin alone. Because of the higher costs involved with vancomycin and gentamicin spacers, and the potential risks of unselective use of vancomycin, further comparative studies are necessary to evaluate their role in the treatment of infected THAs or TKAs. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Fracture of the anteromedial tibial plateau associated with posterolateral complex injury: case study and literature review.

We report an unusual case of anteromedial tibial plateau compression fracture following hyperextension and forced varus of the knee, resulting in an anterior bone fragment large enough to require osteosynthesis. This uncommon lesion was associated with posterolateral complex injury, diagnosed with magnetic resonance imaging (MRI), while both cruciate ligaments were preserved. After proceeding with tibial plateau osteosynthesis, a peroneal tendon allograft was used for supplementation repair of the lateral collateral ligament and biceps tendon in a single surgical intervention. Tibial plateau fractures are often associated with soft-tissue involvement, mainly of the anterior cruciate ligament and external meniscus. Posterolateral complex injuries also occur with a mechanism of forced varus and hyperextension. These lesions require an accurate diagnosis to avoid future knee instability; moreover, adequate treatment in the acute phase provides a better functional outcome. Physicians should suspect associated posterolateral complex injury when an anteromedial tibial plateau fracture is diagnosed. MRI allows adequate diagnosis and permits surgical treatment in one procedure.

Body composition in adolescent idiopathic scoliosis.

STUDY DESIGN: A controlled prospective cross-sectional case study. OBJECTIVE: To investigate body mass index (BMI) and corporal composition in girls with adolescent idiopathic scoliosis (AIS) and compare them with a normal population matched by sex and age. There is controversy as to whether there are real anthropometric alterations in patients with AIS. Relative to the weight or the BMI, some studies find differences and other studies do not detect them. AIS and anorexia nervosa (AN) make their debut during adolescence and both may be associated with an alteration of their subjective physical perception. Some authors propose a link between AIS and AN supported both by an alteration of physical perception and lower BMI. No studies on body composition in AIS have been published. METHODS: Adolescent idiopathic scoliosis patient surgery candidates during 2008 were studied. Body composition was evaluated using the bioelectrical impedance analysis (Bodystat, Isle of Man, UK). A study population of more than 5,000 patients that was published by Kyle et al. (Nutrition 17:534-541, 2001) was chosen as a control (group 1). Another control group (group 2) of healthy volunteers matched by sex and age was selected among a school age and university population in Barcelona, Spain. A variance analysis was used to analyze differences between the mean values of the control group 1, the European control group, and the AIS patient surgery candidates (Epiinfo 6.2001). Comparisons between the AIS patients and control group 2 were performed with the T Student test of unpaired samples using the SPSS 15.0 (Statistical Package Social Science) software. RESULTS: Twenty-seven women with a mean age of 17.4 years. BMI was 18.9 kg/m(2) (SD 1.7; 95 % CI 18.31-19.73). In the variance analysis, a significant difference between AIS and group 1 in BMI was observed (21.0 vs. 18.9, p = 0.000004); fat-free mass (FFM = 42.6 vs. 38.9, p = 0.0000009) and fat mass (FM = 15.6 vs. 13.7, p = 0.03). Significant differences in BMI (22.13 vs. 18.9, p = 0.001; 95 % CI difference 1.85-4.60), fat mass index (FMi = 7.17 vs. 4.97, p = 0.000; 95 % CI difference 1.36-3.05) and fat-free mass index (FFMi = 14.95 vs. 13.09, p = 0.001; 95 % CI difference 0.26-1.86) between AIS and group 2 were also seen. CONCLUSION: The conclusion is that there is a real alteration of body composition in AIS. The BMI, FFMi and FMi are lower than in the general population in the series under study.

Effects of an educational audiovisual videodisc on patients' pre-operative expectations with total knee arthroplasty: a prospective randomized comparative study.

PURPOSE: To investigate the effectiveness of an educational videodisc in modifying pre-operative patients' expectations with total knee arthroplasty (TKA) and to find a biophysical profile of subjects in whom this videodisc could be most effective. It was hypothesized that patients receiving standard information plus additional medical information through audiovisual videodiscs would modify their pre-operative expectations more than those only receiving the standard information through medical interviews. METHODS: Ninety-two patients (age, 50-90 years) with knee osteoarthritis waiting for TKA were randomized into two groups. All patients received general verbal information about this procedure. Forty-two patients (study group) additionally viewed an educational videodisc related to the whole process of TKA, whereas 50 patients did not view it (control group). Patients completed baseline and post-videodisc questionnaires regarding their expected results after TKA. RESULTS: Expectations with TKA were not modified by the audiovisual videodisc, except for knee range of motion and use of stairs. There were no differences in change of expectations between groups depending on demographic, functional, health, emotional, and cognitive variables, except for body mass index. The overall pre-operative, pre-intervention expectations were not modified by the audiovisual videodisc. CONCLUSIONS: Based on these results, the use of this complementary tool may not be systematically recommended. In addition, it was not possible to identify a biophysical profile of patients in whom the intervention could be most effective.

Is Routine Postoperative Radiologic Follow-up Justified in Adolescent Idiopathic Scoliosis?

STUDY DESIGN: Retrospective review. OBJECTIVES: To determine whether routine periodic radiographic examination is worthwhile in adolescent idiopathic scoliosis (AIS) patients undergoing instrumented fusion with third-generation implants. SUMMARY OF BACKGROUND DATA: In common practice, patients who have undergone surgery for idiopathic scoliosis are followed up for a minimum of 2 years by clinical assessment and routine radiographic study at 3, 6, 12, and 24 months. The radiation related to these examinations is not negligible. To our knowledge, the use of routine radiographic follow-up after posterior spinal fusion for adolescent idiopathic scoliosis has not been evaluated. METHODS: We retrospectively analyzed full-spine X-rays and clinical records from the first 2 postoperative years of 43 patients. We sought any clinical feature (eg, pain, deformity progression, material protrusion) justifying X-ray, and any relevant radiologic finding (eg, loss of correction, instrumentation loosening, junctional kyphosis). RESULTS: Excluding the immediate postoperative films, 14.8% of X-rays were clinically justified, 8.3% were associated with a relevant finding, and 4.3% led to a therapy change. All patients with clinical deformity progression had a relevant X-ray finding. Pain was associated with a relevant finding in 23.5% of cases (positive predictive value, 0.1); 7.4% of films with no clinical justification showed a relevant finding (negative predictive value, 0.86). Lower Risser sign increased the risk of having a relevant radiographic finding (p < .05). CONCLUSIONS: With the current use of third-generation implants, routine biplanar postoperative X-rays at 3, 6, 12, and 24 months do not seem to be justified in AIS and should be avoided in mature, asymptomatic patients.

Predictors of blood transfusion in patients undergoing elective surgery for degenerative conditions of the spine.

BACKGROUND: The requirement of blood in the surgery of degenerative conditions of lumbar spine is around 10 %. Preoperative autologous blood donation is an effective method that is used in surgeries with an important blood loss. This is an expensive method because of the great number of predonated blood units not used in the postoperative period (around 70 % in our practice). OBJECTIVE: To know the risk factors associated with transfusion in the postoperative period in patients who undergo surgeries of degenerative conditions of the lumbar spine. METHODS: We designed a retrospective study of 142 cases of patients operated for degenerative conditions of the lumbar spine (not including simple disk hernia or adult degenerative scoliosis). RESULTS: Female sex, age >60 years, preoperative ASA score 3 and preoperative hemoglobin ≤136 g/L are the risk factors related to the need of blood transfusion in the postoperative period. After application of a statistical study, female sex and preoperative ASA score 3 were the most important variables to explain transfusional risk. A woman with ASA score 3 has a 61 % foretold probability to be transfused in the postoperative period, while a man with ASA < 3, only 1.1 %. For this reason, application of this method to patients with these risk factors is more cost-effective. CONCLUSIONS: Females, ASA 3, preoperative hemoglobin ≤136 g/L and age older than 60 years increase the risk to be transfused in the postoperative period for degenerative conditions of the spine.

Recurrent adjacent segment disease and cauda equina syndrome.

PURPOSE: A case of cauda equina lesion as a result of recurrent adjacent segment degeneration (ASD) after multiple lumbar fusions is reported. ASD might be a consequence of biomechanical overload or simply a normal degenerative process. The reported clinical relevance of ASD is rather low. We describe an unusual case of cauda equina compression at L1-L2 in a patient who had undergone L2-L4 fusion 8 years previously and 2 decompression-fusion surgeries 16 years before. MATERIALS AND METHODS: A 72-year-old man, who had two previous lumbar fusion-decompression procedures, underwent a third lumbar surgery in December 2000 to treat symptomatic spinal canal stenosis associated with L3-L4 pseudoarthrosis. After a symptom-free period of 8 years, the patient experienced low back pain radiating to both legs while standing, associated with saddle sensory disturbances and incontinence. Physical examination ruled out significant motor deficits. Plain radiographs showed solid fusion from L2 to L4, good spinal alignment, and low-grade L1-L2 retrolisthesis. Stainless steel pedicular instrumentation distorted magnetic resonance imaging, preventing adequate spinal canal evaluation. Electromyography demonstrated signs of cauda equina compression (bilateral L3-S2). CT myelography showed a stop at L1-L2, due to a severe spinal canal stenosis. L1-L2 decompression and fusion were performed. RESULTS: After an uneventful surgery with no complications, the symptoms abated and incontinence recovered. CONCLUSIONS: Even if the reported clinical relevance of ASD is very low, fused patients with a constitutional narrow spinal canal are at risk of developing severe neural compression at the level adjacent to the fusion.

The visual analog scale and a five-item verbal rating scale are not interchangeable for back pain assessment in lumbar spine disorders.

STUDY DESIGN: Prospective study of patients with chronic back pain from lumbar spine disorders. OBJECTIVE: To evaluate the degree of interchangeability of a 100-mm visual analog scale (VAS) and a 5-point verbal rating scale (VRS) for the assessment of pain intensity. SUMMARY OF BACKGROUND DATA: The fact that VAS and Likert scales are highly intercorrelated does not mean that both types of scales can be used interchangeably. METHODS.: A total of 151 patients (mean age, 52 ± 14.6 years) undergoing elective spine surgery completed a 100-mm VAS and a discrete 5-category VRS corresponding to the first item question of the core set ("How severe was your back pain in the last week?"). Pain intensity on the VAS was rated using the same question than for the VRS. The level of order-consistency (monotonic agreement), disordered pairs (D), percentage of agreement, and systematic disagreement (relative position), and relative concentration ([RC]) were estimated. VAS assessments were transformed into a discrete 5-category, with the cut-off VAS positions being defined by quintiles and equidistantly. RESULTS: For VAS defined equidistantly, monotonic agreement was 0.840, D was 0.080, and the percentage of identical pairs was 53%. The corresponding figures for VAS defined by quintiles were 0.809, 0.096, and 27.8%. Inconsistencies between the VAS and the VRS scales were also demonstrated by the marginal distributions, with PR values of -0.005 (95% confidence interval [CI], -0.011 to -0.002) and RC values of 0.144 (95% CI, 0.137-0.152) for VAS defined equidistantly, and PR values of 0.391 (95% CI, 0.384-0.397) and RC values of 0.265 (95% CI, 0.255-0.275) for VAS defined by quintiles. CONCLUSION: The order-consistency level was low with overlapping of pain records between the 2 scales, indicating that VAS and VRS are not interchangeable and, therefore, a results obtained with the use of each scale cannot be compared.

[Evaluation of the impact of the introduction of a functional knee arthroplasty unit]. / Evaluación del impacto asistencial de la puesta en funcionamiento de una unidad funcional de artroplastia de rodilla.

OBJECTIVES: To evaluate the impact of a functional knee arthroplasty unit in Hospital de l'Esperança (Barcelona) on resource consumption, quality indicators and the direct costs of the healthcare process. METHOD: We performed a retrospective study based on two cross-sections: the first in 317 patients who underwent surgery in 2004 before the implementation of the functional knee arthroplasty unit and the second in 624 patients who underwent surgery in 2005. Data related to the process, complications and costs were collected. RESULTS: The mean length of hospital stay decreased by 9 days (p<0.001). The number of patients requiring convalescence after the intervention increased by 9.5% (p<0.001). Overall, the total cost of the healthcare process decreased by 16%, from 9,031.34 to 7,591.54 euro (p<0.001). This cost reduction was due to decreases in the length of hospital stay (2,946.0 vs. 1,616.8 euro), surgery costs (2,156.7 vs. 1,776.7 euro) and prosthesis costs (2,730.5 vs. 2,678.1 euro). CONCLUSIONS: The implementation of the functional knee arthroplasty unit reduced overall costs and length of hospital stay and substantially increased activity while maintaining a similar complication rate.

Computer-assisted surgery can reduce blood loss after total knee arthroplasty.

The aim of this study was to compare blood loss and transfusion requirements in patients undergoing computer-assisted total knee arthroplasty (TKA) and patients operated with conventional instrumentation with intra-medullar guides. A prospective randomized study of 87 patients undergoing a TKA assigned to conventional technique (n = 44) or computer-assisted surgery (n = 43) was conducted. All patients were operated by the same surgeon and in all cases a cemented arthroplasty and deep recovery drainage were used. Both groups were comparable in all variables except for duration of ischemia, which was 13.7 min higher in the computer-assisted group. Blood loss due to drainage was higher in the conventional technique group (613 vs. 447 ml), as was the number of patients in which blood from the blood recovery system was reinfused (53 vs. 23%). Those patients undergoing computer-assisted surgery experienced less bleeding than those operated with the conventional technique. However, hemoglobin drop and allogenic transfusion rate were not statistically different in both groups.

Bilateral hypoplasia of the medial meniscus.

Only a few cases of the nearly unknown hypoplastic meniscus abnormality have been described. A case report of an incidental finding in a young female with a bilateral hypoplastic medial menisci is presented and, as far as we know, is the first report of bilateral hypoplasia of the medial meniscus in the literature.

Iliotibial band friction syndrome after anterior cruciate ligament reconstruction using the transfix device: report of two cases and review of the literature.

The use of hamstrings is increasing as a treatment for anterior cruciate ligament (ACL) injuries. There are a lot of new devices and techniques that try to fix the graft without causing further injury or increased morbidity. We report two cases in relation to the transfix device for reconstructing the ACL. The first case is a 38-year-old female who was treated with an autologous hamstring graft for chronic ACL instability brought on by a sport trauma. The patient developed iliotibial band friction syndrome 3 months after the operation. MRI showed incorrect positioning and a rupture of the femoral bio-absorbable cross-pin. The hamstring graft always had good fixation and did not produce instability of the knee. We removed the cross-pin fragment in a second surgery and the patient returned to her daily lifestyle after 3 weeks. The second case is a 52-year-old female with a painful and unstable knee due to a previous lateral meniscectomy and failure of an ACL reconstruction. We performed an ACL reconstruction with an autologous hamstring graft and a lateral meniscus transplantation. Some months after the procedure she also developed this syndrome. MRI showed the same features as shown in the first case and a second surgery was needed. To our knowledge this clinical and technical problem has not been previously described.

Factors affecting meniscal extrusion: correlation with MRI, clinical, and arthroscopic findings.

The existence of meniscal extrusion is well known in the natural history of the osteoarthritic knee. However, extruded menisci are also seen in non-pathologic knees. To ascertain the prevalence of meniscal extrusion in non-arthritic patients, the MRIs of 100 knees were prospectively studied. The data were correlated both with clinical and operative arthroscopic findings. The results showed 68.5% of the medial menisci to have some degree of extrusion, averaging at 28% of the meniscal size. While the lateral meniscus were extruded in 18.8% of cases at an average of 15% of the meniscal size. Furthermore, a relationship between the anterior insertion variant of the anterior medial meniscus and meniscal extrusion was found (P=0.001) in this series. The results suggest meniscal extrusion to be much more common in non-arthritic knees than previously estimated. The results also suggest that when the anterior horn of the medial meniscus inserts anteriorly in the tibial plateau, the meniscus tends to be extruded. It must be kept in mind that one of the limitations of this work is that the MRIs are taken in a non-weightbearing position.