Laminectomy in patients with achondroplasia: the impact of time to surgery on long-term function.

STUDY DESIGN: Retrospective analysis, survey. OBJECTIVE: To describe a cohort of individuals with achondroplasia undergoing thoracolumbar laminectomy and to examine if shorter time to surgery was related to improvement in long-term functional outcome. SUMMARY OF BACKGROUND DATA: Data on the long-term benefits of laminectomy are mixed for such patients. Earlier intervention may be associated with greater likelihood of long-term benefit, but quantified data are lacking. METHODS: We retrospectively studied 49 patients with achondroplasia who underwent primary laminectomy for spinal stenosis. Patients completed a questionnaire to assess symptoms, walking distance, and independence (per Modified Rankin Scale), before surgery and currently. Responses were analyzed for the likelihood of improved walking distance or Rankin level. RESULTS: Our patients had the following mean values: age, 37.7 ± 10.6 years; body mass index, 31.8 ± 5.5; symptom duration, 74.0 ± 100.1 months; preoperative symptom severity score, 2.7 ± 1.0 points; mean changes in blocks walked, +0.39 ± 2.0; and Rankin level, +0.08 ± 1.47. Patients with a time-to-surgery interval of <6 months were 7.13 times (95% confidence interval [CI], 1.39-36.66) more likely to experience improvement in walking distance and 4.00 times (95% CI, 1.05-15.21) more likely to experience Rankin level improvement than patients whose interval was >6 months. Intervals of up to 12 and 24 months were associated with increased likelihoods of 4.95 (95% CI, 1.41-17.41) and 3.43 (95% CI, 1.05-11.22), respectively, of improved walking distance compared with those with longer time-to surgery intervals, but those Rankin level improvements were not statistically significant. CONCLUSION: Time from symptom onset to surgery in patients with achondroplasia is an important predictor of long-term functional outcome. For sustained long-term postsurgical improvement, the window of opportunity might be relatively narrow. Patients with achondroplasia should seek medical advice for spinal stenotic symptoms as soon as possible.

Progression of low back and lower extremity pain in a cohort of patients with achondroplasia.

OBJECT: The aim of this study was to assess the natural history of pain associated with spinal stenosis in individuals with achondroplasia and to characterize pain patterns and associated functional and psychological effects. METHODS: The authors measured pain severity, spatial distribution of pain, functional disability, psychological distress, physical symptoms other than pain, and healthcare utilization in 181 individuals with achondroplasia. They also assessed low back and/or lower extremity pain at the initial visit and 1-year follow-up via self-rated patient questionnaires, calculated composite scores from responses via component analyses, and used repeated measures linear regression analyses for score changes (significance, p < or = 0.05). RESULTS: At the follow-up, back pain severity was unchanged. Patients reported significant progression of pain toward involvement of the lower extremities and significant increases in lower extremity pain severity overall. There were also significant increases in healthcare utilization overall. Compared with patients with back pain only, those with back pain and proximal or distal leg pain had higher self-rated pain severity; higher functional disability; and more bowel and bladder dysfunction symptoms, sleep disturbances, extremity numbness, and psychological distress. CONCLUSIONS: Individuals with achondroplasia and symptomatic spinal stenosis often experience back pain, which may progress to lower extremity pain and debilitating consequences. A more thorough understanding of the progression of spatial pain characteristics and pain severity may aid clinical decision making regarding the optimal timing for intervention.

Rates of perioperative complications associated with laminectomies in patients with achondroplasia.

BACKGROUND: Lumbar decompressive surgery can be complicated by dural tears, infection, nerve root injury, deep venous thrombosis, and epidural hematoma. However, perioperative complications of multilevel laminectomies in patients with achondroplasia rarely are reported. Our objective was to determine the perioperative complication rates associated with laminectomies in patients with achondroplasia. METHODS: We reviewed the medical records of the initial laminectomies for all ninety-eight patients with achondroplasia at our institution, which included twenty-eight patients who had had previous spine surgeries at other institutions, and determined the rates of complications in the following categories: neurologic, pulmonary, cardiovascular, and gastrointestinal complications; intraoperative dural tears; infections at the incision site; and mortality. RESULTS: Sixty (61%) of ninety-eight patients had at least one perioperative complication. By category, these included intraoperative dural tears, which occurred in 37% (thirty-six patients); neurologic complications, in 23% (twenty-three patients); infections at the incision site, in 9% (nine patients); deep venous thrombosis, in 3% (three patients); pulmonary complications, in 3% (three patients); and gastrointestinal complications, in 3% (three patients). The only death was caused by a pulmonary embolism. CONCLUSIONS: Perioperative complications are common in patients with achondroplasia undergoing multilevel laminectomies, and the perioperative care team should be aware of these complications when caring for these patients.

Determinants of states' allocations of the master settlement agreement payments.

To determine which factors influence states' allocation decisions for the tobacco Master Settlement Agreement and the four individual settlements' annual payments, including the decision to securitize, we analyzed the effects of voter characteristics, political parties, interest groups, prior spending on public tobacco control programs, and state fiscal health on per capita settlement funds allocated to tobacco-control, health, and other programs. Tobacco-producing states and those with high proportions of conservative Democrats or elderly, black, Hispanic, or wealthy people tended to spend less on tobacco control. Education and medical lobbies had strong positive influences on per capita allocations for tobacco-control and health-related programs. State fiscal crises affected amounts spent by states from settlement funds as well as the probability of securitizing future cash flows from the settlements.