Applications of SPECT/CT in the Evaluation of Spinal Pathology: A Review.

BACKGROUND: Accurate identification of pain generators in the context of low back and spine-related pain is crucial for effective treatment. This review aims to evaluate the potential usefulness of single photon emission computed tomography with computed tomography (SPECT/CT) as an imaging modality in guiding clinical decision-making. METHODS: A broad scoping literature review was conducted to identify relevant studies evaluating the use of SPECT/CT in patients with spine-related pain. Studies were reviewed for their methodology and results. RESULTS: SPECT/CT appears to have advantages over traditional modalities, such as magnetic resonance imaging and CT, in certain clinical scenarios. It may offer additional information to clinicians and improve the specificity of diagnosis. However, further studies are needed to fully assess its diagnostic accuracy and clinical utility. CONCLUSIONS: SPECT/CT is a promising imaging modality in the evaluation of low back pain, particularly in cases where magnetic resonance imaging and CT are inconclusive or equivocal. However, the current level of evidence is limited, and additional research is needed to determine its overall clinical relevance. CLINICAL RELEVANCE: SPECT/CT may have a significant impact on clinical decision-making, particularly in cases in which traditional imaging modalities fail to provide a clear diagnosis. Its ability to improve specificity could lead to more targeted and effective treatment for patients with spinal pathology.

Sacroiliac Joint Fusion-A Shift Toward Variant Anatomy and Clinical Implications.

OBJECTIVE: To investigate impact of patient factors and sacroiliac joint (SIJ) anatomical structure on SIJ fusion outcomes. METHODS: This single-center, retrospective, observational study evaluated patients diagnosed with SIJ dysfunction refractory to conservative measures who had available preoperative imaging of the sacrum and underwent SIJ fusion surgery. The impact of patient sociodemographics on pain improvement was assessed by Mann-Whitney U test. Differences in patient sociodemographics and outcome information between anatomical subtypes were assessed with χ2 and Kruskal-Wallis tests. χ2 test was used to compare joint anatomy distribution between studies analyzing SIJ variations. RESULTS: We included 77 total joints that underwent instrumentation. There were significant differences between the anatomical subtypes with female sex having significantly higher rates of non-normal joint anatomy. Younger age was significantly more common in bipartite/dysmorphic anatomy (53.9 years) than normal anatomy (70 years) (P < 0.05). There was a trend toward better outcomes in bipartite/dysmorphic and accessory variants, while semicircular defect and crescent variants trended toward worse outcomes. Nonnormal anatomy was significantly more frequent in our population than previous reports on nonpathological SIJ. CONCLUSIONS: A pathological SIJ has a significantly higher prevalence of variant joint anatomy. There appears to be a trend toward differences in surgical outcomes based on SIJ anatomy. Future research with larger sample sizes is necessary to confirm these differences.

The Feasibility of Translaminar Screws in the Subaxial Cervical Spine: Computed Tomography and Cadaveric Validation.

BACKGROUND: The use of translaminar screws may serve as a viable salvage method for complicated cases. To our understanding, the study of the feasibility of translaminar screw insertion in the actual entire subaxial cervical spine has not been carried out yet. The purpose of this study was to report the feasibility of translaminar screw insertion in the entire subaxial cervical spine. METHODS: Eighteen cadaveric spines were harvested from C3 to C7 and 1-mm computed tomography (CT) scans and three-dimensional reconstructions were created to exclude any bony anomaly. Thirty anatomically intact segments were collected (C3, 2; C4, 3; C5, 3; C6, 8; and C7, 14), and randomly arranged. Twenty-one segments were physically separated at each vertebral level (group S), while 9 segments were not separated from the vertebral column and left in situ (group N-S). CT measurement of lamina thickness was done for both group S and group N-S, and manual measurement of various length and angle was done for group S only. Using the trajectory proposed by the previous studies, translaminar screws were placed at each level. Screw diameter was the same or 0.5 mm larger than the proposed diameter based on CT measurement. Post-insertion CT was performed. Cortical breakage was checked either visually or by CT. RESULTS: When 1° and 2° screws of the same size were used, medial cortex breakage was found 13% and 33% of the time, respectively. C7 was relatively safer than the other levels. With larger-sized screws, medial cortex breakage was found in 47% and 46% of 1° and 2° screws, respectively. There were no facet injuries due to the screws in group N-S. CONCLUSIONS: Translaminar screw insertion in the subaxial cervical spine is feasible only when the lamina is thick enough to avoid any breakage that could lead to further complications. The authors do not recommend inserting translaminar screws in the subaxial cervical spine except in some salvage cases in the presence of a thick lamina.

Management of degenerative spondylolisthesis: development of appropriate use criteria.

BACKGROUND CONTEXT: Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. PURPOSE: The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. STUDY DESIGN: A Modified Delphi process was used. METHODS: The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. RESULTS: There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. CONCLUSIONS: Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Anatomy of Lamina in the Subaxial Cervical Spine With the Special Reference to Translaminar Screws: CT and Cadaveric Analysis With Screw Trajectory Simulation.

STUDY DESIGN: A cadaveric study. SUMMARY OF BACKGROUND DATA: Translaminar screws were initially developed for C2 fixation. Since then, their usage has expanded to include the subaxial cervical spine, and thoracic and lumbar spine. To the best of our knowledge, special anatomy for inserting translaminar screws in the subaxial cervical spine has not been studied. OBJECTIVE: To report the special anatomy for inserting translaminar screws in the subaxial cervical spine. METHODS: A total of 18 cadaveric spines were harvested from C3 to C7 and 1 mm computed tomography (CT) scans and 3D reconstructions were obtained. Bilateral translaminar screw entry points and trajectories were simulated at each level from C3 to C7 utilizing Kodak Carestream/Pacs Ver 10.2. Constructs were selected to achieve maximal bony purchase with 1 screw, designated the "primary screw." The contralateral screw, designated the "secondary screw," was selected to achieve the optimal allowable diameter possible while avoiding a simulated cortical breach, which was not always necessarily the "best purchase" diameter. Initial screw diameters selected were 3.5 mm; however, in the event that a narrower portion was encountered, then a 3.0 mm diameter screw was utilized instead. The crossing area of both screws were calculated geometrically. Maximal thickness of the lamina was considered in determining the diameter of screws. Whenever possible, 3.5 mm screws were selected in both lamina (3.5/3.5 mm); however, if a 3.5 mm screw was utilized as the primary screw, but the permissible range (P) for the secondary screw was <3.5 mm, then a hybrid construct was utilized (3.5/3.0 mm). In cases where P was <3 mm, then both screws were studied at 3 mm (3.0/3.0 mm). Screw diameters that optimized trajectory and bony purchase, while remaining within the permissible range, were analyzed, tabulated, and recorded. On CT, along the trajectory of the screws, the image was cut and measured in terms of screw length, the narrowest portion of the lamina, vertical angle, and horizontal angle in both primary and secondary screws. On the individually separated cervical spine segments in cadavers (11 of 18), we performed caliper measurements on the same portions that were measured on CT. It could not be exactly the same portions, however, due to the 3-dimensional characteristics of the specimens. RESULTS: For C3, only 1 specimen allowed 2 screws (3/3 mm), while the remaining specimens permitted a unilateral primary screw (3.5 or 3 mm) only. For C4, 37% of specimens allowed 2 screws (3.5/3 mm or 3/3 mm), but the rest allowed only a unilateral primary screw (3.5 or 3 mm). For C5, 58% allowed 2 screws (3.5/3.5, 3.5/3, or 3/3 mm). For C6, 89% of specimen allowed 2 screws (3.5/3.5, 3.5/3, or 3/3 mm). For C7, all levels allowed 2 screws (3.5/3.5, 3.5/3, 4/4, 4/3, 4.5/3, 4.5/3.5, or 4/3.5 mm). On CT, the average lengths of the 1- and 2-degree screws were 26.14 and 24.01 mm, respectively. The average vertical and horizontal angles were 22.26 and 40.66 degrees for the 1-degree screw, and 3.45 and 45.59 degrees for the 2-degree screw. On cadavers, the average lengths of the 1- and the 2-degree screws were 22.58 and 23.44 mm, respectively. The average vertical and horizontal angles were 23.67 and 54.44 degrees for the 1-degree screw, and 2.28 and 54.89 degrees for the 2-degree screw. CONCLUSIONS: This is a report of the anatomy of the lamina in the subaxial cervical spine with the special reference to translaminar screws. It was analyzed with CT and cadaveric spines along with simulated screw trajectories. For the 1-degree translaminar screw, the entry point is the distance of the diameter of desired screw superior to the inferior margin of lamina-spinous process junction. The trajectory should be targeted toward the most superomedial corner of lateral mass. For the 2-degree translaminar screw, the entry point is the distance of the diameter of desired screw below the superior margin of lamina-spinous process junction, and the target is the most superolateral corner of lateral mass, which is typically horizontal. Further studies are needed to assess the feasibility of translaminar screw insertion in the actual subaxial cervical spine.

Predictors of Outcome in Conservative and Minimally Invasive Surgical Management of Pain Originating From the Sacroiliac Joint: A Pooled Analysis.

STUDY DESIGN: A pooled patient-level analysis of two multicenter randomized controlled trials and one multicenter single-arm prospective trial. OBJECTIVE: The aim of this study was to identify predictors of outcome of conservative and minimally invasive surgical management of pain originating from the sacroiliac joint (SIJ). SUMMARY OF BACKGROUND DATA: Three recently published prospective trials have shown that minimally invasive SIJ fusion (SIJF) using triangular titanium implants produces better outcomes than conservative management for patients with pain originating from the SIJ. Due to limitations in individual trial sample size, analyses of predictors of treatment outcome were not conducted. METHODS: We pooled individual patient data from the three trials and used random effects models with multivariate regression analysis to identify predictors for treatment outcome separately for conservative and minimally invasive surgical treatment. Outcome was measured using visual analogue scale (VAS), Oswestry Disability Index (ODI), and EuroQOL-5D (EQ-5D). RESULTS: We included 423 patients assigned to either nonsurgical management (NSM, n = 97) or SIJF (n = 326) between 2013 and 2015. The reduction in SIJ pain was 37.9 points larger [95% confidence interval (95% CI) 32.5-43.4, P < 0.0001] in the SIJF group than in the NSM group. Similarly, the improvement in ODI was 18.3 points larger (95% CI 14.3-22.4), P < 0.0001). In NSM, we found no predictors of outcome. In SIJF, a reduced improvement in outcome was predicted by smoking (P = 0.030), opioid use (P = 0.017), lower patient age (P = 0.008), and lower duration of SIJ pain (P = 0.028). CONCLUSIONS: Our results support the view that SIJF leads to better treatment outcome than conservative management of SIJ pain and that a higher margin of improvement can be predicted in nonsmokers, nonopioid users, and patients of increased age and with longer pain duration. LEVEL OF EVIDENCE: 1.

Two-Year Outcomes from a Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion vs. Non-Surgical Management for Sacroiliac Joint Dysfunction.

BACKGROUND: Sacroiliac joint (SIJ) dysfunction is an important and underappreciated cause of chronic low back pain. OBJECTIVE: To prospectively and concurrently compare outcomes after surgical and non-surgical treatment for chronic SIJ dysfunction. METHODS: One hundred and forty-eight subjects with SIJ dysfunction were randomly assigned to minimally invasive SIJ fusion with triangular titanium implants (SIJF, n = 102) or non-surgical management (NSM, n = 46). SIJ pain (measured with a 100-point visual analog scale, VAS), disability (measured with Oswestry Disability Index, ODI) and quality of life scores were collected at baseline and at scheduled visits to 24 months. Crossover from non-surgical to surgical care was allowed after the 6-month study visit was complete. Improvements in continuous measures were compared using repeated measures analysis of variance. The proportions of subjects with clinical improvement (SIJ pain improvement ≥20 points, ODI ≥15 points) and substantial clinical benefit (SIJ pain improvement ≥25 points or SIJ pain rating ≤35, ODI ≥18.8 points) were compared. RESULTS: In the SIJF group, mean SIJ pain improved rapidly and was sustained (mean improvement of 55.4 points) at month 24. The 6-month mean change in the NSM group (12.2 points) was substantially smaller than that in the SIJF group (by 38.3 points, p<.0001 for superiority). By month 24, 83.1% and 82.0% received either clinical improvement or substantial clinical benefit in VAS SIJ pain score. Similarly, 68.2% and 65.9% had received clinical improvement or substantial clinical benefit in ODI score at month 24. In the NSM group, these proportions were <10% with non-surgical treatment only. Parallel changes were seen for EQ-5D and SF-36, with larger changes in the surgery group at 6 months compared to NSM. The rate of adverse events related to SIJF was low and only 3 subjects assigned to SIJF underwent revision surgery within the 24-month follow-up period. CONCLUSIONS: In this Level 1 multicenter prospective randomized controlled trial, minimally invasive SIJF with triangular titanium implants provided larger improvements in pain, disability and quality of life compared to NSM. Improvements after SIJF persisted to 24 months. This study was approved by a local or central IRB before any subjects were enrolled. All patients provided study-specific informed consent prior to participation.

Motor/Prefrontal Transcranial Direct Current Stimulation (tDCS) Following Lumbar Surgery Reduces Postoperative Analgesia Use.

STUDY DESIGN: Randomized, controlled pilot trial. OBJECTIVE: The present study is the first randomized, double-blind, sham-controlled pilot clinical trial of transcranial direct current stimulation (tDCS) for pain and patient-controlled analgesia (PCA) opioid usage among patients receiving spine surgery. SUMMARY OF BACKGROUND DATA: Lumbar spinal surgeries are common, and while pain is often a complaint that precedes surgical intervention, the procedures themselves are associated with considerable postoperative pain lasting days to weeks. Adequate postoperative pain control is an important factor in determining recovery and new analgesic strategies are needed that can be used adjunctively to existing strategies potentially to reduce reliance on opioid analgesia. Several novel brain stimulation technologies including tDCS are beginning to demonstrate promise as treatments for a variety of pain conditions. METHODS: Twenty-seven patients undergoing lumbar spine procedures at Medical University of South Carolina were randomly assigned to receive four 20-minute sessions of real or sham tDCS during their postsurgical hospital stay. Patient-administered hydromorphone usage was tracked along with numeric rating scale pain ratings. RESULTS: The effect of tDCS on the slope of the cumulative PCA curve was significant (P < 0.001) and tDCS was associated with a 23% reduction in PCA usage. In the real tDCS group a 31% reduction was observed in pain-at-its-least ratings from admission to discharge (P = 0.027), but no other changes in numeric rating scale pain ratings were significant in either group. CONCLUSION: The present pilot trial is the first study to demonstrate an opioid sparing effect of tDCS after spine surgical procedures. Although this was a small pilot trial in a heterogeneous sample of spinal surgery patients, a moderate effect-size was observed for tDCS, suggesting that future work in this area is warranted. LEVEL OF EVIDENCE: 2.

Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion Using Triangular Titanium Implants vs Nonsurgical Management for Sacroiliac Joint Dysfunction: 12-Month Outcomes.

BACKGROUND: Sacroiliac joint (SIJ) dysfunction is a prevalent cause of chronic, unremitting lower back pain. OBJECTIVE: To concurrently compare outcomes after surgical and nonsurgical treatment for chronic SIJ dysfunction. METHODS: A total of 148 subjects with SIJ dysfunction were randomly assigned to minimally invasive SIJ fusion with triangular titanium implants (n = 102) or nonsurgical management (n = 46). Pain, disability, and quality-of-life scores were collected at baseline and at 1, 3, 6, and 12 months. Success rates were compared using Bayesian methods. Crossover from nonsurgical to surgical care was allowed after the 6-month study visit was complete. RESULTS: Six-month success rates were higher in the surgical group (81.4% vs 26.1%; posterior probability of superiority > 0.9999). Clinically important (≥ 15 point) Oswestry Disability Index improvement at 6 months occurred in 73.3% of the SIJ fusion group vs 13.6% of the nonsurgical management group (P < .001). At 12 months, improvements in SIJ pain and Oswestry Disability Index were sustained in the surgical group. Subjects who crossed over had improvements in pain, disability, and quality of life similar to those in the original surgical group. Adverse events were slightly more common in the surgical group (1.3 vs 1.1 events per subject; P = .31). CONCLUSION: This Level 1 study showed that minimally invasive SIJ fusion using triangular titanium implants was more effective than nonsurgical management at 1 year in relieving pain, improving function, and improving quality of life in patients with SIJ dysfunction caused by degenerative sacroiliitis or SIJ disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment.

Sacroiliac Joint Fusion Using Triangular Titanium Implants vs. Non-Surgical Management: Six-Month Outcomes from a Prospective Randomized Controlled Trial.

BACKGROUND: Sacroiliac (SI) joint pain is a prevalent, underdiagnosed cause of lower back pain. SI joint fusion can relieve pain and improve quality of life in patients who have failed nonoperative care. To date, no study has concurrently compared surgical and non-surgical treatments for chronic SI joint dysfunction. METHODS: We conducted a prospective randomized controlled trial of 148 subjects with SI joint dysfunction due to degenerative sacroiliitis or sacroiliac joint disruptions who were assigned to either minimally invasive SI joint fusion with triangular titanium implants (N=102) or non-surgical management (NSM, n=46). SI joint pain scores, Oswestry Disability Index (ODI), Short-Form 36 (SF-36) and EuroQol-5D (EQ-5D) were collected at baseline and at 1, 3 and 6 months after treatment commencement. Six-month success rates, defined as the proportion of treated subjects with a 20-mm improvement in SI joint pain in the absence of severe device-related or neurologic SI joint-related adverse events or surgical revision, were compared using Bayesian methods. RESULTS: Subjects (mean age 51, 70% women) were highly debilitated at baseline (mean SI joint VAS pain score 82, mean ODI score 62). Six-month follow-up was obtained in 97.3%. By 6 months, success rates were 81.4% in the surgical group vs. 23.9% in the NSM group (difference of 56.6%, 95% posterior credible interval 41.4-70.0%, posterior probability of superiority >0.999). Clinically important (≥15 point) ODI improvement at 6 months occurred in 75% of surgery subjects vs. 27.3% of NSM subjects. At six months, quality of life improved more in the surgery group and satisfaction rates were high. The mean number of adverse events in the first six months was slightly higher in the surgical group compared to the non-surgical group (1.3 vs. 1.0 events per subject, p=0.1857). CONCLUSIONS: Six-month follow-up from this level 1 study showed that minimally invasive SI joint fusion using triangular titanium implants was more effective than non-surgical management in relieving pain, improving function and improving quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruptions. CLINICAL RELEVANCE: Minimally invasive SI joint fusion is an acceptable option for patients with chronic SI joint dysfunction due to degenerative sacroiliitis and sacroiliac joint disruptions unresponsive to non-surgical treatments.

The insertion technique of translaminar screws in the thoracic spine: computed tomography and cadaveric validation.

BACKGROUND CONTEXT: Translaminar screws can be a good salvage technique in some cases of severe deformities, infection, tumor, osteoporosis, and revision cases with altered anatomy. To our knowledge, the insertion technique for translaminar screws in the thoracic spine has not been studied. PURPOSE: To suggest a safe insertion technique of translaminar screws in the thoracic spine. STUDY DESIGN: A cadaveric study. METHODS: Fifteen cadaveric spines were harvested from T1 to T12, and 1-mm computed tomography (CT) scans and three-dimensional reconstructions were obtained to rule out any bony anomaly. Eleven of the cadaveric spines were separated at each level from T1 to T12 (Group S) and four were not separated (Group N-S). Translaminar screws were inserted into every level along the trajectories proposed by the previous studies. The screw diameter was determined based on the reference article. For T1-T6, the screw diameter selected was 4 mm, and for T7-T12, a 3.5-mm diameter screw was used instead. The entry point for the 1° screw was at a distance equal to the diameter of the desired screw above the inferior margin of the spinolaminar junction. To create the trajectory, a drill guide was inserted at the entry point and directed toward the middle portion of the base of the transverse process of the contralateral side and was followed carefully to not break the inner/outer cortex of the lamina. The length of the drilled hole, representing the trajectory of the screw made by the drill guide, was measured, and the 1° screws were inserted according to the length measured. The entry point for the 2° screw was at a distance equal to the diameter of the screw below the superior margin of the base of the spinous process and lamina junction. The drill guide was pointed toward the inferior angle of the contralateral junction of the rib and the vertebra along the slope of the contralateral lamina. The 2° screw was inserted in the same manner as previously described. The 2° screw diameter was downsized if there was not enough space because of the 1° screw. For each vertebra from the 11 separated cadaveric spines, inner or outer cortex breakage was checked visually. For the remaining four nonseparated spines, CT scans were used to find any inner or outer cortex breakage. RESULTS: Thirty-three vertebral levels were abandoned from Group S because of altered anatomy (eg, fusion, fracture during separation, anatomical anomaly of having only 11 thoracic spine segments). Out of 147 vertebral levels, there was no vertebra that did not allow screw insertion. No specimen required using smaller diameter 2° screw because of blockage of the 1° screw. There was no cortical breakage by the screws in Group S. In Group N-S, CT scan showed four inner cortex breakages and three outer cortex breakages, all of which were slight cortical breakages. There were no facet injuries due to the screws in Group N-S. There was no blockage of the ribs during screw placement in all specimens, and the drill guide could lean against the rib for guidance because the angle of the rib and the opposite lamina tended to be the same. CONCLUSIONS: Translaminar screws can be inserted relatively safely in the thoracic spine. For the 1° translaminar screw, the entry point is at a distance equal to the diameter of the desired screw superior to the inferior margin of the lamina-spinous process junction. The trajectory should be targeted toward the center of the base of the contralateral transverse process. For the 2° translaminar screw, the entry point is at a distance equal to the diameter of the desired screw below the superior margin of lamina-spinous process junction, and the target is the inferior angle of the junction of the rib and vertebra on the contralateral side.

Outcome of percutaneous sacroiliac joint fixation with porous plasma-coated triangular titanium implants: an independent review.

DESIGN: Independent retrospective review of a single surgeon's experience with a new technique of SI fixation. OBJECTIVE: Examine results of percutaneous fixation of the SI joint with porous coated triangular titanium implants. BACKGROUND: Diagnosis and treatment of a dysfunctional sacroiliac joint is challenging as well as controversial. Recently, percutaneous stabilization techniques have been implemented for fixation. There is minimal literature published on this technique. METHODS: Charts, radiographs, and CT scans of 31 patients operated on by a single surgeon were de-identified and randomized and then reviewed by investigators not involved with the care of the patients. Reviewers had no relationship with the implant manufacturer at the time of the review. OUTCOME MEASURES: intraoperative and postoperative complication, EBL, hospital stays, postoperative image location and number of lucent implants, ingrowth into implants, and bone across SI joint. RESULTS: 27 patients expressed satisfaction, 4 patients did not. Pain relief was noted to be Complete (16 patients), Excellent (5 patients), Good (9 patients), and Fair (1 patients). Four patients had postoperative complications. These were infected hematoma (2), L5 nerve root irritation (1), and L5-S1 discitis (1). One patient required revision. On 6 month postop CT scan, 18/19 patients had radiographic evidence of bone ingrowth and bone into or across the SI joint was evident in 8/19 patients. Lucency was noted around at least one implant in 5/19 patients. CONCLUSIONS: Results are promising for the use of this novel implant for a carefully selected group of patients with disabling SI dysfunction.

The utility of routine postoperative radiographs after cervical spine fusion.

BACKGROUND CONTEXT: The senior author (JAG) recently published an article questioning the utility of routine postoperative radiographs after lumbar spine fusion. That study concluded that routine postoperative radiographs in the presence of a normal physical examination rarely change the clinician's management of these patients. Our aim was to repeat this protocol in patients after cervical spine fusion. We hypothesized that routine postoperative radiographs are unnecessary in most cases after cervical spine fusion. PURPOSE: The purpose of this study was to determine the usefulness of routine postoperative cervical spine radiographs after cervical spine fusion as to whether they help to guide clinical decision making within the first postoperative year. STUDY DESIGN: This is a retrospective chart review of 383 patients who underwent a cervical spine fusion over a 5-year period. Seven different surgeons performed the cervical spine fusions. Our review assessed a total of 1,155 postoperative clinic visits. METHODS: Each clinical postoperative visit was reviewed. The history and exam were graded as either normal or abnormal, and any plain radiographs obtained were graded similarly as either normal or abnormal. Each patient's notes were followed up to 1 year postoperatively. Each patient had to have at least two postoperative visits with X-rays to be included in the study. We then noted any further action taken by the clinician based on the appearance of the radiograph in conjunction with the history and exam. RESULTS: In patients with normal history and exam presentations, further action was taken only 5/879 (0.57%) of the time, sometimes even in the presence of abnormal radiographs. The actions included two surgical revisions, two prolongations of cervical collar immobilization, and one patient who underwent a flexion/extension radiographic evaluation and subsequent prolonged cervical collar immobilization. There were 276 visits with abnormal history and exam; of these, 34/276 (12.3%) had abnormal X-rays. Of the clinic visits with abnormal history and exam and abnormal X-rays, 15/34 (44%) went on to revision. CONCLUSIONS: Routine postoperative radiographs after cervical spine fusion rarely appear to be of value when patients present with a normal history and exam and may expose patients to unnecessary diagnostic studies and expenses. Patients exhibiting a normal postoperative history and exam are likely to have no further additional action taken in the presence of either normal or abnormal radiographs.

Rapid identification of myocardial infarction risk associated with diabetes medications using electronic medical records.

OBJECTIVE To assess the ability to identify potential association(s) of diabetes medications with myocardial infarction using usual care clinical data obtained from the electronic medical record. RESEARCH DESIGN AND METHODS We defined a retrospective cohort of patients (n = 34,253) treated with a sulfonylurea, metformin, rosiglitazone, or pioglitazone in a single academic health care network. All patients were aged >18 years with at least one prescription for one of the medications between 1 January 2000 and 31 December 2006. The study outcome was acute myocardial infarction requiring hospitalization. We used a cumulative temporal approach to ascertain the calendar date for earliest identifiable risk associated with rosiglitazone compared with that for other therapies. RESULTS Sulfonylurea, metformin, rosiglitazone, or pioglitazone therapy was prescribed for 11,200, 12,490, 1,879, and 806 patients, respectively. A total of 1,343 myocardial infarctions were identified. After adjustment for potential myocardial infarction risk factors, the relative risk for myocardial infarction with rosiglitazone was 1.3 (95% CI 1.1-1.6) compared with sulfonylurea, 2.2 (1.6-3.1) compared with metformin, and 2.2 (1.5-3.4) compared with pioglitazone. Prospective surveillance using these data would have identified increased risk for myocardial infarction with rosiglitazone compared with metformin within 18 months of its introduction with a risk ratio of 2.1 (95% CI 1.2-3.8). CONCLUSIONS Our results are consistent with a relative adverse cardiovascular risk profile for rosiglitazone. Our use of usual care electronic data sources from a large hospital network represents an innovative approach to rapid safety signal detection that may enable more effective postmarketing drug surveillance.

Coccygectomy for the treatment of therapy-resistant coccygodynia.

Coccygodynia (pain in the region of the coccyx) has many causes, but it may be posttraumatic beginning after a fracture or contusion. Pain is typically triggered by or occurs while sitting. Nonsurgical management, including cushions, nonsteroidal anti-inflammatory drugs, and corticosteroid injections, can be successful in up to 85% of patients. The objective of the study was to show that coccygectomy can be a successful surgical treatment for patients who fail nonoperative treatment. This study is a retrospective analysis of all patients who underwent a coccygectomy performed by one surgeon between the years 2002 and 2008. All patients were asked to complete an Oswestry low back pain disability questionnaire and a visual analog pain scale. The average Oswestry disability score was 25.75%. The average visual analog score was 3.4 cm. Four patients sustained a wound breakdown. The study concluded that for patients with conservative therapy-resistant coccygodynia, operative treatment with coccygectomy is a feasible management option.

Are routine radiographs needed in the first year after lumbar spinal fusions?

STUDY DESIGN: This is a retrospective chart review of 670 clinic notes from 202 patients who underwent posterior instrumented lumbar spinal fusions (LSF) over a 9-year period by a single surgeon. OBJECTIVE: This study's objective was to investigate the utility of routine radiographs in the first year after LSF to determine if they affect decision-making. SUMMARY OF BACKGROUND DATA: A review of the literature reveals an absence of studies investigating the need for radiographs in the immediate postoperative period after LSF. METHODS: Each patient's history and physical examination (H/E) and the surgeon's interpretation of radiographs were graded as normal or abnormal for all postoperative visits in the first year after surgery. Further action taken not felt to be routine was also recorded. chi was used to statistically analyze the compiled data. RESULTS: No action was taken 100% of the time when H/E was normal and either a normal radiograph or no radiograph was taken. If the patient was H/E normal and radiographs were abnormal, further action was taken in only one instance. This occurred in a patient with asymptomatic implant dissociation who elected to undergo revision. In patients with abnormal H/E, further action was taken 72% of the time even in the presence of normal radiographs and 89% of the time when they also had abnormal radiographs. There was no statistical difference between the 2 groups with abnormal H/E. CONCLUSION: Routine radiographs seem to have limited utility in the early postoperative period after instrumented LSF and may place patients with normal H/E at an increased risk of undergoing unnecessary diagnostic studies. Patients with abnormal H/E were more likely to undergo more extensive testing leading to additional treatment being prescribed regardless of the interpretation of the radiographs.

Biomechanical comparison of augmentation techniques for insufficiency fractures.

STUDY DESIGN: Biomechanical laboratory research. OBJECTIVE: To compare 4 techniques for vertebral body insufficiency fracture repair by analyzing restoration of height, strength, and stiffness, and quantifying cement leakage. SUMMARY OF BACKGROUND DATA: Current techniques for insufficiency fracture repair, restore prefracture strength, and all potentially have the complication of cement extrusion. To our knowledge, there is no information directly comparing different augmentation techniques. METHODS: There were 4 osteoporotic/osteopenic fresh cadaveric spines' (T6-L5) vertebral bodies divided into the 4 groups and by levels (thoracic, thoracolumbar, lumbar). They were compressed to 25% of their initial height to simulate insufficiency fractures. Fixation techniques were vertebroplasty, osteoplasty (Interpore Cross Int., Irvine, CA), the Cavity Creation System (Synthes, Paoli, PA), and kyphoplasty (Kyphon, Sunnyvale, CA). Fractures were fixed using 3 cc of bone cement and recompressed. RESULTS: No significant difference was found in strength, height restoration, or stiffness among techniques (P < 0.05). Stiffness was significantly different in the lumbar levels between initial and post-fixation measurements (P < 0.05). Cement extrusion of 1 mL was seen in 1 vertebroplasty specimen. CONCLUSIONS: The 4 techniques equally restored strength and stiffness. No difference was seen in height restoration. Cement extrusion was significant in only 1 vertebral body, which may be attributable to the cement quantity.

Return on investment for a computerized physician order entry system.

OBJECTIVE: Although computerized physician order entry (CPOE) may decrease errors and improve quality, hospital adoption has been slow. The high costs and limited data on financial benefits of CPOE systems are a major barrier to adoption. The authors assessed the costs and financial benefits of the CPOE system at Brigham and Women's Hospital over ten years. DESIGN: Cost and benefit estimates of a hospital CPOE system at Brigham and Women's Hospital (BWH), a 720-adult bed, tertiary care, academic hospital in Boston. MEASUREMENTS: Institutional experts provided data about the costs of the CPOE system. Benefits were determined from published studies of the BWH CPOE system, interviews with hospital experts, and relevant internal documents. Net overall savings to the institution and operating budget savings were determined. All data are presented as value figures represented in 2002 dollars. RESULTS: Between 1993 and 2002, the BWH spent $11.8 million to develop, implement, and operate CPOE. Over ten years, the system saved BWH $28.5 million for cumulative net savings of $16.7 million and net operating budget savings of $9.5 million given the institutional 80% prospective reimbursement rate. The CPOE system elements that resulted in the greatest cumulative savings were renal dosing guidance, nursing time utilization, specific drug guidance, and adverse drug event prevention. The CPOE system at BWH has resulted in substantial savings, including operating budget savings, to the institution over ten years. CONCLUSION: Other hospitals may be able to save money and improve patient safety by investing in CPOE systems.