Does the Application of Topical Intrawound Vancomycin Powder Affect Deep Surgical Site Infection and the Responsible Organisms after Spinal Surgery?: A Retrospective Case Series with a Historical Control Group.

STUDY DESIGN: Retrospective case series with a historical control group. PURPOSE: To compare the deep wound infection rates in patients undergoing spinal surgery with the application of topical intrawound vancomycin powder (TIVP) in the surgical site in addition to standard systemic prophylaxis with those in a matched historical cohort of patients for whom TIVP was not used. OVERVIEW OF LITERATURE: Surgical site infection (SSI) after spine surgery is debilitating and is responsible for a significant increase in the health care costs, hospital stay, and morbidities. Although the application of TIVP before surgical closure is a promising method for reducing the SSI rate after spine surgery, its use is controversial, and currently, research trials are focusing on identifying its safety, efficacy, and the potential patient population. METHODS: A group of 88 patients who underwent posterior spinal surgery with TIVP administration (treatment group) was compared to a historical control group of 70 patients who had received only standard systemic intravenous prophylaxis (control group) for the analysis of deep SSI rate and the involved organisms. RESULTS: The overall rate of deep SSIs was 2.5% (4/158). All the SSIs were observed in patients who had posterior instrumentation and fusion for ≥3 levels. In the treatment group, the SSI rate was 3.4% (3/88), and the bacteria isolated were Escherichia coli (n=2) and Pseudomonas aeruginosa (n=1). In the control group, the infection rate was 1.4% (1/70), and the isolated bacteria were Morganella morganii and Staphylococcus epidermidis. No statistically significant association was found between the SSI rates of the treatment and control groups. CONCLUSIONS: Although the difference in the SSI rates was not statistically significant, the present results suggest that TIVP administration could not reduce the risk of deep SSIs after spinal surgery. Moreover, TIVP administration might also affect the underlying pathogens by increasing the propensity for gram-negative species.

Complementary Specific Pelvic Sequences on Routine Lumbar Magnetic Resonance Imaging Scans: An Imaging-Based Study Focused on Piriformis Syndrome.

AIM: To discuss the rationale and merit of specific pelvic sequences as an adjunct to routine lumbar magnetic resonance imaging (MRI) for early detection of piriformis syndrome (PS) and to disclose its frequency in patients who underwent radiological evaluation. MATERIAL AND METHODS: This retrospective, imaging-based study included all individuals who underwent lumbar MRI and those who were further evaluated with a pelvic MRI, but excluded all high-energy trauma cases. The patients' demographics and radiological features were reviewed using electronic patient records and hospital-based picture image archiving and communication system. RESULTS: Overall, 1321 individuals (659 females; 662 males) underwent lumbar MRI during the study period, and of these, 485 (238 females; 247 males) were further analyzed with a pelvic MRI for differential diagnosis. Forty patients (8.2%) (23 females; 17 males) were diagnosed with PS-all confirmed with MR neurography (MRN). On re-evaluation of all lumbar and pelvic MRIs and MRNs, we realized that adding just three specific pelvic sequences to routine lumbar MRI scans were enough to accurately delineate the piriformis muscle pathologies and sciatic nerve intensities. The calculated frequencies of PS in females, males, and the whole study population within 57 months were 3.49%, 2.57%, and 3.03%, respectively. CONCLUSION: Although PS being a clinical diagnosis, this study indicated that in patients whom PS was not suspected at the initial examination, 8.2% of them were finally diagnosed after MRI evaluations. Performing specific pelvic sequences as an adjunct to routine lumbar MRI can salvage underdiagnosed patients with PS and facilitate early detection of this pathological condition.

Adult Spinal Deformity Over 70 Years of Age: A 2-Year Follow-Up Study.

BACKGROUND: Treatment of adult spinal deformity (ASD) in elderly patients remains controversial. The aim of this study was to identify the factors leading to the surgical treatment by comparing the baseline characteristics of operative versus nonoperative patients, to evaluate the safety and efficacy of surgery, and to compare operative and nonoperative management of elderly ASD patients at the end of the 2-year follow-up period. METHODS: Retrospective review of a multicenter, prospective ASD database was performed. Patients over 70 years of age with ASD who were scheduled to undergo surgical treatment and who were treated and/or followed without surgical intervention participated in the study. Demographic, clinical, surgical, and radiological characteristics and health-related quality-of-life (HRQOL) (Core Outcome Measures Index [COMI], Oswestry Disability Index [ODI], Short-Form-36 Mental Component Summary [SF-36 MCS], Short-Form-36 Physical Component Summary [SF36-PCS], and Scoliosis Research Society-22 [SRS-22]) parameters of such group of patients were evaluated pre- and posttreatment. RESULTS: A total 90 patients (females: 71, males: 29; operative: 61, nonoperative: 29) made up the study group. The comparison between the operative and the nonoperative groups at baseline showed statistical significance for all the HRQOL parameters and the major coronal Cobb angle (P < .05). The calculated optimal cutoff values to diverge operative and nonoperative groups for COMI, ODI, SF-36 PCS, and SRS-22 were 5.7, 37.0, 37.5, and 3.2, respectively (P < .05). All operative patients were treated with posterior surgery. Overall, 135 complications (71 major, 64 minor) and 1 death were observed. Surgically treated patients were found to be improved both clinically and in HRQOL parameters 2 years after surgery for all HRQOL parameters except SF-36 MCS, even in the presence of complications (P < .05), while nonoperative patients have not changed or deteriorated at the end of 2 years. CONCLUSIONS: Despite a relatively high incidence of complications, the likelihood of achieving a clinically significant and relevant HRQOL improvement was superior for patients who were treated surgically in the present population.

Minimum clinically important difference of the health-related quality of life scales in adult spinal deformity calculated by latent class analysis: is it appropriate to use the same values for surgical and nonsurgical patients?

BACKGROUND CONTEXT: Health-related quality of life (HRQOL) parameters have been shown to be reliable and valid in patients with adult spinal deformity (ASD). Minimum clinically important difference (MCID) has become increasingly important to clinicians in evaluating patients with a threshold of improvement that is clinically relevant. PURPOSE: To calculate MCID and minimum detectable change (MDC) values of total scores of the Core Outcome Measures Index (COMI), Oswestry Disability Index (ODI), Physical Component Summary (PCS), Mental Component Summary (MCS) of the Short Form 36 (SF-36), and Scoliosis Research Society 22R (SRS-22R) in surgically and nonsurgically treated ASD patients who have completed an anchor question at pretreatment and 1-year follow-up. STUDY DESIGN/SETTING: Prospective cohort. PATIENT SAMPLE: Surgical and nonsurgical patients from a multicenter ASD database. OUTCOME MEASURES: Self-reported HRQOL measures (COMI, ODI, SF-36, SRS-22R, and anchor question). METHODS: A total of 185 surgical and 86 nonsurgical patients from a multicenter ASD database who completed pretreatment and 1-year follow-up HRQOL scales and the anchor question at the first year follow-up were included. The anchor question was used to determine MCID for each HRQOL measure. MCIDs were calculated by an anchor-based method using latent class analysis (LCA) and MDCs by a distribution-based method. RESULTS: All differences between means of baseline and first year postoperative total score measures for all scales demonstrated statistically significant improvements in the overall population as well as the surgically treated patients but not in the nonsurgical group. The calculated MDC and MCID values of HRQOL parameters in the entire study population were 1.34 and 2.62 for COMI, 10.65 and 14.31 for ODI, 6.09 and 7.33 for SF-36 PCS, 6.14 and 4.37 for SF-36 MCS, and 0.42 and 0.71 for SRS-22R. The calculated MCID values for surgical and non-surgical treatment groups were 2.76 versus 1.20 for COMI, 14.96 versus 2.45 for ODI, 7.83 versus 2.15 for SF-36 PCS, 5.14 versus 2.03 for SF-36 MCS, and 0.94 versus 0.11 for SRS-22R; the MDC values for surgical and nonsurgical treatment groups were 1.22 versus 1.51 for COMI, 10.27 versus 9.45 for ODI, 5.16 versus 6.77 for SF-36 PCS, 6.05 versus 5.67 for SF-36 MCS, and 0.38 versus 0.43 for SRS-22R. CONCLUSIONS: This study has demonstrated that MCID calculations for the HRQOL scales in ASD using LCA yield values comparable to other studies that had used different methodologies. The most important finding was the significantly different MCIDs for COMI, ODI, SF-36 PCS and SRS-22 in the surgically and nonsurgically treated cohorts. This finding suggests that a universal MCID value, inherent to a specific HRQOL for an entire cohort of ASD may not exist. Use of different MCIDs for surgical and nonsurgical patients may be warranted.

The Influence of Diagnosis, Age, and Gender on Surgical Outcomes in Patients With Adult Spinal Deformity.

STUDY DESIGN: Retrospective review of prospectively collected data from a multicentric database. OBJECTIVES: To determine the clinical impact of diagnosis, age, and gender on treatment outcomes in surgically treated adult spinal deformity (ASD) patients. METHODS: A total of 199 surgical patients with a minimum follow-up of 1 year were included and analyzed for baseline characteristics. Patients were separated into 2 groups based on improvement in health-related quality of life (HRQOL) parameters by minimum clinically important difference. Statistics were used to analyze the effect of diagnosis, age, and gender on outcome measurements followed by a multivariate binary logistic regression model for these results with statistical significance. RESULTS: Age was found to affect SF-36 PCS (Short From-36 Physical Component Summary) score significantly, with an odds ratio of 1.017 (unit by unit) of improving SF-36 PCS score on multivariate analysis (P < .05). The breaking point in age for this effect was 37.5 years (AUC = 58.0, P = .05). A diagnosis of idiopathic deformity would increase the probability of improvement in Oswestry Disability Index (ODI) by a factor of 0.219 and in SF-36 PCS by 0.581 times (P < .05). Gender was found not to have a significant effect on any of the HRQOL scores. CONCLUSIONS: Age, along with a diagnosis of degenerative deformity, may have positive effects on the likelihood of improvement in SF-36 PCS (for age) and ODI (for diagnosis) in surgically treated patients with ASD and the breaking point of this effect may be earlier than generally anticipated. Gender does not seem to affect results. These may be important in patient counseling for the anticipated outcomes of surgery.

Cryo-Compression Therapy After Elective Spinal Surgery for Pain Management: A Cross-Sectional Study With Historical Control.

OBJECTIVE: Postoperative dynamic cryo-compression (DC) therapy has been proposed as a method of reducing pain and the inflammatory response in the early postoperative period after orthopedic joint reconstruction surgery. Our aim was to analyze the analgesic efficacy of DC therapy after adult lumbar spinal surgery. METHODS: DC was applied for 30 minutes every 6 hours after surgery. Pain was measured by a visual analogue scale (VAS) in the preoperative period, immediately after surgery, and every 6 hours postoperatively for the first 72 hours of the hospital stay. Patients' pain medication requirements were monitored using the patient-controlled analgesia system and patient charts. Twenty patients who received DC therapy were compared to 20 historical controls who were matched for demographic and surgical variables. RESULTS: In the postanesthesia care unit, the mean VAS back pain score was 5.87 ± 0.9 in the DC group and 6.95±1.0 (p=0.001) in the control group. The corresponding mean VAS scores for the DC vs. control groups were 3.8±1.1 vs. 5.4±0.7 (p < 0.001) at 6 hours postoperatively, and 2.7±0.7 vs. 6.25±0.9 (p<0.001) at discharge, respectively. The cumulative mean analgesic consumption of paracetamol, tenoxicam, and tramadol in the DC group vs. control group was 3,733.3±562.7 mg vs. 4,633.3±693.5 mg (p<0.005), 53.3±19.5 mg vs. 85.3±33.4 mg (p<0.005), and 63.3±83.4 mg vs. 393.3±79.9 mg (p<0.0001), respectively. CONCLUSION: The results of this study demonstrated a positive association between the use of DC therapy and accelerated improvement in patients during early rehabilitation after adult spine surgery compared to patients who were treated with painkillers only.

Analysis of factors affecting baseline SF-36 Mental Component Summary in Adult Spinal Deformity and its impact on surgical outcomes.

OBJECTIVES: To identify the factors that affect SF-36 mental component summary (MCS) in patients with adult spinal deformity (ASD) at the time of presentation, and to analyse the effect of SF-36 MCS on clinical outcomes in surgically treated patients. METHODS: Prospectively collected data from a multicentric ASD database was analysed for baseline parameters. Then, the same database for surgically treated patients with a minimum of 1-year follow-up was analysed to see the effect of baseline SF-36 MCS on treatment results. A clinically useful SF-36 MCS was determined by ROC Curve analysis. RESULTS: A total of 229 patients with the baseline parameters were analysed. A strong correlation between SF-36 MCS and SRS-22, ODI, gender, and diagnosis were found (p < 0.05). For the second part of the study, a total of 186 surgically treated patients were analysed. Only for SF-36 PCS, the un-improved cohort based on minimum clinically important differences had significantly lower mean baseline SF-36 MCS (p < 0.001). SF-36 MCS was found to have an odds ratio of 0.914 in improving SF-36 PCS score (unit by unit) (p < 0.001). A cut-off point of 43.97 for SF-36 MCS was found to be predictive of SF-36 PCS (AUC = 0.631; p < 0.001). CONCLUSIONS: The factors effective on the baseline SF-36 MCS in an ASD population are other HRQOL parameters such as SRS-22 and ODI as well as the baseline thoracic kyphosis and gender. This study has also demonstrated that baseline SF-36 MCS does not necessarily have any effect on the treatment results by surgery as assessed by SRS-22 or ODI. LEVEL OF EVIDENCE: Level III, prognostic study.

Does Surgery for Adult Spinal Deformity Affect the Cognitive Abilities in Patients over 50 Years of Age?

AIM: To analyze the cognitive abilities of older patients undergoing spinal deformity surgery so as to understand whether adult spinal deformity (ASD) surgery is associated with postoperative cognitive malfunction. MATERIAL AND METHODS: A prospective longitudinal study was performed on surgical patients older than 50 years, enrolled in a prospective multicenter database. Mini-mental state examination (MMSE) was performed to assess cognitive function in addition to the health-related quality of life (HRQOL) tests; (SF-36, ODI and SRS-22) at the pre-operative, post-operative 6 weeks and 6 months points. Demographics, preoperative health status, co-morbidities and surgical characteristics were also analyzed. Descriptive statistics and repeated measures of variance analysis were performed. RESULTS: A total of 90 patients with a mean age of 67.4±8.2 years were enrolled in the study; all had MMSE evaluations at 6 weeks follow-up and 58 patients had both 6 weeks and 6 months follow-up. Average (SD) surgical time, estimated blood loss, number of levels fused and hospital stay were 240.1 (111.9) minutes, 1621.2 (1058.7) ml, 11.2 (4.4) levels and 14.2 (11.45) days, respectively. On analysis, a slight increase in mean MMSE score (p > 0.05) between time points was found despite decreases of > 2 points (3 or 4) in 6 patients (6.7%) at both time points. CONCLUSION: Although ASD surgery in older patients is recognized as challenging, this study suggests that it is not necessarily associated with a significant deterioration in the cognitive abilities of patients undergoing surgery. This may be due to the relatively minor influence of ASD itself on the cognitive abilities of the patients involved as well as to the relatively stable hemodynamic conditions obtainable during modern ASD surgery.

Multidisciplinary assessment of congenital insensitivity to pain syndrome.

BACKGROUND: Congenital insensitivity to pain and anhidrosis (CIPA) is a rare clinical condition characterized by the absence of normal subjective and objective responses to noxious stimuli in patients with intact central and peripheral nervous systems. CASE PRESENTATIONS: Two patients with CIPA are reported. The first patient was a 13-year-old girl who presented to our hospital with multiple joint destructions secondary to osteomyelitis. The second patient was a 10-year-old boy who presented with multiple hand lesions and right leg osteomyelitis. Our patients were treated with multiple debridements and intravenous antibiotics according to our hospital protocol. CONCLUSION: Early recognition of the disease is important. The treatment for this condition is focused more on the prevention of bone injuries and joint infection, as opposed to a cure. There are no standard techniques or guidelines available to treat this rare disease. Overall, effective CIPA treatment is built around family education and patient training.

The validity and reliability of "Spinal Mouse" assessment of spinal curvatures in the frontal plane in pediatric adolescent idiopathic thoraco-lumbar curves.

PURPOSE: Radiological measurement has been accepted as the gold standard for evaluating scoliosis for many years. However, exposure of children to X-ray constitutes a major limitation of the radiological methods. Spinal Mouse (SM) is a safe, practical and easy to perform measurement of curvature in scoliosis, but its validity and reliability have not been investigated. The aim of this study was to investigate the validity and reliability of Cobb angle and SM measurements in children with adolescent idiopathic scoliosis (AIS). METHODS: Fifty-one patients with AIS who were followed up conservatively were included in the study. The mean age of the patients was 14.4 years (9-18 years). Frontal plane curvatures were evaluated with SM by 2 physiotherapists and the results were compared with radiological measurements. Radiological measurements were performed by 2 orthopedists. RESULTS: All the measurements were of the thoraco-lumbar curve and the mean value was 35.08° according to Cobb angle measurement. There was no difference between the interobserver measurements of SM (p = 0.256) while the Cobb degrees measured by the 2 orthopedists was different (p = 0.0001). We did not find a statistically significant difference between Cobb measurements and the SM measurements of observer 1 and 2 (p = 0.505). The interobserver and intraobserver agreement of the Cobb and SM measurements was excellent (ICC = 0.872-0.962). When the differences between the evaluations were compared, the interobserver SM differences were seen to be lower than the interobserver Cobb angle differences (p = 0.003). The agreement between the Cobb and SM measurements was higher for curves over 40°. We found a strong or very strong relationship between measurements made with the Cobb and SM methods (p < 0.0001). CONCLUSIONS: We conclude that SM can be used for research and patient follow-up in the clinic as a safe, reliable, quick, and easy to use method with no side effects although it cannot be the only factor to consider when determining the treatment plan of AIS patients.

A migrated knitting needle in a paediatric spine: case report.

PURPOSE: The aims of this study were to present migration of a sharp metal material into the spinal canal in a paediatric patient and to discuss the management of metallic foreign bodies in the spinal canal. METHODS: Patient's medical reports, radiological tests, review of intraoperative findings, and literature search were examined. RESULTS: The migration and penetration of a knitting needle in a 7-year-old-boy are presented. CONCLUSIONS: There is a significant risk of migration of penetrating foreign materials into the spinal canal. Early identification and removal of these foreign bodies retained in the spinal canal may be important even when the patient is asymptomatic.