Substantial improvement in short-term pain following carpal tunnel surgery for patients with moderate preoperative electromyography findings is diminished with diabetes and smoking.

Purpose: Carpal tunnel syndrome is a common orthopedic diagnosis that often benefits from surgical intervention. There is limited published data analyzing the correlation of smoking and diabetes with the outcomes of open carpal tunnel release, specifically with pain perception and electrophysiology results. The purpose of this study is to determine if smoking and diabetes affect preoperative pain perception in patients with carpal tunnel syndrome when correlated with EMG findings and to determine the differences in pain relief obtained 2 weeks post-operatively in this population. Methods: Following IRB approval, the authors conducted a retrospective chart review of consecutive patients who underwent open carpal tunnel release from January 1, 2019, to June 30, 2022, by a single surgeon at an academic hospital. Demographic information was collected. Pre- and 2-week postoperative VAS pain scores and the severity of disease assessed by EMG preoperatively were recorded. Subgroup analysis was performed, and patients were further stratified by preoperative EMG result into mild, moderate, and severe cohorts. Results: Patients who smoked compared to non-smokers had an average improvement in VAS of 2.1 versus 2.8. Patients with reported diabetes compared to non-diabetics had an average improvement in VAS of 2.3 versus VAS of 2.7. Patients who smoked and had diabetes compared to non-smoking, non-diabetic patients reported a change in VAS of 1.92 compared to 2.6. Subgroup analysis of patients with moderate EMG findings demonstrated that patients with diabetes had significantly less improvement in VAS compared to patients without diabetes and smokers had significantly less improvement in VAS compared to non-smokers. Conclusion: This study showed that among the subgroup of patients with moderate preoperative EMG findings, there was more improvement in pain following carpal tunnel release in non-diabetic patients compared to diabetic patients, and among non-smokers compared to smokers. This study is useful when counseling patients on confounding factors that affect 2-week postoperative recovery.

Differences in evaluation and management coding of outpatient clinic visits for patients undergoing elective spine surgery with use of a standardized template.

Background: In a large teaching institution with providers of various levels of training and backgrounds, and a coding department responsible for all evaluation and management (E&M) billing, variations in documentation can hinder accurate medical management and compensation. The purpose of this study is to assess differences in re-imbursement between templated and non-templated outpatient documentation for patients who eventually underwent single level lumbar microdiscectomy and anterior cervical discectomy and fusion (ACDF) both before and after the E&M billing changes were implemented in 2021. Methods: Data was collected from three spine surgeons on 41 patients who underwent a single level lumbar microdiscectomy at a tertiary care center from July 2018 to June 2019 and 35 patients seen by four spine surgeons from January through December of 2021 given the new E&M billing changes. ACDF data was collected for 52 patients between 2018 and 2019 for three spine surgeons and 30 patients from January through December of 2021 from four spine surgeons. Billing level was decided by independent coders for preoperative visits. Results: During the study period from 2018-2019 for lumbar microdiscectomy, each surgeon averaged about 14 patients. Results showed variability of billing level between the three spine surgeons (surgeon 1, 3.2±0.4; surgeon 2, 3.5±0.6; and surgeon 3, 2.9±0.8). Interestingly, even after the implementation of the 2021 E&M billing changes, there was a statistically significant increased level of billing for templated notes for lumbar microdiscectomy (P=0.013). However, this did not translate to the clinic visits for patients who underwent ACDF in 2021. When data was aggregated for all the patients from 2021 who either underwent lumbar microdiscectomy or ACDF, using a template still resulted in a statistically significant higher level of billing (P<0.05). Conclusions: Utilization of templates for clinical documentation reduces variability in billing codes. This impacts subsequent reimbursements and potentially prevents significant financial losses at large tertiary care facilities.

Intradural cervical herniated nucleus pulposus presentation and management: a case report.

Background: Intradural disc herniations (IDH) are uncommon and can be found in the cervical spine. It is commonly associated with Brown-Sequard syndrome (BSS). The case report describes cervical spine magnetic resonance imaging (MRI) findings that assists in identifying IDH pre-operatively and discusses surgical management. Case Description: This is a case report regarding a 42-year-old obese male who developed atraumatic spontaneous bilateral upper extremity numbness, right upper extremity weakness and right lower extremity weakness. MRI showed a C6-7 herniated nucleus pulposus that focally protruded through the posterior longitudinal ligament with a beak-like projection similar to what has been described in previous reports. Clinical exam revealed an incomplete spinal cord injury (SCI) most consistent with BSS. He underwent anterior cervical discectomy and fusion at the level of C6-7. Intra-operatively, a disc fragment was found to be embedded in the dura. Three months post-operatively, the patient had persistent weakness in his right lower extremity but no longer had any bilateral upper extremity weakness. Conclusions: An anterior cervical decompression and fusion was performed shortly after the patient presented, with adequate neurological recovery after 3 months. Advanced imaging with an MRI could lead to the diagnosis of an IDH and surgical intervention via the anterior approach could facilitate removal of the disc and adequate dura repair.

Comorbidities associated with cervical spine degenerative disc disease.

Determining important links between medical comorbidities and cervical spine degenerative disc disease (DDD) will help elucidate pathomechanisms of disc degeneration. Electronic medical records and magnetic resonance imaging were retrospectively reviewed to evaluate 799 patients assessed for cervical spine pathology. Bivariate analysis identified older age, diabetes, ASA class, cancer, COPD, depression, hypertension, hypothyroidism, Medicare status, peripheral vascular disease, history of previous cervical spine surgery, smoking, and lower median household income as having strong associations with increased cumulative grade of cervical spine DDD. This study provides evidence suggesting aging and accumulation of medical comorbidities influence severity of cervical spine DDD.

Responsiveness of routine diagnostic tests for vertebral osteomyelitis may be influenced by the infecting organism.

BACKGROUND CONTEXT: Vertebral osteomyelitis (VO) becomes increasingly more prevalent as people age, and it is a condition seen frequently by referral center spine surgeons. It can take as long as 6 months for a proper diagnosis to be made. Staphylococcus aureus (S. aureus) is the most common isolated organism in up to 80% of the affected population. The clinical presentation of vertebral osteomyelitis is typically non specific (back pain), which can make timely diagnosis challenging. Fever is often absent. Serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC) and serum polymorphonuclear leukocyte percentage (PMN%) are traditionally used as first-line tests because of their perceived sensitivity to help diagnose vertebral osteomyelitis. It is not known whether these test values are affected by the infecting organism. PURPOSE: To determine whether individual first-line diagnostics differed based on infecting organism and whether certain organisms are associated with lower lab values. Additionally, this study sought to determine if VO caused by lower virulent (eg, culture-negative and nonpyogenic organisms) could contribute to delays in treatment due to lack of elevated biomarkers. STUDY DESIGN/SETTING: Single-center retrospective cohort study. PATIENT SAMPLE: We reviewed clinical data of 133 patients (60% male) diagnosed with VO from 2015-2019 in a US Midwest academic hospital. OUTCOMES MEASURES: Primary outcome measures included the maximum temperature upon presentation, serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC), and percentage neutrophils during the hospital admission. METHODS: Inclusion criteria were adult patients diagnosed with vertebral osteomyelitis who underwent blood culture and/or biopsy prior to treatment. All patients enrolled in the study were diagnosed with VO and confirmed via magnetic resonance imaging (MRI). MRI findings associated with VO included destruction of endplates, increased signal in vertebral bodies, and the surrounding disc on T2-weighted imaging were confirmed. The patients had laboratory work up and clinical follow up regardless of positive culture or negative culture. The mean peak inflammatory marker levels were compared among organisms with student's t test. Demographics, comorbidities, and CCI were collected and multivariable logistic regression models were used. Receiver operating characteristic curve analysis was performed to delineate separate, optimal cut offs for CRP, ESR, WBC, and PMN% for patients with culture positive osteomyelitis RESULTS: Patients' average age was 57.0±13.7 years with a mean BMI of 30.5±9.70 kg/m2, and a mean Charleston Comorbidity Index (CCI) of 3.17±2.35. Staphylococcus aureus and antibiotic resistant organisms (MRSA and VRE) demonstrated a higher mean CRP and ESR than culture negative, fungal and TB cases. Staphylococcus aureus, antibiotic resistant organisms, and coagulase negative Staphylococcus demonstrated a higher mean WBC than culture negative as well as fungal and TB cases. Staphylococcus aureus, antibiotic resistant organisms, coagulase negative Staphylococcus, and Streptococcus species had a higher mean peak PMN%, than culture negative as well as fungal and TB case. Temperature did not correlate with a diagnosis of osteomyelitis. CONCLUSIONS: Serum laboratory markers in the diagnosis of VO appear to be influenced by the infecting organism type. Laboratory values in patients diagnosed with VO with culture negative or non-pyogenic organisms are lower compared to antibiotic resistant and S. aureus organisms. Fever did not correlate with a diagnosis of VO.

Evaluation of Predictors and Outcomes of Bracing with Emphasis on the Immediate Effects of in-Brace Correction in Adolescent Idiopathic Scoliosis.

Background: Adolescent idiopathic scoliosis (AIS) is defined as a lateral curvature of the spine of unknown etiology with a Cobb angle of greater than 10 degrees with vertebral rotation. Bracing, specifically with a rigid thoracolumbosacral orthosis (TLSO), decreases the risk of curve progression to over 50 degrees, the threshold for surgical intervention. Some authors have suggested that 30-50% in-brace correction of the Cobb angles is required to prevent significant curve progression. The purpose of the study is to evaluate the current bracing protocol at the University of Iowa as a quality control exercise for the treatment team. Methods: AIS patients (n = 61; 8 male, 53 female) who received a Rosenberger TLSO at the University of Iowa Department of Orthopaedics and Rehabilitation from 2016-2017 were included in the study. Inclusion criteria include presence of pre-brace and in-brace x-rays within 3 months of initiating brace treatment. Patients with other diagnoses were excluded. Radiographic indicators of brace effectiveness, such as the Cobb angle, were measured. Results: The in-brace x-rays of 46 (76%) patients showed less than 30% correction. Minimal changes from the pre- to in-brace x-ray were observed in other radiographic measures. Conclusions: Results indicate that if the 30-50% correction recommended by the literature is valid, then modifications to the process of measuring, fabricating or modifying our current TLSO's for AIS are warranted.Level of evidence: III.

Paravertebral spinal injection for the treatment of patients with degenerative facet osteoarthropathy: Evidence of motor performance improvements based on objective assessments.

BACKGROUND: This study examined short- and long-term improvements in motor performance, quantified using wearable sensors, in response to facet spine injection in degenerative facet osteoarthropathy patients. METHODS: Adults with confirmed degenerative facet osteoarthropathy were recruited and were treated with medial or intermediate branch block injection. Self-report pain, health condition, and disability (Oswestry), as well as objective motor performance measures (gait, balance, and timed-up-and-go) were obtained in five sessions: pre-surgery (baseline), immediately after the injection, one-month, three-month, and 12-month follow-ups. Baseline motor performance parameters were compared with 10 healthy controls. FINDINGS: Thirty patients (age=50 (14) years) and 10 controls (age=46 (15) years) were recruited. All motor performance parameters were significantly different between groups. Results showed that average pain and Oswestry scores improved by 51% and 24%, respectively among patients, only one month after injection. Similarly, improvement in motor performance was most noticeable in one-month post-injection measurements; most improvements were observed in gait speed (14% normal walking, P<0.02), hip sway within balance tests (63% eyes-open P<0.01), and turning velocity within the timed-up-and-go test (28%, P<0.02). Better baseline motor performance led to better outcomes in terms of pain relief; baseline turning velocity was 18% faster among the responsive compared to the non-responsive patients. INTERPRETATIONS: Spinal injection can temporarily (one to three months) improve motor performance in degenerative facet osteoarthropathy patients. Successful pain relief in response to treatment is independent of demographic characteristics and initial pain but dependent on baseline motor performance. Immediate self-reported pain relief is unrelated to magnitude of gradual improvement in motor performance.

Postural Balance Parameters as Objective Surgical Assessments in Low Back Disorders: A Systematic Review.

Balance assessments could render useful objective performance measures to evaluate the efficacy of low back surgeries, yet these assessments have not been collectively examined to determine longitudinal sensitivity across surgical interventions. The purpose of this review was to determine sensitivity of balance measurements for disparate spinal disorders after surgical intervention. We searched PubMed, Embase, Scopus, the Cochrane Library, Web of Science, and CINAHL. Articles were selected based on: (1) sample consisted of low back disorder individuals and (2) balance measurements were obtained both pre- and postsurgery. Most of the articles addressed 2 specific low back disorders: (1) adolescent idiopathic scoliosis/spinal fusion and (2) disc herniation/decompression surgery. For scoliosis patients, body sway increased (14-97%) immediately following surgery but gradually reduced (1-33%) approaching the 1-year post spinal fusion assessment. For patients with disc herniation, sway range, sway velocity, sway area, and sway variability all decreased (19-42%) immediately postsurgery. Balance assessments for adolescents with idiopathic scoliosis who underwent surgical intervention should be performed with visual occlusion, focus on time domain parameters, and evaluated with longer follow-up times. Patients with disc herniation who underwent decompression surgery should have balance assessments with visual deprivation, test conditions specifically addressing hip strategy, and correlation with pain.

Gait behaviors as an objective surgical outcome in low back disorders: A systematic review.

BACKGROUND: Objective motor performance measures, especially gait assessment, could improve evaluation of low back disorder surgeries. However, no study has compared the relative effectiveness of gait parameters for assessing motor performance in low back disorders after surgery. The purpose of the current review was to determine the sensitive gait parameters that address physical improvements in each specific spinal disorder after surgical intervention. METHODS: Articles were searched with the following inclusion criteria: 1) population studied consisted of individuals with low back disorders requiring surgery; 2) low back disorder was measured objectively using gait assessment tests pre- and post-surgery. The quality of the selected studies was assessed using Delphi consensus, and meta-analysis was performed to compare pre- and post-surgical changes. FINDINGS: Thirteen articles met inclusion criteria, which, almost exclusively, addressed two types of spinal disorders/interventions: 1) scoliosis/spinal fusion; and 2) stenosis/decompression. For patients with scoliosis, improvements in hip and shoulder motion (effect size=0.32-1.58), energy expenditure (effect size=0.59-1.18), and activity symmetry of upper-body muscles during gait were present after spinal fusion. For patients with spinal stenosis, increases in gait speed, stride length, cadence, symmetry, walking smoothness, and walking endurance (effect size=0.60-2.50), and decrease in gait variability (effect size=1.45) were observed after decompression surgery. INTERPRETATION: For patients with scoliosis, gait improvements can be better assessed by measuring upper-body motion and EMG rather than the lower extremities. For patients with spinal stenosis, motor performance improvements can be captured by measuring walking spatio-temporal parameters, gait patterns, and walking endurance.