Do Patients Accurately Recall Pain Levels Following Sacroiliac Joint Steroid Injection? A Cohort Study of Recall Bias in Patient-reported Outcomes.

BACKGROUND: Sacroiliac joint (SIJ) injections are crucial in the diagnostic toolkit for evaluating SIJ pathology. Recall bias is an important component in patient-reported outcomes that has not been well studied in SIJ injection. OBJECTIVE: The purpose of this study was to characterize the accuracy, direction, and magnitude of pain level recall bias following SIJ steroid injection and study the factors that affect patient recollection. STUDY DESIGN: Prospective cohort study. SETTING: Level 1 academic medical center. METHODS: Using standardized questionnaires, baseline Numeric Rating Scale (NRS-11) scores were recorded for patients undergoing SIJ steroid injections at preinjection, at 4 hours postinjection, and at 24 hours postinjection. At a minimum of 2 weeks postinjection, patients were asked to recall their preinjection, 4-hour, and 24-hour postinjection NRS-11 scores. Actual and recalled NRS-11 scores were compared using paired t tests for each time interval. Multivariable linear regression was used to identify factors that correlated with consistent recall. RESULTS: Sixty patients with a mean age of 66 years (65% women) were included. Compared to their preinjection pain score, patients showed considerable improvement at both 4 hours (mean difference [MD] = 3.28; 95% CI, 2.68 - 3.89), and 24 hours (MD = 3.23; 95% CI, 2.44 - 4.03) postinjection. Patient recollection of preinjection symptoms was more severe than actual (MD = 0.65; 95% CI, 0.31 - 0.99). Patient recollection of symptoms was also more severe than actual at 4 hours (MD = 0.50; 95% CI .04 - 1.04) as well as at 24 hours postinjection (MD = 0.80; 95% CI, 0.16 - 1.44). The magnitude of recall bias was mild and did not exceed the minimal clinically important difference. There was a moderate correlation between actual and recalled pain levels when comparing preinjection with the 4-hour postinjection NRS-11 score (correlation coefficient [r] =0.64; P < 0.001) and moderate correlation when comparing preinjection with the 24-hour postinjection NRS-11 score (r = 0.62; P < 0.001). Linear regression models showed that at preinjection, patients with a lower body mass index and the presence of coexisting psychiatric diagnoses were better at recalling their pain (P < 0.05). Patients with a higher body mass index also experienced less pain relief when comparing preinjection with the 4-hour postinjection NRS-11 score (P < 0.05). LIMITATIONS: Recall pain scores were obtained via telephone surveys, which can lead to interview bias. One patient died, and 3 were lost to follow-up. We did not control for patient use of adjunctive pain relief modalities, which may modulate the overall response to injection. SIJ injections can also be diagnostic, so some patients may not have shared the same indication for injection or pain-generating diagnosis. CONCLUSIONS: Patients had favorable pain level responses to their SIJ steroid injection for both actual and recall surveys. Although patients demonstrated poor recall of absolute pain scores at preinjection, 4-hour postinjection, and 24-hour postinjection, they demonstrated robust recall of their net pain score improvement at both 4- and 24-hours postinjection. These findings suggest that there is utility in using patient recollection to describe the magnitude of pain relief following treatment for sacroiliac joint dysfunction.

The rate of disuse osteopenia in admitted, non-weight-bearing patients.

Disuse osteopenia is a well-recognized consequence of prolonged physical inactivity, but its rate after orthopaedic injuries necessitating non-weight-bearing is not well studied. The purpose of this study was to estimate the rate of disuse osteopenia at the lumbar spine and proximal femur in patients with lower extremity trauma admitted to the hospital. We performed a retrospective chart review of patients with lower extremity trauma with a period of strict non-weight-bearing between completion of two computed tomography (CT) scans. The radiodensity of the proximal femur or lumbar vertebrae was measured from the earliest and latest available CT scans within the non-weight-bearing timeframe. The change in estimated bone mineral density (eBMD) was calculated as a proxy for disuse osteopenia. A total of 189,111 patients were screened, with 17 patients in the proximal femur group and 15 patients in the lumbar spine group meeting inclusion and exclusion criteria. The average rate of change in eBMD of the proximal femur was a decrease of 7.54 HU/day, 95% confidence interval (CI) [3.65, 11.43]. The average rate of change in eBMD of the lumbar spine was an increase of 1.45 HU/day, 95% CI [-3.15, 6.06]. In admitted, non-weight-bearing orthopaedic trauma patients, our novel study suggests that the proximal femur experiences disuse osteopenia during periods of non-weight-bearing, although this finding was not observed at the lumbar spine. The clinical significance of this data underscores the important consideration of disuse osteopenia by all physicians when caring for patients that may require non-weight-bearing restrictions.

Outcomes and Complications Associated With the Learning Curve for Endoscopic Cervical Foraminotomy: A Systematic Review and Meta-Analysis.

STUDY DESIGN: A systematic review and meta-analysis. OBJECTIVE: The objective of this study is to examine the impact of the learning curve for endoscopic cervical foraminotomy for clinical outcomes and patient safety. SUMMARY OF BACKGROUND DATA: Endoscopic cervical foraminotomy is a minimally invasive surgical technique emerging in the literature for surgical management of cervical radiculopathy without the use of open incision. The adoption of endoscopic cervical foraminotomy may be hindered by the learning curve, although no review and meta-analysis exists to date on the topic. MATERIALS AND METHODS: A systematic review and meta-analysis was performed using PubMed, CINAHL, and MEDLINE from database inception until July 11, 2023. Inclusion criteria were articles that examined endoscopic cervical foraminotomy, reported outcomes, and/or complications for endoscopic cervical spine surgery relevant to the learning curve and had full-text. A random effects meta-analysis was performed for outcomes and complications. RESULTS: A total of three articles (n=203 patients) were included from 792 articles initially retrieved. The learning curves from four surgeons were examined with a FWM 21 procedures until the competency phase. There was no significant difference in the postoperative hospitalization length ( P =0.669), postoperative recovery room time ( P =0.415), intraoperative blood loss ( P =0.064), and total complication rates (10.9% vs . 1.2%, P =0.139) between endoscopic cervical foraminotomy procedures performed in the learning phase as compared with the competency phase of the learning curve. There was a significant decrease in operative time from the learning phase to the competency phase ( P =0.005). CONCLUSION: Competency was achieved on the learning curve for endoscopic cervical foraminotomy after about 21 procedures. There is no significant difference in postoperative hospitalization time, postoperative recovery room time, intraoperative blood loss, and complication rates between the learning phase and the competency phase of the learning curve for endoscopic cervical foraminotomy, noting the relatively small sample size of this study that may underpower this finding.

Operative Technique for Sacral Insufficiency Fractures Causing Spinopelvic Dissociation: A Case Report.

CASE: We present a case of a 54-year-old man with atraumatic, U-type sacral insufficiency and L5 compression fractures leading to spinopelvic dissociation, inability to ambulate, and bowel/bladder compromise. The patient underwent L3-4 percutaneous pedicle screw fixation with bilateral iliac bolts and percutaneous iliosacral screw fixation. Postoperatively, the patient had return of bowel/bladder function and independent ambulation at 2.5 years. CONCLUSION: Atraumatic spinopelvic dissociation is an underappreciated pathology in older patients. Here, we describe the result of our preferred treatment strategy, triangular osteosynthesis, to preserve function and independence. Despite optimal, prompt treatment, these injuries pose a difficult rehabilitation process for patients.

Multilevel Cervical Disk Arthroplasty: Moving Beyond Two Levels.

Cervical disk arthroplasty (CDA) is well-studied for 1-level and 2-level cervical pathology. There is an increasing trend towards its utilization for greater than 2-level disease as an alternative to the gold standard, anterior cervical discectomy and fusion (ACDF). The number of high-level, prospective studies or randomized trials regarding multilevel CDA is limited but continues to grow as the procedure gains popularity. In appropriately indicated patients with multilevel disease caused by disk herniations or spondylosis without extensive facet arthropathy, CDA shows promising results. Multilevel CDA should be avoided in patients with prior spinal trauma, significant degenerative spondylolisthesis with translation, arthrodesis without mobility, severely incompetent facet joints, ossification of the posterior longitudinal ligament, or kyphotic deformity. With overall similar risk profiles to ACDF but lower theoretical rates of pseudarthrosis and adjacent segment disease, multilevel CDA has been shown to preserve, or perhaps even increase, preoperative cervical range of motion. There are negligible differences in postoperative neck and arm pain, VAS scores, modified Japanese Orthopaedic Association scores, and Neck Disability Index scores when comparing multilevel CDA and ACDF. Despite current indications for multilevel CDA largely being based on single and 2-level data, careful patient selection is critical. Expansion of indications can be expected as literature continues to emerge regarding outcomes and complications in multilevel CDA, as well as with improvements in prosthesis design.

Patient satisfaction with follow-up after spinal fusion.

Background: Postoperative follow-up visits (PFUs) allow providers to track patient recovery but can be costly to patients. With the advent of the novel coronavirus pandemic, virtual/phone visits have been utilized as an alternative to in-person PFUs. Patients were surveyed to elucidate patient satisfaction with postoperative care in the setting of increased virtual follow-up visits. A prospective survey with retrospective cohort analysis of chart data was conducted to better understand the factors influencing patient satisfaction related to their PFUs after spine fusion with the goal of improving the value of postoperative care. Methods: Adult patients at least 1 year postoperative from cervical or lumbar fusion surgery completed a telephone survey related to their postoperative clinic experience. Medical record data including complications, number of visits and length of follow-up, and presence of phone/virtual visits were abstracted and analyzed. Results: Fifty patients (54% female) were included. Univariate analysis demonstrated no association between satisfaction and patient demographics, rates of complication, mean length or number of PFUs, or incidence of phone/virtual visits. Patients "very satisfied" with their clinic experience were more likely to be "very satisfied" with their outcome (P<0.01), and to feel their concerns were "very well addressed" (P<0.01). Multivariate analysis additionally demonstrated that satisfaction was positively associated with how well patient concerns were addressed (P<0.01) and the incidence of virtual/phone visits (P=0.01), and negatively associated with age (P=0.01) and level of education (P=0.01). Conclusions: After spinal fusion, patient satisfaction is positively related to virtual/phone visits and to how well their concerns are addressed. As long as patient concerns remain adequately addressed, surgeons can eliminate excess PFUs which are not clinically beneficial without adversely impacting patients' postoperative experience.

Do Patients Accurately Recall Their Preoperative Symptoms After Elective Orthopedic Procedures?

Patient-reported outcome measures are a frequent tool used to assess orthopedic surgical outcomes. However, recall bias is a potential limitation of these tools when used retrospectively, as they rely on patients to accurately recall their preoperative symptoms. A database search of Cochrane Library, PubMed, Medline Ovid, and Scopus until May 2021 was completed in duplicate by two reviewers. Studies considered eligible for inclusion were those which reported on patient recall bias associated with orthopedic surgery. The primary outcome of interest investigated was the accuracy of patient recollection of preoperative health status. Any factors that were identified as affecting patient recall were secondary outcomes of interest. Of the 4,065 studies initially screened, 20 studies with 3,454 patients were included in the final analysis. Overall, there were 2,371 (69%) knee and hip patients, 422 (12%) shoulder patients, 370 (11%) spine patients, 208 (6%) other upper extremity patients, and 83 (2%) foot and ankle patients. Out of the eight studies that evaluated patient recall within three months postoperatively, seven studies concluded that patient recall is accurate. Out of the 13 studies that evaluated patient recall beyond three months postoperatively, nine studies concluded that patient recall is inaccurate. The accuracy of patient recall of preoperative symptoms after elective orthopedic procedures is not reliable beyond three months postoperatively.

Investigating the Association of Patient Body Mass Index With Posterior Subcutaneous Fat Thickness in the Cervical Spine: A Retrospective Radiographic Study.

INTRODUCTION: Although BMI is often used as a surrogate for posterior cervical subcutaneous fat thickness (SFT), the association of BMI with cervical SFT is unknown. We performed a retrospective radiographic study to analyze the relationship between BMI and cervical SFT. METHODS: This was a retrospective cohort study of patients with cervical CT scans. SFT was assessed by measuring the distance (mm) from the spinous processes of C2-C7 to the skin edge. Pearson correlations and linear regression were used to analyze the relationship between BMI and SFT. One-way ANOVA was used to analyze differences in C2-C7 distances while stratifying by BMI. RESULTS: A total of 96 patients were included. BMI had a moderate correlation with average C2-C7 (r=0.546, p < 0.05) SFT, and a weak to moderate correlation with each individual C2-C7 distance. The strongest correlation was at the C7 level (r= 0.583, p < 0.05). These analyses remained significant controlling for potential confounders of patient age, sex, and diabetes. No difference was found in the average C2-C7 distance in patients with BMIs of 25-30 compared to those with BMIs of 30-40 (p=0.996), whereas in patients with BMI <25 and BMI >40, differences were significant (p < 0.05). CONCLUSIONS: BMI is not strongly correlated with SFT in the cervical spine. Although BMI less than 25 or greater than 40 is correlated with respectively decreased or increased cervical SFT, BMI of 25-40 is not correlated with cervical SFT. This is clinically important information for surgeons counseling patients on perioperative risk before undergoing cervical spine procedures, namely infection. Further research delineating the relationship between posterior SFT and surgical site infection in the cervical spine is warranted.

Limiting the Surveillance Period to 90 Days Misses a Large Portion of Infections in the First Year After Total Hip and Knee Arthroplasty.

Background: In 2013, the Centers for Disease Control and Prevention reduced the periprosthetic joint infection (PJI) surveillance period from 1 year to 90 days for total hip (THA) and knee arthroplasty (TKA). Our aim was to determine how the reduced surveillance window impacts capture of PJIs. Material and methods: Primary and revision THA and TKA cases were retrospectively identified in a statewide registry from October 1, 2015, to September 30, 2018. Infections were defined using the Periprosthetic Joint/Wound Infection measure (Centers for Medicare and Medicaid Services). We compared the cumulative incidence of infected primary and revision THA (pTHA/rTHA) and TKA (pTKA/rTKA) at 0-90 days and 91-365 days postoperatively. Results: A total of 136,491 patients were included, 59.59% female, mean age 65.8 years, and mean body mass index 32.3 kg/m2. The overall rate of PJI diagnosed by 1 year was 1.33%. The percent of infections diagnosed between 0-90 days and 91-365 days were pTHA 76.78% and 23.22%, rTHA 74.12% and 25.88%, pTKA 57.67% and 42.33%, and rTKA 53.78% and 46.22%, respectively. More infections were diagnosed after 90 days in pTKA than in pTHA and in rTKA than in rTHA (P < .0001). There was a higher risk of infection throughout the year when comparing rTKA to rTHA (P = .0374) but not when comparing pTKA to pTHA (P = .0518). Conclusion: A substantial portion of infections are missed by the 90-day surveillance period. More infections are missed after TKA than after THA. Extension of the surveillance period would allow for identification of opportunities for quality improvement.

Postoperative Neurological Complications Following Revision Spine Surgery: A State Inpatient Database Analysis.

BACKGROUND: Postoperative neurological complications after spine surgery can result in increased mortality and morbidity. Despite the introduction of new spinal implants and surgical technology, reoperation rates have remained stable over recent years. Understanding the reasons for revision (refusion) surgery and the risk of neurological complications can assist in developing more effective screening protocols for repeat surgeries and early detection of potential neurological complications. METHODS: This study was designed and conducted as a retrospective cohort study. The primary objective of this study was to evaluate whether revision spine surgery increased the risk of postoperative neurological deficits. A secondary objective of the study was to analyze whether deficits following repeat spine surgery increased morbidity and mortality. Data on revision spine procedures were extracted from the California State Inpatient Database for years 2008 to 2011. Patients who developed postoperative neurological deficits were then subdivided into causative procedure: revision anterior cervical discectomy and fusion, revision posterior cervical fusion, and revision thoracolumbar fusion. These data were then used to calculate the total incidence of postoperative neurological deficits following each type of procedure. The impact of neurological deficits on in-hospital morbidity following revision procedures was also calculated. RESULTS: Revision procedures accounted for 5.84% of all spine procedures in a total of 7645 patients. Among these patients, 67 patients (0.88%) developed a postoperative neurological deficit with an adjusted odds ratio of 1.56 (95% CI, 1.20-2.00, P < .05). When using individuals with no neurological deficit as the reference group, the odds of morbidity were 5.3 (95% CI, 3.15-9.00, P < .05) in those who sustained neurological deficit following revision procedure. CONCLUSIONS/CLINICAL RELEVANCE: This study exposes the increased risk of postoperative neurological complications in revision spine surgeries. In response, further studies are needed to evaluate the use of intraoperative neurophysiological monitoring to reduce this risk.

Meta-Analysis of Perioperative Stroke and Mortality in Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) is a rapidly evolving safe method with decreasing incidence of perioperative stroke. There is a void in literature concerning the impact of stroke after TAVI in predicting 30-day stroke-related mortality. The primary aim of this meta-analysis was to determine whether perioperative stroke increases risk of stroke-related mortality after TAVI. Online databases, using relevant keywords, and additional related records were searched to retrieve articles involving TAVI and stroke after TAVI. Data were extracted from the finalized studies and analyzed to generate a summary odds ratio (OR) of stroke-related mortality after TAVI. The stroke rate and stroke-related mortality rate in the total patient population were 3.07% (893 of 29,043) and 12.27% (252 of 2,053), respectively. The all-cause mortality rate was 7.07% (2,053 of 29,043). Summary OR of stroke-related mortality after TAVI was estimated to be 6.45 (95% confidence interval 3.90 to 10.66, p <0.0001). Subgroup analyses were performed among age, approach, and valve type. Only 1 subgroup, transapical TAVI, was not significantly associated with stroke-related mortality (OR 1.97, 95% confidence interval, 0.43 to 7.43, p = 0.42). A metaregression was conducted among females, New York Heart Association class III/IV status, previous stroke, valve type, and implantation route. All failed to exhibit any significant associations with the OR. In conclusion, perioperative strokes after TAVI are associated with >6 times greater risk of 30-day stroke-related mortality. Transapical TAVI is not associated with increased stroke-related mortality in patients who suffer from perioperative stroke. Preventative measures need to be taken to alleviate the elevated rates of stroke after TAVI and subsequent direct mortality.

Value of intraoperative neurophysiological monitoring to reduce neurological complications in patients undergoing anterior cervical spine procedures for cervical spondylotic myelopathy.

The primary aim of this study was to conduct a systematic review of reports of patients with cervical spondylotic myelopathy and to assess the value of intraoperative monitoring (IOM), including somatosensory evoked potentials, transcranial motor evoked potentials and electromyography, in anterior cervical procedures. A search was conducted to collect a small database of relevant papers using key words describing disorders and procedures of interest. The database was then shortlisted using selection criteria and data was extracted to identify complications as a result of anterior cervical procedures for cervical spondylotic myelopathy and outcome analysis on a continuous scale. In the 22 studies that matched the screening criteria, only two involved the use of IOM. The average sample size was 173 patients. In procedures done without IOM a mean change in Japanese Orthopaedic Association score of 3.94 points and Nurick score by 1.20 points (both less severe post-operatively) was observed. Within our sub-group analysis, worsening myelopathy and/or quadriplegia was seen in 2.71% of patients for studies without IOM and 0.91% of patients for studies with IOM. Variations persist in the existing literature in the evaluation of complications associated with anterior cervical spinal procedures. Based on the review of published studies, sufficient evidence does not exist to make recommendations regarding the use of different IOM modalities to reduce neurological complications during anterior cervical procedures. However, future studies with objective measures of neurological deficits using a specific IOM modality may establish it as an effective and reliable indicator of injury during such surgeries.

Diagnostic Value of Somatosensory-Evoked Potential Monitoring During Cerebral Aneurysm Clipping: A Systematic Review.

BACKGROUND: Perioperative stroke is a known complication in patients undergoing surgical clipping of cerebral aneurysms. OBJECTIVE: To evaluate whether intraoperative changes in somatosensory-evoked potential (SSEP) monitoring during cerebral aneurysm clipping is diagnostic of perioperative stroke. METHODS: An electronic search of PubMed, Embase, and Web of Science databases was done for studies published through May 2015 on SSEP monitoring in cerebral aneurysm clipping for predicting postoperative outcomes. All titles and abstracts were screened independently on the basis of predetermined criteria. Inclusion criteria included randomized clinical trials and prospective or retrospective cohort reviews; patients with intracranial aneurysms who underwent surgical clipping with intra-operative SSEP monitoring and postoperative neurologic assessment; studies published in English on adult humans ≥18 years with sample size of ≥50; and studies inclusive of an abstract with adequate details on outcomes. RESULTS: A total of 14 articles with a sample population of 2015 patients were analyzed. SSEP monitoring demonstrated a strong mean specificity of 84.5% (95% confidence interval [95% CI] -76.3 to 90.3) but weaker sensitivity of 56.8% (95% CI 44.1-68.6) for predicting stroke. A diagnostic odds ratio of 7.772 (95% CI 5.133-11.767) suggested that the odds of observing an SSEP change among those with a postoperative neurologic deficit were 7 times greater than those without a neurologic deficit. CONCLUSION: Intraoperative SSEP monitoring is highly specific for predicting neurologic outcome after cerebral aneurysm clipping. Patients with postoperative neurologic deficits are 7 times more likely to have had intraoperative SSEP changes. SSEP monitoring may help design prevention strategies to reduce stroke rates after cerebral aneurysm clipping.

The need for kidney transplantation in low- and middle-income countries in 2012: an epidemiological perspective.

Epidemiological and demographic transitions are shifting the burden of modifiable risk factors for chronic and end-stage kidney disease to low- and middle-income countries (LMIC). This shifting burden of disease--combined with economic transitions and health system reforms--has led to the rapid growth of dialysis populations in LMIC including Malaysia, Tunisia, Turkey, Chile, Mexico, and Uruguay. Yet, compared to 1.5 million on dialysis in LMIC, only approximately 33,000 kidney transplants were performed in 2012. Reasons include health system factors (personnel, infrastructure, system coordination, and financing) and cultural factors (public and professional attitudes and the legal environment). The size of the dialysis populations, however, is generally a poor indicator of the potential need for kidney transplantation in LMIC. Population needs for kidney transplantation should instead be assessed based on the epidemiology of the actual underlying burden of disease (both treated and untreated), and the costs and benefits of treatment as well as prevention strategies relative to existing service provision. Here, we review current data on the global burden of end-stage kidney disease and the distribution of major risk factors, and compare this to access to kidney transplantation in 2012.