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1.
Spine J ; 2020 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-32565316

RESUMO

BACKGROUND CONTEXT: Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain. PURPOSE: This study sought to determine: 1) the proportion of patients having surgery following CESI, and 2) the timing of and factors associated with subsequent surgery. STUDY DESIGN: Retrospective analysis of a large, national administrative claims database. PATIENT SAMPLE: The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof. OUTCOME MEASURES: The primary outcome was the time from index CESI to surgery. METHODS: Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year prior to CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models. RESULTS: Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35-54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery. CONCLUSIONS: Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making.

2.
Spine (Phila Pa 1976) ; 45(5): E288-E295, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-32045403

RESUMO

STUDY DESIGN: This was a retrospective study using national administrative data from the MarketScan database. OBJECTIVE: To investigate the complication rates, quality outcomes, and costs in a nationwide cohort of patients with movement disorders (MD) who undergo spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Patients with MD often present with spinal deformities, but their tolerance for surgical intervention is unknown. METHODS: The MarketScan administrative claims database was queried to identify adult patients with MD who underwent spinal deformity surgery. A propensity-score match was conducted to create two uniform cohorts and mitigate interpopulation confounders. Perioperative complication rates, 90-day postoperative outcomes, and total costs were compared between patients with MD and controls. RESULTS: A total of 316 patients with MD (1.7%) were identified from the 18,970 undergoing spinal deformity surgery. The complication rate for MD patients was 44.6% and for the controls 35.6% (P = 0.009). The two most common perioperative complications were more likely to occur in MD patients, acute-posthemorrhagic anemia (26.9% vs. 20.8%, P < 0.05) and deficiency anemia (15.5% vs. 8.5%, P < 0.05). At 90 days, MD patients were more likely to be readmitted (17.4% vs. 13.2%, P < 0.05) and have a higher total cost ($94,672 vs. $85,190, P < 0.05). After propensity-score match, the overall complication rate remained higher in the MD group (44.6% vs. 37.6%, P < 0.05). 90-day readmissions and costs also remained significantly higher in the MD cohort. Multivariate modeling revealed MD was an independent predictor of postoperative complication and inpatient readmission. Subgroup analysis revealed that Parkinson disease was an independent predictor of inpatient readmission, reoperation, and increased length of stay. CONCLUSION: Patients with MD who undergo spinal deformity surgery may be at risk of higher rate of perioperative complications and 90-day readmissions compared with patients without these disorders. LEVEL OF EVIDENCE: 3.

3.
Clin Spine Surg ; 33(3): E92-E95, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31693517

RESUMO

INTRODUCTION: Anterior cervical discectomy and fusion (ACDF) remain an effective treatment option for multiple pathologies of the cervical spine. As the health care economic climate has changed, so have reimbursements with a concomitant push toward outpatient procedures. Certificate of Need (CON) programs were established in response to burgeoning health care costs which require states to demonstrate need before expansion of medical facilities. The impact of this program on spine surgery is largely unknown. The purpose of this study was to examine the impact of CON status on reimbursement and utilization trends of ACDF in both inpatient and outpatient settings. MATERIALS AND METHODS: We queried a combined private payer and Medicare database from 2007 to 2015. All single-level ACDFs were identified. We then split each procedure into those performed in CON versus non-CON states. We then further split each group into the inpatient and outpatient settings. Compound annual growth rate (CAGR) was used to compare utilization and reimbursement trends. Reimbursement was adjusted for inflation using the United States Bureau of Labor Statistics consumer price index. RESULTS: A total of 32,727 single-level ACDFs were identified, of which 28,441 were performed in the inpatient setting, and 4286 were performed in the outpatient setting. Reimbursement decreased across all settings, with the most pronounced decrease in the non-CON outpatient setting with an adjusted CAGR of -11.0%. Utilization increased across all groups, although the fastest growth was seen in the outpatient CON setting with a CAGR of 47.7%, and the slowest growth seen in the inpatient non-CON setting at a CAGR of 12.9%. CONCLUSIONS: ACDF utilization increased most rapidly in the outpatient setting, and CON status did not appear to hinder growth. Reimbursement decreased across all settings, with the outpatient setting in non-CON states most affected. Surgeons should be aware of these trends in the changing health care environment.

4.
J Am Acad Orthop Surg ; 28(10): 419-426, 2020 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-31567900

RESUMO

INTRODUCTION: To assess bounds of shared decision making in orthopaedic surgery, we conducted an exploratory study to examine the extent to which patients want to be involved in decision making in the management of a musculoskeletal condition. METHODS: One hundred fifteen patients at an orthopaedic surgery clinic were asked to rate preferred level of involvement in 25 common theoretical clinical decisions (passive [0], semipassive [1 to 4], equally shared involvement between patient and surgeon [5], semiactive [6 to 9], active [10]). RESULTS: Patients preferred semipassive roles in 92% of decisions assessed. Patients wanted to be most involved in scheduling surgical treatments (4.75 ± 2.65) and least involved in determining incision sizes (1.13 ± 1.98). No difference exists in desired decision-making responsibility between patients who had undergone orthopaedic surgery previously and those who had not. Younger and educated patients preferred more decision-making responsibility. Those with Medicare desired more passive roles. DISCUSSION: Despite the importance of shared decision making on delivering patient-centered care, our results suggest that patients do not prefer to share all decisions.

5.
Spine J ; 20(2): 300-306, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31377475

RESUMO

BACKGROUND CONTEXT: Smoking is detrimental to obtaining a solid spinal fusion mass with previous studies demonstrating its association with pseudoarthrosis in patients undergoing spinal fusion. Varenicline is a pharmacologic adjunct used in smoking cessation which acts as a partial agonist of the same nicotinic receptors activated during tobacco use. However, no clinical or basic science studies to date have characterized if varenicline has negative effects on spinal fusion and bone healing by itself. PURPOSE: Our study's aim was to elucidate whether varenicline affects the frequency or quality of posterolateral spinal fusion in a rodent model at an endpoint of 12 weeks. STUDY DESIGN: Randomized control trial. PATIENT SAMPLE: Fourteen male Lewis rats randomly separated into two experimental groups. OUTCOME MEASURES: Manual palpation of fusion segment, radiography, µCT imaging, and four-point bend. METHODS: Fourteen male Lewis rats were randomly separated into two experimental groups undergoing L4-L5 posterior spinal fusion procedure followed by daily subcutaneous injections of human dose varenicline or saline (control) for 12 weeks postsurgery. Spine samples were explanted, and fusion was determined via manual palpation of segments by two independent observers. High-resolution radiographs were obtained to evaluate bridging fusion mass. µCT imaging was performed to characterize fusion mass and consolidation. Lumbar spinal fusion units were tested in four-point bending to evaluate stiffness and peak load. Study funding sources include $5000 OREF Grant. There were no applicable financial relationships or conflicts of interest. RESULTS: At 3 months postsurgery, 12 out of 14 rats demonstrated lumbar spine fusion (86% fused) with no difference in fusion frequency between the varenicline and control groups as detected by manual palpation. High-resolution radiography revealed six out of seven rats (86%) having complete fusion in both groups. µCT showed no significant difference in bone mineral density or bone fraction volume between groups in the region of interest. Biomechanical testing demonstrated no significant different in the average stiffness or peak loads at the fusion site of the varenicline and control groups. CONCLUSION: Based on the results of our rat study, there is no indication that varenicline itself has a detrimental effect on the frequency and quality of spinal fusion.

6.
Global Spine J ; 9(7): 697-707, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31552149

RESUMO

Study Design: In vitro cadaveric biomechanical study. Objective: To compare the biomechanics of integrated anchor and blade versus traditional screw fixation techniques for interbody fusion. Methods: Fifteen cadaveric cervical spines were divided into 3 equal groups (n = 5). Each spine was tested: intact, after discectomy (simulating an injury model), interbody spacer alone (S), integrated interbody spacer (iSA), and integrated spacer with lateral mass screw and rod fixation (LMS+iS). Each treatment group included integrated spacers with either screw, anchor, or blade integrated spacers. Constructs were tested in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) under pure moments (±1.5 N m). Results: Across all 3 planes, the following range of motion trend was observed: Injured > Intact > S > iSA > LMS+iS. In FE and LB, integrated anchor and blade significantly decreased motion compared with intact and injured conditions, before and after supplemental posterior fixation (P < .05). Comparing tested devices revealed biomechanical equivalence between screw, anchor, and blade fixation methods in all loading modes (P > .05). Conclusion: All integrated interbody devices reduced intact and injured motion; lateral mass screws and rods further stabilized the single motion segment. Comparing screw, anchor, or bladed integrated anterior cervical discectomy and fusion spacers revealed no significant differences.

7.
Spine Deform ; 7(5): 796-803.e1, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31495481

RESUMO

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Assess differences between staged (≤3 days) and same-day surgery in perioperative factors, radiographic measures, and complications. SUMMARY OF BACKGROUND DATA: Surgical adult spinal deformity correction may require combined anterior and posterior approaches. To modulate risk, some surgeons perform surgery that is expected to be longer and/or more complex in two stages. Prior studies comparing staged (≥7 days) and same-day surgery demonstrated mixed results and none have examined results with shorter staging intervals. METHODS: Retrospective review of adults undergoing combined anterior/posterior approaches for spinal deformity over a 3-year period at a single institution (n=92). Univariate differences between staged and same-day surgery were assessed with chi-squared, Fisher exact, and Mann-Whitney U tests. Generalized estimating equations assessed whether differences in perioperative outcomes between groups remained after adjusting for differences in demographic and surgical characteristics. RESULTS: In univariate analyses, staged surgery was associated with a length of stay (LOS) 3 days longer than same-day surgery (9.2 vs. 6.3 days, p < .001), and greater operative time, blood loss, transfusion requirement, and days in intensive care unit (p < .001 for each). Staged surgery had a higher rate of thrombotic events (p = .011) but did not differ in readmission rates or other complications. Radiographically, improvements in Cobb angle (average 13° vs. 17°, p = .028), lumbar lordosis (average 14° vs. 23°, p = .019), and PI-LL mismatch (average 10° vs. 2° p = .018) were greater for staged surgery, likely related to more extensive use of osteotomies in the staged group. After risk adjustment, taking into account the procedural specifics including longer fusion constructs and greater number of osteotomies, LOS no longer differed between staged and same-day surgery; however, the total operative time was 98 minutes longer for staged surgery (p < .001). Differences in blood loss between groups was accounted for by differences in operative time and patient and surgical characteristics. CONCLUSIONS: Although univariate analysis of our results were in accordance with previously published works, multivariate analysis allowing individual case risk adjustment revealed that LOS was not significantly increased in the staged group as reported in previous studies. There was no difference in infection rates as previously described but an increase in thrombotic events was observed. LEVEL OF EVIDENCE: Level III.


Assuntos
Curvaturas da Coluna Vertebral/cirurgia , Fusão Vertebral , Idoso , Procedimentos Cirúrgicos Ambulatórios , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodos , Fusão Vertebral/estatística & dados numéricos , Resultado do Tratamento
8.
World Neurosurg ; 132: 421-428.e1, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31398524

RESUMO

BACKGROUND: Grade II spondylolisthesis remains a complex surgical pathology for which there is no consensus regarding optimal surgical strategies. Surgical strategies vary regarding extent of reduction, use of instrumentation/interbody support, and anterior versus posterior approaches with or without decompression. Here we provide the first report on the efficacy of robotic spinal surgery systems in support of the treatment of grade II spondylolisthesis. METHODS: Using 2 illustrative cases, we provide a technical report describing how robotic spinal surgery platform can be used to treatment grade II spondylolisthesis with a novel instrumentation strategy. RESULTS: We describe how the "reverse Bohlman" technique to achieve a large anterior fusion construct spanning the pathological level and buttressed by the adjacent level above, coupled with a novel, high-fidelity posterior fixation scheme with transdiscal S1-L5 and S2 alar iliac (S2AI) screws placed in a minimally invasive fashion with robot guidance allows for the best chance of fusion in situ. CONCLUSIONS: The reverse Bohlman technique coupled with transdiscal S1-L5 and S2AI screw fixation accomplishes the surgical goals of creating a solid fusion construct, avoiding neurologic injury with aggressive reduction, and halting the progression of anterolisthesis. The use of robot guidance allows for efficient placement of these difficult screw trajectories in a minimally invasive fashion.


Assuntos
Parafusos Ósseos , Procedimentos Neurocirúrgicos/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Coluna Vertebral/cirurgia , Espondilolistese/cirurgia , Idoso , Feminino , Humanos , Fixadores Internos , Dor Lombar/etiologia , Dor Lombar/cirurgia , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Sacro/cirurgia , Fusão Vertebral/instrumentação , Fusão Vertebral/métodos , Espondilolistese/diagnóstico por imagem , Resultado do Tratamento
9.
J Spine Surg ; 5(2): 185-193, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31380471

RESUMO

Background: The goal of the current study was to compare the perioperative and post-operative outcomes of eXtreme lateral trans-psoas approach (XLIF) versus anterior lumbar interbody fusion (ALIF) for single level degenerative spondylolisthesis. The ideal approach for degenerative spondylolisthesis remains controversial. Methods: Consecutive patients undergoing single level XLIF (n=21) or ALIF (n=54) for L4-5 degenerative spondylolisthesis between 2008-2012 from a single academic center were retrospectively reviewed. Groups were compared for peri-operative data (estimated blood loss, operative time, adjunct procedures or additional implants), radiographic measurements (L1-S1 cobb angle, disc height, fusion grade, subsidence), 30-day complications (infection, DVT/PE, weakness/paresthesia, etc.), and patient reported outcomes (leg and back Numerical Rating Scale, and Oswestry Disability Index). Results: Estimated blood loss was significantly lower for XLIF [median 100; interquartile range (IQR), 50-100 mL] than for ALIF (median 250; IQR, 150-400 mL; P<0.001), including after adjusting for significantly higher rates of posterior decompression in the ALIF group. There were no significant differences in rates of complications within 30 days, radiographic outcomes, or in re-operation rates. Both groups experienced significant pain relief post-operatively. Conclusions: The lateral trans-psoas approach is associated with diminished blood loss compared to the anterior approach in the treatment of degenerative spondylolisthesis. We were unable to detect differences in radiographic outcomes, complication rates, or patient reported outcomes. Continued efforts to directly compare approaches for specific indications will minimize complications and improve outcomes. Further studies will continue to define indications for lateral versus anterior approach to lumbar spine for degenerative spondylolisthesis.

10.
J Spine Surg ; 5(2): 201-206, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31380473

RESUMO

Background: To analyze perioperative and radiographic outcomes following revision surgery using lateral lumbar interbody fusion (LLIF) performed entirely in the lateral position. Traditionally, patients undergoing interbody fusion in the lateral decubitus position are placed prone for pedicle screw fixation. However prone positioning carries known risks and may increase surgical time due to the need to re-drape and reposition. Little is published regarding revision surgery in a single position. Methods: Sixteen patients over the age of 18 with degenerative lumbar pathology who underwent a revision of previous lumbar fusion using interbody fusion via lateral access and revision of posterior instrumentation from a single surgeon met inclusion criteria. Patients who underwent combined procedures requiring repositioning or had inadequate preoperative imaging were excluded. Patients remained in the lateral decubitus position for the entirety of the procedure including interbody placement, revision of prior instrumentation, and pedicle screw fixation. Demographics, surgical details, and perioperative outcomes were reported. Results: The mean operative time was 211 minutes for all cases, 161 minutes for single-level procedures and 296 minutes for two-level procedures. Mean estimated blood loss was 206 cc. The mean patient age was 66, 70% of which were male. The mean body mass index (BMI) was 27.4 and Charleson Comorbidity Index (CCI) was 3. All cases were performed on the lumbar spine (T12/L1-L4/L5), with the majority of procedures performed at the L2/3 level (44%). The mean pelvic incidence (PI) was 60 degrees (range, 41-71 degrees) with mean preoperative PI/lumbar lordosis (LL) mismatch of 23.9 degrees. Mean postoperative PI/LL mismatch was 12 degrees. Conclusions: Revision surgery in the lateral position is feasible with complication rates comparable to published literature. The need to reposition is eliminated and single position surgery reduces operative time.

11.
Int J Mol Sci ; 20(9)2019 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-31064083

RESUMO

Avian infectious bronchitis virus (IBV) causes considerable economic losses in the poultry industry worldwide, including Taiwan. IBV is among the most important pathogens in chickens, and it spreads rapidly among flocks. In addition to dozens of known serotypes, new viral variants have emerged due to the viral evolution and antigenic variation in IBVs. Therefore, the development of a sensitive, specific, and easily performed assay is crucial for the rapid detection and surveillance of IBV infections. A rapid and simple immunochromatographic strip (ICS) was developed in this study by employing monoclonal antibodies against spike and nucleocapsid proteins of IBV as the tracer and the capture antibody. The ICS showed high specificity in detecting IBV antigens, including several IBV genotypes and novel variants, as opposed to three other common avian respiratory viruses. The detection limit of the strip reached 104.4 50% embryo-infective dose. Moreover, in the experimental chicken model, the strip test demonstrated consistency in detecting IBV with RT-PCR gene detection. Taken together, this antigen detection strip has the potential to serve as an on-farm rapid test for IBV; therefore, it may facilitate surveillance and control of the disease.


Assuntos
Infecções por Coronavirus/diagnóstico , Vírus da Bronquite Infecciosa/imunologia , Técnicas de Diagnóstico Molecular/veterinária , Doenças das Aves Domésticas/diagnóstico , Animais , Antígenos Virais/imunologia , Galinhas , Infecções por Coronavirus/veterinária , Infecções por Coronavirus/virologia , Feminino , Imunoensaio/métodos , Imunoensaio/normas , Imunoensaio/veterinária , Camundongos , Camundongos Endogâmicos BALB C , Técnicas de Diagnóstico Molecular/métodos , Técnicas de Diagnóstico Molecular/normas , Doenças das Aves Domésticas/virologia , Fitas Reagentes/normas
12.
Spine J ; 19(8): 1324-1330, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31078698

RESUMO

BACKGROUND CONTEXT: It is recognized that radiological parameters of type 2 dens fractures, including displacement and angulation, are predictive of treatment outcomes and are used to guide surgical decision-making. The reproducibility of such measurements, therefore, is of critical importance. Past literature has shown poor interobserver reliability for both displacement and angulation measurements of type 2 dens fractures. Since such studies however, various advancements of radiological review systems and measurement tools have evolved to potentially improve such measurements. PURPOSE: To re-examine the inter-rater reliability of measuring displacement and angulation of type 2 dens fractures using modern radiological review systems. Besides quantitative measurements, the reliability of raters in identifying diagnostic classifications based on translational and angulational displacement was also examined. STUDY DESIGN: Radiographic measurement reliability and agreement study. PATIENT SAMPLE: Thirty-seven patients seen at a single institution between 2002 and 2017 with primary diagnosis of acute type 2 dens fracture with complete computed tomography (CT) imaging. OUTCOME MEASURES: Radiological measurements included displacement and angulation. Diagnostic classifications based on consensus-based clinical cutoff points were also recorded. METHODS: Measurements were performed by five surgeons with varying years of experience in spine surgery using the hospital's electronic medical record radiological measuring tools. The radiological measurements included displacement and angulation. Diagnostic classifications based on consensus-based clinical cutoff points were also recorded. Each rater received a graphic demonstration of the measurement methods, but had the autonomy to select a best cut from the sagittal CT to measure. All raters were blinded to patient information. RESULTS: Measurements for displacement and angulation among the five raters demonstrated "excellent" reliability. Intra-rater reliability was also "excellent" in measuring displacement and angulation. The reliability of diagnostic classification of displacement (above vs. below 5 mm), was found to be "very good" among the raters. The reliability of diagnostic classification of angulation (above vs. below 11°) demonstrated "good" reliability. CONCLUSIONS: Advancement of radiological review systems, including review tools and embedded image processing software, has facilitated more reliable measurements for type 2 odontoid fractures.


Assuntos
Processo Odontoide/diagnóstico por imagem , Fraturas da Coluna Vertebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X/normas , Feminino , Humanos , Processamento de Imagem Assistida por Computador/normas , Masculino , Variações Dependentes do Observador , Processo Odontoide/lesões , Reprodutibilidade dos Testes
13.
Sci Rep ; 9(1): 2529, 2019 02 21.
Artigo em Inglês | MEDLINE | ID: mdl-30792462

RESUMO

Since 2010, newly identified variants of porcine epidemic diarrhoea virus (PEDV) have caused high mortality in neonatal piglets which has devastated the swine industry. The spike (S) glycoprotein of PEDV contains multiple neutralizing epitopes and is a major target for PEDV neutralization and vaccine development. To understand the antigenicity of the new PEDV variant, we characterized the neutralizing epitopes of a new genotype 2b PEDV isolate from Taiwan, PEDV Pintung 52 (PEDV-PT), by the generation of neutralizing monoclonal antibodies (NmAbs). Two NmAbs, P4B-1, and E10E-1-10 that recognized the ectodomain of the full-length recombinant PEDV S protein and exhibited neutralizing ability against the PEDV-PT virus were selected. Recombinant truncated S proteins were used to identify the target sequences for the NmAbs and P4B-1 was shown to recognize the C-terminus of CO-26K equivalent epitope (COE) at amino acids (a.a.) 575-639 of the PEDV S. Interestingly, E10E-1-10 could recognize a novel neutralizing epitope at a.a. 435-485 within the S1A domain of the PEDV S protein, whose importance and function are yet to be determined. Moreover, both NmAbs could not bind to linearized S proteins, indicating that only conformational epitopes are recognized. This data could improve our understanding of the antigenic structures of the PEDV S protein and facilitate future development of novel epitope-based vaccines.

14.
Spine (Phila Pa 1976) ; 44(14): 1003-1009, 2019 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-30664100

RESUMO

STUDY DESIGN: Retrospective review and prospective validation study. OBJECTIVE: To develop a classification system of lumbar lateral listhesis that suggests different likelihoods of having radiculopathy in adult scoliosis. SUMMARY OF BACKGROUND DATA: The association of lumbar lateral listhesis with radiculopathy remains uncertain. METHODS: A retrospective cohort of patients with adult scoliosis enrolled from 2011 to 2015 was studied to develop a classification system of lateral listhesis that can stratify the likelihood of having radiculopathy. Four radiological aspects of lateral listhesis, including Nash and Moe vertebral rotation, L4-L5 lateral listhesis, the number of consecutive listheses, and the presence of a contralateral lateral listhesis at the thoracolumbar junction above a caudal listhesis, were evaluated on radiographs. Their associations with the presence of radicular leg pain were evaluated using multivariable logistic regression. The classification system of lateral listhesis was thus developed using the most influential radiological factors and then validated in a prospective cohort from 2016 to 2017. RESULTS: The retrospective cohort included 189 patients. Vertebral rotation is more than or equal to grade 2 (odds ratio [OR] = 9.45, 95% confidence interval [CI]: 4.07-25.14) and L4-5 listhesis (OR = 4.56, 95%CI: 1.85-12.35) were the two most influential listhesis factors associated with radiculopathy. The classification system of lateral listhesis was thus built based on the combinations of their respective presence: Type 0, 1, 2, 3 were defined as not having listhesis at all, none of the two factors present, one of the two presents, and both present, respectively. This classification significantly stratified the probability of radiculopathy, in both the retrospective cohort (0%, 6.4%, 33.8%, and 68.4% in Type 0, 1, 2, and 3, respectively; P < 0.001) and a prospective cohort of 105 patients (0%, 16.7%, 46.9%, and 72.7%; P < 0.001). CONCLUSION: Lumbar lateral listhesis is associated with the presence of radiculopathy in adult scoliosis. Types 2 and 3 lateral listhesis on radiographs may alert surgeons treating patients with spinal deformity. LEVEL OF EVIDENCE: 2.


Assuntos
Radiculopatia/diagnóstico por imagem , Radiculopatia/patologia , Escoliose/diagnóstico por imagem , Escoliose/patologia , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Vértebras Lombares , Região Lombossacral , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Radiografia , Estudos Retrospectivos , Rotação
15.
Spine J ; 19(2): e28-e33, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-24239034

RESUMO

BACKGROUND CONTEXT: Protein biomarkers associated with lumbar disc disease have been studied as diagnostic indicators and therapeutic targets. Recently, a cartilage degradation product, the fibronectin-aggrecan complex (FAC) identified in the epidural space, has been shown to predict response to lumbar epidural steroid injection in patients with radiculopathy from herniated nucleus pulposus (HNP). PURPOSE: Determine the ability of FAC to predict response to microdiscectomy for patients with radiculopathy due to lumbar disc herniation STUDY DESIGN/SETTING: Single-center prospective consecutive cohort study. PATIENT SAMPLE: Patients with radiculopathy from HNP with concordant symptoms to MRI who underwent microdiscectomy. OUTCOMES MEASURES: Oswestry disability index (ODI) and visual analog scores (VAS) were noted at baseline and at 3-month follow-up. Primary outcome of clinical improvement was defined as patients with both a decrease in VAS of at least 3 points and ODI >20 points. METHODS: Intraoperative sampling was done via lavage of the excised fragment by ELISA for presence of FAC. Funding for the ELISA was provided by Cytonics, Inc. RESULTS: Seventy-five patients had full complement of data and were included in this analysis. At 3-month follow-up, 57 (76%) patents were "better." There was a statistically significant association of the presence of FAC and clinical improvement (p=.017) with an 85% positive predictive value. Receiver-operating-characteristic (ROC) curve plotting association of FAC and clinical improvement demonstrates an area under the curve (AUC) of 0.66±0.08 (p=.037). Subset analysis of those with weakness on physical examination (n=48) plotting the association of FAC and improvement shows AUC on ROC of 0.81±0.067 (p=.002). CONCLUSIONS: Patients who are "FAC+" are more likely to demonstrate clinical improvement following microdiscectomy. The data suggest that the inflammatory milieu plays a significant role regarding improvement in patients undergoing discectomy for radiculopathy in lumbar HNP, even in those with preoperative weakness. The FAC represents a potential target for treatment in HNP.


Assuntos
Agrecanas/metabolismo , Discotomia/efeitos adversos , Fibronectinas/metabolismo , Degeneração do Disco Intervertebral/cirurgia , Deslocamento do Disco Intervertebral/cirurgia , Complicações Pós-Operatórias/metabolismo , Adulto , Biomarcadores/metabolismo , Feminino , Humanos , Degeneração do Disco Intervertebral/metabolismo , Deslocamento do Disco Intervertebral/metabolismo , Vértebras Lombares/metabolismo , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico
16.
Spine J ; 19(2): 199-205, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29959098

RESUMO

BACKGROUND CONTEXT: Lumbosacral epidural steroid injections (ESIs) have increased dramatically despite a narrowing of the clinical indications for use. One potential indication is to avoid or delay surgery, yet little information exists regarding surgery rates after ESI. PURPOSE: The purpose of this research was to determine the proportion of patients having surgery after lumbar ESI for disc herniation or stenosis and to identify the timing and factors associated with this progression. STUDY DESIGN/SETTING: This study was a retrospective review of nationally representative administrative claims data from the Truven Health MarketScan databases from 2007 to 2014. PATIENT SAMPLE: The study cohort was comprised of 179,025 patients (54±15 years, 48% women) having lumbar ESIs for diagnoses of stenosis and/or herniation. OUTCOME MEASURES: The primary outcome measure was the time from ESI to surgery. METHODS: Inclusion criteria were ESI for stenosis and/or herniation, age ≥18 years, and health plan enrollment for 1 year before ESI to screen for exclusions. Patients were followed longitudinally until they progressed to surgery or had a lapse in enrollment, at which time they were censored. Rates of surgery were assessed with the Kaplan-Meier survival curves. Demographic and treatment factors associated with surgery were assessed with multivariable Cox proportional hazard models. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work. RESULTS: Within 6 months, 12.5% of ESI patients underwent lumbar surgery. By 1 year, 16.9% had surgery, and by 5 years, 26.1% had surgery. Patients with herniation had surgery at rates of up to five-fold to seven-fold higher, with the highest rates of surgery in younger patients and those with both herniation and stenosis. Other concomitant spine diagnoses, male sex, previous tobacco use, and residence a rural areas or regions other than the Northeastern United States were associated with higher surgery rates. Medical comorbidities (previous treatment for drug use, congestive heart failure, obesity, chronic obstructive pulmonary disease, hypercholesterolemia, and other cardiac complications) were associated with lower surgery rates. CONCLUSIONS: In the long term, more than one out of every four patients undergoing ESI for lumbar herniation or stenosis subsequently had surgery, and nearly one of six had surgery within the first year. After adjusting for other patient demographics and comorbidities, patients with herniation were more likely have surgery than those with stenosis. The improved understanding of the progression from lumbar ESI to surgery will help to better inform discussions regarding the value of ESI and aid in the shared decision-making process.


Assuntos
Descompressão Cirúrgica/estatística & dados numéricos , Injeções Epidurais/efeitos adversos , Degeneração do Disco Intervertebral/tratamento farmacológico , Deslocamento do Disco Intervertebral/tratamento farmacológico , Estenose Espinal/tratamento farmacológico , Esteroides/uso terapêutico , Adulto , Idoso , Feminino , Humanos , Incidência , Degeneração do Disco Intervertebral/cirurgia , Deslocamento do Disco Intervertebral/cirurgia , Região Lombossacral/patologia , Região Lombossacral/cirurgia , Masculino , Pessoa de Meia-Idade , Estenose Espinal/cirurgia , Esteroides/administração & dosagem , Esteroides/efeitos adversos
17.
J Vet Sci ; 20(1): 51-57, 2019 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-30481981

RESUMO

Monoclonal antibodies (MAbs) are widely applied in disease diagnoses. Herein, we report a MAb, WF-4, against Influenza A virus nucleoprotein (NP), its broad response with Influenza A virus, and its application in an immunohistochemistry (IHC) assay. WF-4 was screened by immunofluorescence assay (IFA). The results showed that its reactivity with baculovirus-expressed full-length recombinant NP (rNP) in Western blot (WB), indicating its IHC applicability. Fifteen Influenza A virus (reference subtypes H1 to H15) infected chicken embryonated chorioallantoic membranes (CAM), fixed by formalin, were all detectable in the WF-4-based IHC assay. Also, the reactivity of the IHC test with NP from experimentally inoculated H6N1 and from all recent outbreaks of H5 subtype avian Influenza A virus (AIV) field cases in Taiwan showed positive results. Our data indicate that CAM, a by-product of Influenza A virus preparation, is helpful for Influenza A virus-specific MAb characterization, and that the WF-4 MAb recognizes conserved and linear epitopes of Influenza A virus NP. Therefore, WF-4 is capable of detecting NP antigens via IHC and may be suitable for developing various tests for diagnosis of Influenza A virus and, especially, AIV infection.


Assuntos
Galinhas , Imuno-Histoquímica/veterinária , Vírus da Influenza A Subtipo H5N2/imunologia , Vírus da Influenza A/imunologia , Proteínas de Ligação a RNA/imunologia , Proteínas do Core Viral/imunologia , Animais , Anticorpos Monoclonais/imunologia , Anticorpos Antivirais/imunologia , Membrana Corioalantoide/imunologia , Imunofluorescência/veterinária , Taiwan
18.
Viruses ; 10(10)2018 10 04.
Artigo em Inglês | MEDLINE | ID: mdl-30287770

RESUMO

The porcine epidemic diarrhea virus (PEDV) poses a great threat to the global swine industries and the unreliable protection induced by the currently available vaccines remains a major challenge. We previously generated a genogroup 2b (G2b) PEDV Taiwan Pintung 52 (PEDVPT) strain, PEDVPT-P96, and determined its promising host immune response against the virulent PEDVPT-P5 strain. To study the attenuation determinants of PEDVPT-P96 and establish a PEDVPT-P96-based recombinant vector as a vaccine platform for further antigenicity modification, iPEDVPT-P96, a full-length cDNA clone of PEDVPT-P96, was established. Comparing to the parental PEDVPT-P96 virus, the iPEDVPT-P96 virus showed efficient replication kinetics with a delayed decline of viral load and similar but much more uniform plaque sizes in Vero cells. In the 5-week-old piglet model, fecal viral shedding was observed in the PEDVPT-P96-inoculated piglets, whereas those inoculated with iPEDVPT-P96 showed neither detectable fecal viral shedding nor PEDV-associated clinical signs. Moreover, inoculation with iPEDVPT-P96 elicited comparable levels of anti-PEDV specific plasma IgG and fecal/salivary IgA, neutralizing antibody titers, and similar but less effective immunoprotection against the virulent PEDVPT-P5 challenge compared to the parental PEDVPT-P96. In the present study, an infectious cDNA clone of an attenuated G2b PEDV strain was successfully generated for the first time, and the in vitro and in vivo data indicate that iPEDVPT-P96 is further attenuated but remains immunogenic compared to its parental PEDVPT-P96 viral stock. The successful development of the iPEDVPT-P96 cDNA clone could allow for the manipulation of the viral genome to study viral pathogenesis and facilitate the rapid development of effective vaccines.


Assuntos
Infecções por Coronavirus/veterinária , Vírus da Diarreia Epidêmica Suína/genética , Vírus da Diarreia Epidêmica Suína/imunologia , Doenças dos Suínos/imunologia , Doenças dos Suínos/prevenção & controle , Vacinas Virais/imunologia , Animais , Anticorpos Neutralizantes/sangue , Anticorpos Antivirais/sangue , Chlorocebus aethiops , Infecções por Coronavirus/imunologia , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/virologia , DNA Complementar/genética , Fezes/virologia , Genoma Viral/genética , Testes de Neutralização , Genética Reversa , Suínos , Doenças dos Suínos/virologia , Vacinas Atenuadas/administração & dosagem , Vacinas Atenuadas/imunologia , Células Vero , Carga Viral , Vacinas Virais/administração & dosagem , Eliminação de Partículas Virais
19.
Vet Microbiol ; 222: 124-131, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30080667

RESUMO

In the case of serotype O foot-and-mouth disease virus (FMDV), antibodies against five neutralizing sites play a pivotal role in protection of animals, with site 1 being considered the most crucial. However, recent studies indicated that the antibodies of vaccinated farm animals are mainly against site 2 rather than site 1. In Taiwan, blanket vaccination had been implemented for more than fifteen years, in which the porcinophilic isolate O/Penghu/2012 showed significant amino acid alterations in site 2 compared to the early isolate O/TW/97. To study the antigenicity of site 2, MAbs against site 2 are required. In this study, we generated site 2 mutated virus-like particles (mVLPs) with only VP2-S72 N mutation, and successfully identified five site 2 MAbs from a previously prepared O/TW/97 MAb panel by immunofluorescence assay (IFA) and ELISA based on the different reactivity to wild-type VLP and mVLP. In conclusion, the established model was proved as an effective method to reveal the epitope that a MAb recognizes. By applying this MAb panel and sequence alignment, we demonstrated that the O/Penghu/2012 isolate not only showed significant genetic difference in site 2 but also significant antigenic difference from the ancestral O/TW/97.


Assuntos
Anticorpos Monoclonais/imunologia , Anticorpos Neutralizantes/imunologia , Antígenos Virais/imunologia , Vírus da Febre Aftosa/genética , Vírus da Febre Aftosa/imunologia , Febre Aftosa/imunologia , Mutação , Animais , Anticorpos Antivirais/imunologia , Antígenos Virais/genética , Epitopos/genética , Epitopos/imunologia , Febre Aftosa/epidemiologia , Febre Aftosa/virologia , Testes de Neutralização , Suínos , Doenças dos Suínos/epidemiologia , Doenças dos Suínos/imunologia , Doenças dos Suínos/prevenção & controle , Doenças dos Suínos/virologia , Taiwan/epidemiologia
20.
J Spine Surg ; 4(2): 247-253, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30069514

RESUMO

Background: The retroperitoneal trans-psoas extreme lateral interbody fusion (XLIF) technique has improved over the last decade with increased efficiency and an emphasis on complication avoidance. After all known procedural safeguards are enacted, the most common failure of neuro-monitoring precision may be the use of non-depolarizing muscle relaxants (MR) for induction that is standard of care for anesthesia. Even when non-depolarizing MRs are minimized there is often a small dose given to decrease risk of vocal cord injury with intubation. The most common neurological adverse events (AE) attendant to the lateral approach are thigh dysesthetic pain and hip flexor weakness. The purpose of this study is to present a consecutive series of L3-4 and L4-5 XLIF patients treated by a single surgeon using all procedural safeguards with and without the use of a low dose of non-depolarizing MRs prior to intubation. Methods: A retrospective review of 74 consecutive patients treated at 150 levels with XLIF and no muscle relaxants (NMR) were compared to a group of 124 consecutive XLIF patients treated at 238 levels with MR. The surgeon upon discovering a small dose of rocuronium was used for intubation, questioned the effect on the neuromonitoring and NMR group was begun. All procedural technique details remained the same. All patients had XLIF at L3-4, L4-5, or both levels. Perioperative variables were collected, including evoked and free-run EMG readings and postoperative neural and muscular side effects. Hospital records including progress notes describing postoperative symptoms and anesthesia records describing the drugs, dosages, and timing were studied. Clinical records were reviewed at 1, 3 and 6 months for complaints of neurologic AE. Results: NMR patients had a perfect twitch test (>99%) immediately. MR patients had slower arrival of the twitch and often settled at a lower level (80-92%). No surgery was attempted until the twitch test was at least 80%. NMR had 8/74 (10.8%) and MR 36/125 (28.8%) thigh AE (thigh dysthetic pain) at 1 month (P<0.005). No lower extremity weaknesses (femoral nerve injury) were observed in the NMR group and three in the MR group. All NMR thigh AEs resolved by the third month postoperative visit compared with 17/125 at 3 months (P=0.001) and 6/125 at 6 months (P=0.176) with persistent thigh AEs in the MR group. Conclusions: Eliminating MRs altogether appears to have allowed the evoked and free running EMG to be more reliable and accurate in predicting the proximity of the neurologic structures. Thigh AEs related to neural and muscular integrity in NMR patients were limited and eliminated by the 3rd month. The MR group was significantly more likely to have a thigh AE at 1 month and persistent at 3 months. Neurologic AEs may be limited or eliminated when MRs are avoided in lateral lumbar fusion surgery.

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