The effect of short (2-weeks) versus long (6-weeks) post-operative restrictions following lumbar discectomy: a prospective randomized control trial.

PURPOSE: We sought to evaluate how short (2-week) versus long (6-week) post-operative restrictions following lumbar discectomy impacted outcomes and reherniation rates for a period up to 1 year following surgery. METHODS: This study included 108 patients undergoing index lumbar discectomy. Patients were randomized immediately following surgery. Outcomes included back and leg visual analog pain scales (VAS), Oswestry Disability Index (ODI), and reherniation rates at 2-weeks, 6-weeks, 3-months, and 1-year following surgery. Differences in reherniation rates were analyzed using Fisher's exact test. VAS and ODI scores were evaluated using Student's t test. RESULTS: Six patients (11%) in the 2-week restriction group had a reherniation event and four patients (7%) in the 6-week restriction group experienced a reherniation (p = 0.52). VAS back pain (p < 0.001), leg pain (p < 0.001), and ODI scores (p < 0.001) were significantly improved for both cohorts as compared to baseline at the 2-week time point and remained significantly improved through 1-year [VAS back (p < 0.001); VAS leg (p < 0.001); ODI (p < 0.001)]. No significant differences in ODI, VAS back, or VAS leg scores were detected at any of the time points between the 2- and 6-week restriction groups. CONCLUSIONS: The results of this randomized trial suggest equivalent clinical outcomes irrespective of the length of post-operative restriction. From a clinical perspective, if patients are deemed at low risk for a reherniation event they may be confidence that early return to activity at 2 weeks will not compromise outcomes and may not adversely impact the risk of reherniation. Level of Evidence II.

Relationship between size of disc and early postoperative outcomes after lumbar discectomy.

BACKGROUND: Previous studies suggest that patients with larger disc herniations (greater than 6 mm) will have better outcomes following discectomy. This has not been validated in a large series of patients. PURPOSE: We sought to empirically evaluate this relationship in a series of patients who had data collected prospectively as part of a randomized trial. METHODS: This retrospective review included 63 consecutive adult patients who underwent a single-level, primary lumbar discectomy. Outcomes were VAS for leg and back pain and the modified oswestry disability index (MODI). Statistical tests were used to compare patients using different cutoffs of preoperative disc diameters and disc volume removed. Regression analysis was performed to determine if there was a relationship between outcomes and the measured parameters. RESULTS: While patients who achieved substantial clinical benefit (SCB) for MODI had larger disc diameters, this relationship was not found for leg or back pain for any of the measured parameters. Using 5, 6, 7, or 8 mm as a cutoff for disc diameter demonstrated no differences. Regression analysis did not demonstrate a significant relationship between disc volume removed and final MODI scores. CONCLUSION: While patients with larger disc herniations on average might have a greater likelihood of superior clinical outcomes, the previously suggested "6 mm rule" was not supported.

The influence of adjacent level disc disease on discectomy outcomes.

PURPOSE: The state of adjacent level discs and its impact on surgical outcomes following single-level lumbar discectomy have not been previously investigated. The purpose of the present study was to determine if a significant relationship exists between the degree of preoperative adjacent level disc degeneration and post-operative clinical outcomes following lumbar discectomy. METHODS: This study retrospectively used preoperative magnetic resonance imaging (MRI) and prospectively collected data from a randomized clinical trial at two tertiary-care academic hospitals. Patients who underwent a primary, single-level lumbar discectomy were included. Exclusion criteria included prior lumbar surgery. Outcome measures were the Modified Oswestry Disability Index (ODI) score and Visual Analog Scale (VAS) scores for back and leg pain. These were recorded at baseline and at 3 months, 1, and 2 years postoperatively. An independent reviewer graded adjacent level disc degeneration on all preoperative MRIs using the Pfirrmann grading scale. These data were then analyzed for correlation with each outcome measure. RESULTS: Forty-seven patients were included in the study. No statistically significant correlations were found when comparing preoperative 3-month or 1-year postoperative scores or change from baseline of any outcome measure between Pfirrmann grades. Only about half the patients had 2-year follow-up, but at that time point a statistically significant difference in back VAS scores was observed between Pfirrmann groups. No other significant differences were observed at that point. CONCLUSIONS: The degree of preoperative adjacent level degeneration does not significantly affect functional or pain relief outcomes following lumbar discectomy up to 1 year after surgery.

Virtually bloodless posterior midline exposure of the lumbar spine using the "para-midline" fatty plane.

PURPOSE: The authors have developed a "para-midline" approach to the posterior lumbar spine using a virtually avascular surgical plane not previously described in the literature. It was their purpose to document consistent MRI presence of this plane and to prospectively evaluate its clinical use in terms of blood loss. METHODS: Fifty consecutive patients undergoing primary lumbar surgery on 1-3 levels were prospectively enrolled from September 2014 to May 2015. The para-midline approach was used in all cases. The deep lumbar fascia is longitudinally incised on either side of the spinous processes instead of directly in the midline, which reveals the para-midline fatty plane. Blood loss during the approach and overall blood loss were recorded for all patients. MRIs from each patient were reviewed by an experienced neuroradiologist to determine the presence of the para-midline fatty plane. RESULTS: There was no recorded blood loss during the approach for all procedures. The average overall blood loss was 60 cc (20-200 cc). No patient required a transfusion intraoperatively or postoperatively. The fatty para-midline plane was noted on preoperative MRI at all operated levels in all patients. The average width of this plane was 6.5 mm (2-17 mm). CONCLUSIONS: The para-midline approach for lumbar surgery is associated with less blood loss than traditional, subperiosteal exposure techniques. The fatty interval through which this approach is made is universally present and identifiable on MRI. The authors offer this approach as a means of decreasing the risks associated with blood loss and transfusion with posterior lumbar surgery.

Methods for Reducing Intraoperative Breast Radiation Exposure of Orthopaedic Surgeons.

BACKGROUND: Standard lead aprons and vests do not adequately shield the most common breast cancer site, the upper outer quadrant (UOQ), from intraoperative radiation. The purpose of the present study was to determine if lead sleeves, wings, and/or axillary supplements decreased intraoperative radiation exposure of the UOQ of the breast. METHODS: An anthropomorphic torso phantom (simulating the female surgeon) was placed adjacent to a standard operating room table. Dosimeters were placed bilaterally over the UOQ of the breast. Scatter radiation dose equivalent rates (mrem/hr) were measured during continuous fluoroscopy of a pelvic phantom (simulating the patient). Five protection configurations (no lead; lead vest; and vest with sleeves, wings, and axillary supplements), 2 surgeon positions (facing the table and perpendicular to the table), and 2 C-arm positions (anteroposterior and cross-table lateral projection) were tested. The t test was utilized with a Bonferroni correction for multiple t tests. RESULTS: Lead sleeves and axillary supplements decreased intraoperative radiation exposure to the UOQ of the breast when compared with a well-fitted standard lead vest alone (p < 0.01) across all surgeon and C-arm positions. The addition of wings decreased radiation exposure to a lesser extent than sleeves or axillary supplements, and the difference when compared with the lead vest alone did not reach significance (p = 0.29). Breast radiation exposure in the C-arm cross-table lateral projection was highest across all testing. CONCLUSIONS: The UOQ of the breast is not adequately protected by standard lead vests alone or vests with the addition of wings. Axillary supplements and sleeves improved protection of the breast. CLINICAL RELEVANCE: Modifications of lead protective vests may improve intraoperative breast radiation protection.

Posterior Sternoclavicular Dislocation: Do We Need "Cardiothoracic Backup"? Insights From a National Sample.

OBJECTIVES: To describe the incidence of and risk factors for vascular injury associated with P-SCD. METHODS: We used data from the HCUP-NIS from 2015 to 2016 and defined a cohort of patients with sternoclavicular dislocation (SCD) using ICD-10-CM diagnosis codes. We further isolated a subset with P-SCD. We describe the incidence of thoracic vascular injury, demographics, and injury severity score in this cohort. RESULTS: Of an estimated 550 patients who had SCD, 140 (25%) were identified as having a P-SCD. No vascular injuries occurred in the P-SCD cohort. Among all patients with SCD, <2% of patients had a vascular injury, all of whom had an injury severity score ≥15, independent of the vascular injury itself. Among patients with an isolated P-SCD injury (55), overall length of stay was 1.8 days and total charges averaged $29,724.45. There was no mortality among patients with isolated P-SCD. CONCLUSIONS: Here, we report no vascular injuries in the largest known series of P-SCD. Among all patients with SCD, vascular injury was rare, occurring only in severely polytraumatized patients. The recommendation for routine involvement of cardiothoracic surgeons in all cases of P-SCD should be re-examined. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Utility of Adding Magnetic Resonance Imaging to Computed Tomography Alone in the Evaluation of Cervical Spine Injury: A Propensity-Matched Analysis.

STUDY DESIGN: Adult patients who received computed tomography (CT) alone or CT-magnetic resonance imaging (MRI) for the evaluation of cervical spine injury. OBJECTIVE: To evaluate the utility of CT-MRI in the diagnosis of cervical spine injury using propensity-matched techniques. SUMMARY OF BACKGROUND DATA: The optimal evaluation (CT alone vs. CT and MRI) for patients with suspected cervical spine injury in the setting of blunt trauma remains controversial. METHODS: The primary outcome was the identification of a cervical spine injury, with decision for surgery and change in management considered secondarily. A propensity score was developed based on the likelihood of receiving evaluation with CT-MRI, and this score was used to balance the cohorts and develop two groups of patients around whom there was a degree of clinical equipoise in terms of the imaging protocol. Logistic regression was used to evaluate for significant differences in injury detection in patients evaluated with CT alone as compared to those receiving CT-MRI. RESULTS: Between 2007 and 2014, 8060 patients were evaluated using CT and 693 with CT-MRI. Following propensity-score matching, each cohort contained 668 patients. There were no significant differences between the two groups in baseline characteristics. The odds of identifying a cervical spine injury were significantly higher in the CT-MRI group, even after adjusting for prior injury recognition on CT (odds ratios 2.6; 95% confidence interval 1.7-4.0; P < 0.001). However, only 53/668 patients (8%) in the CT-MRI group had injuries identified on MRI not previously recognized by CT. Only a minority of these patients (n = 5/668, 1%) necessitated surgical intervention. CONCLUSION: In this propensity-matched cohort, the addition of MRI to CT alone identified missed injuries at a rate of 8%. Only a minority of these were serious enough to warrant surgery. This speaks against the standard addition of MRI to CT-alone protocols in cervical spine evaluation after trauma. LEVEL OF EVIDENCE: 3.

The prognostic value of preoperative participation in activities of daily living on postoperative outcomes following lumbar discectomy.

OBJECTIVES: In other surgical fields, preoperative level of participation in activities of daily living (ADLs) has been found to be important in predicting outcomes. To date, postoperative ADL measurements have only been used to characterize outcomes following lumbar discectomy. The present study's goal was to determine if patients' preoperative ability to perform ADLs correlates with their postoperative outcomes after lumbar discectomy at 3 months and 1 year. PATIENTS AND METHODS: This retrospective study was performed using prospectively collected data from patients prospectively enrolled in a randomized clinical trial. All patients were 18 years or older, spoke English, had not previously had lumbar surgery, and underwent discectomy for a single-level lumbar disc herniation. Oswestry disability index (ODI) and visual analogue scale (VAS) back and leg pain scores were collected preoperatively and at 3 months and 1 year postoperatively. Simple linear regression analysis was performed to detect any significant correlations between three preoperative ODI domain values and postoperative scores. Additionally, regression analysis was used to determine the correlation between the preoperative ODI domains and percentage of good and poor outcomes, where an improvement of at least 18.8 points for ODI and at least 2 points for VAS constituted a good outcome. RESULTS: 90 subjects satisfied inclusion criteria (average age 42, 53 males, 37 females). Patients' ability to take care of themselves and to stand preoperatively were correlated with improvement in ODI postoperatively, with worse ability corresponding to more improvement (p<0.001 for both). Only personal care scores correlated with good improvement in leg pain. No significant correlations were found with back pain. When evaluating patients by dichotomized outcome (good or poor), only preoperative ability to participate in personal care was consistently significantly correlated to a good outcome. CONCLUSION: This is the first study to suggest that lower preoperative ability to take part in personal care might predict better surgical outcomes after discectomy. The current data might prompt reassessment of the importance of ADLs in pre-operative patient evaluation and may help anticipate outcomes following lumbar discectomy.

The importance of fluency of terminology in the applicability of imaging findings.

COMMENTARY ON: Fu MC, Webb ML, Buerba RA, Neway WE, Brown JE, Trivedi M, et al. Comparison of agreement of cervical spine degenerative pathology findings in magnetic resonance imaging studies. Spine J 2016:16:42-8 (in this issue).

Predictors of 30- and 90-Day Survival Following Surgical Intervention for Spinal Metastases: A Prognostic Study Conducted at Four Academic Centers.

STUDY DESIGN: A retrospective review. OBJECTIVE: We sought to use data from 4 tertiary medical centers to explore surgical, medical, and demographic factors that influence survival within the first 90 days following surgery for spinal metastases. SUMMARY OF BACKGROUND DATA: Over the last 2 decades, patients with spinal metastases have become more likely to receive surgical intervention. The impact of surgical intervention and its potential benefits must be weighed against the risk of complications and peri-operative mortality. Risk factors that elevate the risk of mortality in the acute postoperative period are not well understood. METHODS: All records of patients who underwent surgery for metastatic spinal disease at 1 of 4 academic medical centers in New England from 2007 to 2013 were obtained. Patient demographics, tumor characteristics, medical comorbidities, nutritional and functional status, as well as surgical variables were abstracted. Mortality was assessed for patients at 30 and 90 days following the procedure. Factors predictive of survival were assessed using bivariate logistic regression. Those factors with P values < 0.20 in the bivariate assessment were included in a final multivariable model that adjusted for confounders. RESULTS: Between 2007 and 2013, 318 patients received surgical intervention for metastatic disease involving the spine. Cancer type did not influence the odds of survival at 30 days, while nutritional status and ambulatory capacity increased survival. Lung cancer significantly decreased the odds of survival at 90 days following surgery (odds ratio 0.36; 95% confidence interval 0.18-0.72), while ambulatory function and nutritional status remained significantly associated with improved survival. CONCLUSION: This effort is one of the first to identify predictors of acute postoperative survival in a large series of patients treated for spinal metastases. Improved nutritional status and ambulatory function may enhance postoperative survival among individuals who undergo surgical intervention for spinal metastases. LEVEL OF EVIDENCE: 3.

The effect of chronic liver disease on acute outcomes following cervical spine trauma.

BACKGROUND CONTEXT: The adverse impact of chronic liver diseases, including chronic hepatitis and cirrhosis, on outcomes following orthopedic surgery has been increasingly recognized in recent years. The impact of these conditions on acute outcomes following spinal trauma remains unknown. STUDY DESIGN: This is a cohort control study that uses patient records in the Massachusetts Statewide Inpatient Dataset (2003-2010). PURPOSE: The study aimed to evaluate whether chronic liver disease increased the odds of mortality, complications, failure to rescue (FTR), reoperation, and hospital length of stay (LOS) following cervical spine trauma. PATIENT SAMPLE: The sample is composed of 10,841 patients with cervical spine trauma. OUTCOME MEASURES: Posttreatment morbidity, mortality, reoperation, and LOS were the outcome measures. METHODS: Differences between patients with and without chronic liver disease were evaluated using chi-square or Wilcoxon rank-sum tests. Logistic and negative binomial regression techniques were used to adjust for confounders, including whether a surgical intervention was performed. Receiver operator characteristic curves were used to assess final model discrimination. RESULTS: There were 117 patients with chronic liver disease identified in the cohort. The rate of surgical intervention for cervical trauma was not significantly different between patients with and without chronic liver disease (odds ratio [OR]: 0.82, 95% confidence interval [CI]: 0.52-1.29). Mortality (OR: 2.12, 95% CI: 1.23-3.66), FTR (OR: 2.86, 95% CI: 1.34-6.11), complications (OR: 1.65, 95% CI: 1.12-2.45), and LOS (regression coefficients: 0.31, 95% CI: 0.14-0.48) were all significantly increased for patients with chronic liver disease in final adjusted models that controlled for differences in case-mix and whether a surgical procedure was performed. Final models explained approximately 72% of the variation in mortality and FTR. CONCLUSIONS: Our novel findings indicate that patients with chronic liver disease may be at elevated risk of posttreatment morbidity and mortality following cervical spine trauma. Medical comanagement in the acute period following injury and optimization before surgery may diminish the potential for adverse events.

Idiopathic Spinal Epidural Lipomatosis in the Lumbar Spine.

Overgrowth of epidural fat, known as spinal epidural lipomatosis (SEL), can cause symptomatic compression of the spinal cord, conus medullaris, or cauda equina. Suggested predisposing factors such as obesity, steroid use, and diabetes mellitus have been based on a few reported cases, many of which were not surgically confirmed. There is a paucity of epidemiological data in surgically confirmed cases for this disorder. The purpose of this independently reviewed, retrospective, matched cohort analysis was to compare the demographics and incidence of comorbidities of patients who underwent lumbar decompression for SEL vs degenerative stenosis without SEL. Two surgeons' databases were reviewed to identify patients older than 18 years who underwent decompression surgery for magnetic resonance imaging-verified, symptomatic lumbar SEL. A matched control group comprised an equal number of patients with degenerative stenosis (n=14). Demographic data, body mass index, symptom type/duration, comorbidities, complications, treatment history, and associated pathology were collected from medical records. Previously suggested risk factors, such as obesity, endocrinopathy, and epidural steroid injections, were not significantly different between the SEL and control groups. Furthermore, there were no differences in operative times, complications, or blood loss. The only noted difference between the 2 groups was the preoperative duration of symptoms, on average double in patients with SEL. This series represents the largest of its kind reported to date. Because symptom duration was the only difference noted, it is postulated to be the result of lack of awareness of SEL. Future prospective study in a larger group of patients is warranted. [Orthopedics. 2016; 39(3):163-168.].

Assessing the utility of a clinical prediction score regarding 30-day morbidity and mortality following metastatic spinal surgery: the New England Spinal Metastasis Score (NESMS).

BACKGROUND CONTEXT: The New England Spinal Metastasis Score (NESMS) was recently proposed to help predict 1-year survival following surgery for spinal metastases. Its ability to predict short-term outcomes, including 30-day morbidity, mortality, and hospital length of stay, has not been evaluated. PURPOSE: Assess the capacity of NESMS to predict 30-day morbidity and mortality, as well as hospital length of stay, following surgery for spinal metastases. STUDY DESIGN: Validation study. PATIENT SAMPLE: All patients who had undergone spinal surgery with a history of metastatic spinal disease within the National Surgical Quality Improvement Program (NSQIP; 2007-2013). OUTCOME MEASURE: Mortality, complications, failure to rescue, and length of stay. METHODS: Demographic, oncologic, laboratory, and surgical data were obtained from the NSQIP. All patients were assigned an NESMS score (0-3). The effect of the NESMS score on the outcomes of interest was assessed using multivariable logistic regression and negative binomial regression that controlled for confounders. Final model discrimination and calibration were assessed using the c-statistic and Hosmer-Lemeshow test, respectively. Internal validation was performed using a bootstrapping procedure. RESULTS: NSQIP data on 776 patients were included in this analysis. The 30-day mortality rate was 11% (N=87), and 51% of patients (N=395) sustained one or more complications. The final adjusted model demonstrated that the NESMS was a statistically significant predictor of 30-day mortality (p<.001), major systemic complications (p<.001), and failure to rescue (p=.03) following metastatic spinal surgery. Patients with an NESMS score of 3 had an 89% reduction in mortality (95% confidence interval [CI]: 0.04, 0.31), a 74% reduction in major systemic complications (95% CI: 0.11, 0.62), and an 88% reduction in failure to rescue (95% CI: 0.03, 0.47) as compared with those with a score of 0. The final model explained 71% of the variation in 30-day mortality. Findings were unchanged in the bootstrap analysis performed among 77,600 patient replicates. CONCLUSION: This study demonstrates the clinical accuracy of the NESMS score for predicting short-term major morbidity and mortality following metastatic spinal surgery. The success of this score in an independent cohort of patients collected from centers across the United States indicates its potential for translation to clinical practice.

Modeling 1-year survival after surgery on the metastatic spine.

BACKGROUND CONTEXT: Choosing appropriate surgical patients in the setting of spinal metastases can be challenging. Existing scoring systems focus primarily on patient selection or operative techniques. These scores are limited in their capacity to predict postoperative survival. PURPOSE: The aim was to model survival after spine surgery for metastastic disease. STUDY DESIGN: This was a retrospective multicenter study. PATIENT SAMPLE: All patients who had undergone surgery for the treatment of metastatic spinal disease at one of four tertiary care centers between 2007 and 2013 were included. OUTCOME MEASURE: The outcome measure was 1-year survival after surgery. METHODS: Demographic, medical, oncologic, surgical, and survival data were abstracted from medical records. The effect of predictor variables on survival was evaluated alone and in combination using stepwise logistic regression. Multivariable logistic regression was subsequently used to adjust for confounders. A predictive score was then developed and compared against that of the modified Bauer score alone in terms of prognosticating 1-year survival after surgery. RESULTS: In the time period under investigation, 318 patients underwent surgical intervention for metastastic disease involving the spine, with 307 having data available for analysis. The survival rate at 1 year was 48% (n=142), with a median survival of 10 months. In final adjusted analysis, preoperative modified Bauer score (odds ratio [OR] 3.00; 95% confidence interval [CI] 1.80-5.01; p<.001), ambulatory status (OR 2.47; 95% CI 1.48-4.14; p=.001), and serum albumin (OR 2.80; 95% CI 1.66-4.72; p<.001) were all independent predictors of 1-year survival. The most parsimonious model weighted the modified Bauer score with 2 points and intact ambulatory status and normal serum albumin level with 1 point each, with a ceiling score of 3. The final model using the predictive score was able to explain 74% of the variation in 1-year survival. In contrast, the modified Bauer score alone was only able to explain 64% of the variation in 1-year survival. CONCLUSIONS: This study demonstrates the importance of including factors related to the overall health of a patient, in addition to parameters surrounding their cancer diagnosis, to better prognosticate survival. Our predictive score performed better than the modified Bauer alone and may be used to predict survival after surgical intervention for metastatic disease. LEVEL OF EVIDENCE: III.