ABSTRACT
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A case-control retrospective analysis comparing patients who developed a postoperative spinal epidural hematoma with patients who did not develop this complication. To identify risk factors for the development of an epidural hematoma... more
A case-control retrospective analysis comparing patients who developed a postoperative spinal epidural hematoma with patients who did not develop this complication. To identify risk factors for the development of an epidural hematoma following spinal surgery. Neurologic deterioration following spinal surgery is a rare but devastating complication. Epidural hematomas should be suspected in the patient who demonstrates a new postoperative neurologic deficit. The risk factors that predispose a patient to a postoperative spinal epidural hematoma have not been identified. Patients who underwent spinal surgery at a single institution over a 10-year period were retrospectively reviewed. Twelve patients who demonstrated neurologic deterioration after surgery and required surgical decompression because of an epidural hematoma were identified. All cases involved lumber laminectomies. A total of 404 consecutive patients that underwent lumbar decompression and did not develop an epidural hematoma formed the control group. Factors postulated to increase the risk of postoperative spinal epidural hematoma were compared between the two groups using logistic regression. Multilevel procedures (P = 0.037) and the presence of a preoperative coagulopathy (P < 0.001) were significant risk factors. Age, body mass index, perioperative durotomies, and postoperative drains were not statistically significant risk factors. Patients who require multilevel lumbar procedures and/or have a preoperative coagulopathy are at a significantly higher risk for developing a postoperative epidural hematoma.
Research Interests: Biomedical Engineering, Causality, Medicine, Comorbidity, Complication, and 15 moreHumans, Coagulopathy, Anesthesia, Incidence, Clinical Sciences, Epidural hematoma, Odds ratio, Hematoma, Laminectomy, Decompression, Logistic Models, Case Control Studies, Lumbosacral Region, lumbar, and Blood coagulation disorders
Research Interests: Randomization, Exercise therapy, Medicine, Observation, Humans, and 15 moreFemale, Male, Middle Aged, Outcomes Research, Adult, Observational Study, Orthotic Devices, JAMA, Confidence Interval, Cohort Studies, lumbar vertebrae, Diskectomy, lumbar, Oswestry Disability Index, and Medical and Health Sciences
Research Interests: Chronic Pain, Magnetic Resonance Imaging, Medicine, Low back pain, Neuropathic pain, and 15 moreNeck Pain, Anesthesia, Cyst, Nausea, Clinical Sciences, Radiography, Stimulation, Neurosciences, Methylprednisolone, spondylolisthesis, lumbar, Adverse effect, Interventional pain management, pacu, and Radicular pain
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BACKGROUND Chronic low back pain (CLBP) is a primary indication for opioid therapy. OBJECTIVE To evaluate the hypothesis that CLBP patients reporting reduced opioid use have superior functional outcomes following basivertebral nerve (BVN)... more
BACKGROUND Chronic low back pain (CLBP) is a primary indication for opioid therapy. OBJECTIVE To evaluate the hypothesis that CLBP patients reporting reduced opioid use have superior functional outcomes following basivertebral nerve (BVN) radiofrequency ablation. METHODS This post hoc analysis from a sham-controlled trial examined short-acting opioid use from baseline through 1 yr. Opioid use was stratified into 3 groups by two blinded external reviewers. Two-sample t-tests were used to compare Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) measurements between those patients who increased or decreased their opioid usage compared to baseline. RESULTS Actively treated patients with decreased opioid use at 12 mo had a mean ODI improvement of 24.9 ± 16.0 (n = 27) compared to 7.3 ± 9.8 (n = 18) for patients reporting increased opioid use (P < .001). In the sham arm, the improvements in ODI were 17.4 ± 16.1 (n = 19) and 1.2 ± 14.3 (n = 5; P = .053) for the patients reporting decreased vs increased opioid usage, respectively. Actively treated patients reporting decreased opioid use had a mean improvement in VAS of 3.3 ± 2.5 (n = 27) compared to 0.6 ± 1.8 (n = 18) for patients reporting increased opioid use (P < .001). In the sham arm, the improvements in VAS were 2.5 ± 2.6 (n = 19) and 1.4 ± 1.9 (n = 5; P = .374) for patients reporting decreased vs increased opioid use, respectively. CONCLUSION Subjects undergoing BVN ablation who decreased opioid use had greater improvement in ODI and VAS scores compared with those reporting increased opioid usage. There is an association between functional benefit from BVN ablation and reduced opioid use.
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Research Interests: Osseointegration, Medicine, Bone Morphogenetic Proteins, Bone graft, Animals, and 15 moreAnimal Model, Cervical Vertebrae, Clinical Sciences, Goats, Pilot study, Gold Standard, Implant, Cervical Spine, Arthrodesis, Bone Substitutes, Recombinant Proteins, Neurosciences, Diskectomy, Anterior cervical discectomy and fusion, and Experimental Group
Research Interests: Osseointegration, Immunohistochemistry, Medicine, Extracellular Matrix, Bone Morphogenetic Proteins, and 15 moreBone graft, Prospective studies, Humans, Animals, Clinical Sciences, Molecular cloning, Clinical Study, Risk Factors, Bone Formation, Arthrodesis, Recombinant Proteins, Neurosciences, Human Bone, Bone Transplantation, and Haplorhini
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Research Interests: Polymers, Medicine, Bone Morphogenetic Proteins, Dogs, Cell Differentiation, and 15 moreCollagen, Animals, Polylactic Acid, Clinical Sciences, Ilium, Bone Marrow Transplantation, Osteogenesis, Spinal, Recombinant Proteins, Biocompatible Materials, Drug Carriers, Lactic Acid, Spinal Fusion, Bone Transplantation, and lumbar
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This study evaluated clinical and magnetic resonance imaging differences of patients treated surgically for lumbar disc herniation. Clinical follow-up and magnetic resonance imaging evaluation of epidural fibrosis were used to assess... more
This study evaluated clinical and magnetic resonance imaging differences of patients treated surgically for lumbar disc herniation. Clinical follow-up and magnetic resonance imaging evaluation of epidural fibrosis were used to assess patient outcome. The purpose of this study was to evaluate the difference in clinical outcome with either free-fat graft, Gelfoam, or no interposition membrane placed in the laminectomy defect after nerve root decompression. Epidural fibrosis has been considered a cause of recurrent symptoms after lumbar laminectomy, and numerous materials have been evaluated for prophylaxis of the "laminectomy membrane." These have been mainly histologic and animal studies with no data correlating clinical symptoms and postoperative epidural scar formation. One hundred fifty-six patients who were treated surgically for lumbar disc herniation were randomly assigned to one of three groups and followed prospectively for at least 1 year. Thirty-three of these patients were received magnetic resonance imaging evaluations after 6 months by an independent radiologist who graded the amount of epidural scar formation. The patients were assessed at 1 year and given a rating of excellent, good, fair, or poor, and the scar was graded as none, minimal, or moderate. Although 97% of all patients improved, 83% were rated excellent or good. There were no statistical differences between the three groups clinically and radiographically. Patients with workers compensation had a statistically significant lower success rate (P < 0.001). Clinical outcome after lumbar disc surgery does not correlate with the use or type of interposition membrane used to prevent epidural fibrosis.
Research Interests: Biomedical Engineering, Magnetic Resonance Imaging, Adolescent, Comparative Study, Medicine, and 15 moreHumans, Female, Male, Discectomy, Clinical Sciences, Aged, Middle Aged, Adult, Nuclear Magnetic Resonance Imaging, Laminectomy, Decompression, Lumbar disc herniation, lumbar vertebrae, Diskectomy, and lumbar
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Study DesignRetrospective review of a prospective randomized trial.ObjectivesTo compare outcome scores and fusion rates in patients with and without pedicle screw-associated facet joint violation (FJV) after a single-level lumbar... more
Study DesignRetrospective review of a prospective randomized trial.ObjectivesTo compare outcome scores and fusion rates in patients with and without pedicle screw-associated facet joint violation (FJV) after a single-level lumbar fusion.MethodsClinical outcomes data and computed tomography (CT) imaging were reviewed for 157 patients participating in a multicenter prospective trial. Post-operative CT scans at 12-months follow-up were examined for fusion status and FJV. Patient-reported outcomes (PROs) included Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for leg and low back pain. Chi-square test of independence was used to compare proportions between groups on categorical measures. Two-sample t-test was used to identify differences in mean patient outcome scores. Logistic regression models were performed to determine association between FJV and fusion rates.ResultsOf the 157 patients included, there were 18 (11.5%) with FJV (Group A) and 139 (88.5%) without FJV (Group B). Patients with FJV experienced less improvement in ODI (P = .004) and VAS back pain scores (P = .04) vs patients without FJV. There was no difference in mean VAS leg pain (P = .4997). The rate of fusion at 12-months for patients with FJV (27.8%) was lower compared to those without FJV (71.2%) (P = .0002). Patients with FJV were 76% less likely to have a successful fusion at 12-months.ConclusionPedicle screw-associated violation of the adjacent unfused facet joint during single-level lumbar fusion is associated with less improvement in back pain, back pain-associated disability, and a lower fusion rate at 1-year after surgery.
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The use of thoracic pedicle screws in deformity surgery provides a stable fixation system. The concept of acceptably positioned screws includes a worrisome subset of screws that perforate the medial pedicle cortex and may result in some... more
The use of thoracic pedicle screws in deformity surgery provides a stable fixation system. The concept of acceptably positioned screws includes a worrisome subset of screws that perforate the medial pedicle cortex and may result in some compromise of the spinal canal. A significant higher incidence of cortical wall penetration on the concave side compared with the convex was previously found. Although several authors assumed that the spinal cord hugs the concave pedicles when the spinal deformity is scoliosis, the position of spinal cord in adolescent idiopathic scoliosis (AIS) has not been studied in depth. We reviewed 45 patients who were candidate for operative treatment for AIS between August 2007 and October 2010 at our institution. Posteroanterior and lateral 3-ft standing preoperative radiographs of the spine were reviewed to determine: Cobb angle of the thoracic curves, apex vertebra of the curves, and end vertebras of the curves. Magnetic resonance images were retrospectively reviewed. The lateral cord space (LCS) ratio, which reflects the relative position of the spinal cord in the spinal canal, was calculated for each level with a thoracic curve. The average LCS for thoracic curves of >50 degrees was 2.123. The average LCS for thoracic curves of <50 degrees was 1.551 (P=0.002). The LCS for the apex vertebra was 1.699. The LCS for the upper end vertebra and lower end vertebra were 1.212, 1.225, respectively (P<0.001). There was a statistically significant difference between right thoracic curves and left thoracic curve regarding the LCS. In right thoracic curve the LCS was 1.487 (1.487+0.45) while in left thoracic curve it was 0.761 (0.761+0.17) meaning that in both curves the spinal cord moved to the concave side of the curve. Our study confirms that spinal cord in AIS tend to follow the appearance of the curve with its being tethered on the concave side. The spinal cord is close to the pedicle around the apex area.
Research Interests: Magnetic Resonance Imaging, Adolescent, Medicine, Anatomy, Humans, and 15 moreChild, Female, Spinal Cord, Male, Young Adult, Radiography, Scoliosis, Retrospective Studies, Pediatric Orthopaedics, Thoracic Vertebrae, Pediatric Orthopedics, Deformity, Bone screws, Vertebra, and Paediatrics and reproductive medicine
Open reduction and internal fixation techniques do not allow early weight bearing. In an effort to develop a better method to obtain calcaneal fracture reduction and maintain it in the face of early weight bearing, a circular external... more
Open reduction and internal fixation techniques do not allow early weight bearing. In an effort to develop a better method to obtain calcaneal fracture reduction and maintain it in the face of early weight bearing, a circular external fixator was applied to seven patients in combination with a limited lateral approach and open reduction and internal fixation of the depressed subtalar joint fragments. The operative technique uses the Ilizarov circular external fixator to obtain a ligamentotaxis reduction, following which the depressed subtalar joint fragments are elevated open; then, the fixator is used to reduce the lateral translation. All displacements of the fracture fragments are corrected. This method proved successful in six patients, all of whom achieved a satisfactory result with anatomic restoration of the subtalar joint and heel. One patient went on to late partial collapse of the posterior facet. Subtalar motion was greater than 50% in four of seven patients. None of the patients complained of heel pad pain, which was attributed to the desensitization of the heel by early weight bearing. This technique has produced encouraging preliminary results in two- to four-year follow-up evaluation.
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Research Interests: Risk assessment, Medicine, Humans, Female, Orthopedics, and 13 moreIntervertebral disc degeneration, Aged, Middle Aged, Radiography, Observer Variation, Prognosis, Reproducibility of Results, Risk Assessment, Sensitivity and Specificity, X ray Computed Tomography, lumbar vertebrae, spondylolisthesis, and Vertebra
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Study Design: Retrospective cohort study. Objective: Our objective was to determine whether lateral pedicle screw breach affects fusion rates and patient-reported outcomes in lumbar fusion surgery. Summary of Background Data: Although... more
Study Design: Retrospective cohort study. Objective: Our objective was to determine whether lateral pedicle screw breach affects fusion rates and patient-reported outcomes in lumbar fusion surgery. Summary of Background Data: Although lateral pedicle screw malposition is considered relatively benign, few studies have focused specifically on clinical outcomes or fusion rates associated with lateral screw malposition. Methods: Twelve-month postoperative computed tomography scans were reviewed for lateral breach, severity of breach, and fusion status. Patients with lateral breach were compared with patients with no breach. Outcome measures included Numerical Pain Rating Scale for back and leg pain, Oswestry Disability Index, and SF-36 physical function (SF-36 PF). Multivariable linear and logistic regression and were adjusted for age, procedure, level, and/or baseline pain score. Results: Forty-five patients (31%) demonstrated 1 or more lateral breaches as compared with 99 patients wit...
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BACKGROUND Impaired neuromuscular control and degeneration of the multifidus muscle have been linked to the development of refractory chronic low back pain (CLBP). An implantable restorative-neurostimulator system can override the... more
BACKGROUND Impaired neuromuscular control and degeneration of the multifidus muscle have been linked to the development of refractory chronic low back pain (CLBP). An implantable restorative-neurostimulator system can override the underlying multifidus inhibition by eliciting episodic, isolated contractions. The ReActiv8-B randomized, active-sham-controlled trial provided effectiveness and safety evidence for this system, and all participants received therapeutic stimulation from four months onward. OBJECTIVE This study aimed to evaluate the two-year effectiveness of this restorative neurostimulator in patients with disabling CLBP secondary to multifidus muscle dysfunction and no indications for spine surgery. MATERIALS AND METHODS Open-label follow-up of 204 participants implanted with a restorative neurostimulation system (ReActiv8, Mainstay Medical, Dublin, Ireland) was performed. Pain intensity (visual analog scale [VAS]), disability (Oswestry disability index [ODI]), quality-of-life (EQ-5D-5L), and opioid intake were assessed at baseline, six months, one year, and two years after activation. RESULTS At two years (n = 156), the proportion of participants with ≥50% CLBP relief was 71%, and 65% reported CLBP resolution (VAS ≤ 2.5 cm); 61% had a reduction in ODI of ≥20 points, 76% had improvements of ≥50% in VAS and/or ≥20 points in ODI, and 56% had these substantial improvements in both VAS and ODI. A total of 87% of participants had continued device use during the second year for a median of 43% of the maximum duration, and 60% (34 of 57) had voluntarily discontinued (39%) or reduced (21%) opioid intake. CONCLUSIONS At two years, 76% of participants experienced substantial, clinically meaningful improvements in pain, disability, or both. These results provide evidence of long-term effectiveness and durability of restorative neurostimulation in patients with disabling CLBP, secondary to multifidus muscle dysfunction. CLINICAL TRIAL REGISTRATION The study is registered on clinicaltrials.gov with identifier NCT02577354.
Research Interests: Cognitive Science, Neuromodulation, Chronic Pain, Spine, Medicine, and 15 morePhysical Therapy, Pain Management, Low back pain, Lumbar Muscles, Clinical Sciences, Visual Analogue Scale, Randomized Controlled Trial, Neurostimulation, Chronic Low Back Pain, Neuromodulation Devices, Multifidus, Neurosciences, Chronic nonspecific low back pain, Nonspecific chronic low back pain, and Oswestry Disability Index
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Chronic low back pain can be caused by impaired control and degeneration of the multifidus muscles and consequent functional instability of the lumbar spine. Available treatment options have limited effectiveness and prognosis is... more
Chronic low back pain can be caused by impaired control and degeneration of the multifidus muscles and consequent functional instability of the lumbar spine. Available treatment options have limited effectiveness and prognosis is unfavorable. We conducted an international randomized, double-blind, sham-controlled trial at 26 multidisciplinary centers to determine safety and efficacy of an implantable, restorative neurostimulator designed to restore multifidus neuromuscular control and facilitate relief of symptoms (clinicaltrials.gov identifier: NCT02577354). Two hundred four eligible participants with refractory mechanical (musculoskeletal) chronic LBP and a positive prone instability test indicating impaired multifidus control were implanted and randomized to therapeutic (N = 102) or low-level sham (N = 102) stimulation of the medial branch of the dorsal ramus nerve (multifidus nerve supply) for 30 minutes twice daily. The primary endpoint was the comparison of responder proportio...
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Degenerative spondylolisthesis (DS) is one of the more commonly encountered spine conditions. The diagnosis of DS has changed little in the last 30 years. However, there has been an evolution in the treatment of this disease entity. There... more
Degenerative spondylolisthesis (DS) is one of the more commonly encountered spine conditions. The diagnosis of DS has changed little in the last 30 years. However, there has been an evolution in the treatment of this disease entity. There have been several landmark papers that helped govern our treatment. These helped serve as the basis for the treatment arms of the Spine Patient Outcomes Research Trial (SPORT), which offers the highest quality evidence to date. Although few would argue that the fusion of the diseased segment appears to offer the best and most durable results, treatment of this disease is best tailored to the individual. Fusion may offer the best results in the young active patient, but the same results may never become evident in the medically infirm patient. Laminectomy or unilateral laminoforaminotomy still plays a role in disease treatment. This review will focus on the diagnosis and the treatment of DS as well as discuss the author's preferred treatment of ...