Neuromonitoring in Cervical Spine Surgery: When Is a Signal Drop Clinically Significant?

Methods@#Clinical and neuromonitoring data of 207 consecutive adult patients who underwent cervical spine surgeries at multiple surgical centers using bimodal IONM were analyzed. Signal changes were divided into three groups. Group 0 had transient signal changes in either MEPs or SSEPs, group 1 had sustained unimodal changes, and group 2 had sustained changes in both MEPs and SSEPs. The incidences of true neurological deficits in each group were recorded. @*Results@#A total of 25% (52/207) had IONM signal alerts. Out of these signal drops, 96% (50/52) were considered to be false positives. Groups 0 and 1 had no incidence of neurological deficits, while group 2 had a 29% (2/7) rate of true neurological deficits. The sensitivities of both MEP and SSEP were 100%. SSEP had a specificity of 96.6%, while MEP had a lower specificity at 76.6%. C5 palsy rate was 6%, and there was no correlation with IONM signal alerts (p=0.73). @*Conclusions@#This study shows that we can better predict its clinical significance by dividing IONM signal drops into three groups. A sustained, bimodal (MEP and SSEP) signal drop had the highest risk of true neurological deficits and warrants a high level of caution. There were no clear risk factors for false-positive alerts but there was a trend toward patients with cervical myelopathy.

A Novel Scale for Assessing the Burden of Caregiving for Functionally Compromised Patients: Proposal and Validation / 가정의학회지

Background@#Disability not only burdens the patient, but also the caregiver. To quantify this caregiving burden, we propose a simple four-part questionnaire tool. Our objective is to validate this questionnaire by administering it to caregivers who oversee patients with low back pain and are functionally compromised. @*Methods@#Twenty-five spouse caregivers who were taking care of in-patients awaiting surgery for various lumbar spine pathologies were shortlisted. The content-validated questionnaire was administered on different occasions during the care recipient’s treatment. Cronbach’s α was calculated to assess internal consistency. Interrelationships between the care recipient’s pain score, extent of functional compromise, and caregiver burden were calculated. The questionnaire’s ability to track changes in the caregivers’ attitudes over time was assessed. @*Results@#The percentage of caregiver burden before the surgery of the care recipient was 52.5. This increased significantly to 61.1% (P=0.001) 3 days after surgery, but was found to decrease to 32.5% (P<0.001) a month after the surgery; demonstrating the questionnaire’s efficacy to track changes. Cronbach’s alpha of 0.948 signifies the questionnaire’s excellent internal consistency. Pearson’s correlation coefficient (r) between the care recipient’s pain score and caregiver’s burden score was 0.41 (P=0.04), and between the care recipient’s disability score and caregiver’s burden score was 0.9 (P<0.001). @*Conclusion@#The proposed questionnaire is consistent and can track changes in a caregiver’s attitude over time. It can be adopted for clinical use to assess the burden of caregiving for functionally compromised patients.

Neuromonitoring in Cervical Spine Surgery: When Is a Signal Drop Clinically Significant?

Methods@#Clinical and neuromonitoring data of 207 consecutive adult patients who underwent cervical spine surgeries at multiple surgical centers using bimodal IONM were analyzed. Signal changes were divided into three groups. Group 0 had transient signal changes in either MEPs or SSEPs, group 1 had sustained unimodal changes, and group 2 had sustained changes in both MEPs and SSEPs. The incidences of true neurological deficits in each group were recorded. @*Results@#A total of 25% (52/207) had IONM signal alerts. Out of these signal drops, 96% (50/52) were considered to be false positives. Groups 0 and 1 had no incidence of neurological deficits, while group 2 had a 29% (2/7) rate of true neurological deficits. The sensitivities of both MEP and SSEP were 100%. SSEP had a specificity of 96.6%, while MEP had a lower specificity at 76.6%. C5 palsy rate was 6%, and there was no correlation with IONM signal alerts (p=0.73). @*Conclusions@#This study shows that we can better predict its clinical significance by dividing IONM signal drops into three groups. A sustained, bimodal (MEP and SSEP) signal drop had the highest risk of true neurological deficits and warrants a high level of caution. There were no clear risk factors for false-positive alerts but there was a trend toward patients with cervical myelopathy.

A Novel Scale for Assessing the Burden of Caregiving for Functionally Compromised Patients: Proposal and Validation / 가정의학회지

Background@#Disability not only burdens the patient, but also the caregiver. To quantify this caregiving burden, we propose a simple four-part questionnaire tool. Our objective is to validate this questionnaire by administering it to caregivers who oversee patients with low back pain and are functionally compromised. @*Methods@#Twenty-five spouse caregivers who were taking care of in-patients awaiting surgery for various lumbar spine pathologies were shortlisted. The content-validated questionnaire was administered on different occasions during the care recipient’s treatment. Cronbach’s α was calculated to assess internal consistency. Interrelationships between the care recipient’s pain score, extent of functional compromise, and caregiver burden were calculated. The questionnaire’s ability to track changes in the caregivers’ attitudes over time was assessed. @*Results@#The percentage of caregiver burden before the surgery of the care recipient was 52.5. This increased significantly to 61.1% (P=0.001) 3 days after surgery, but was found to decrease to 32.5% (P<0.001) a month after the surgery; demonstrating the questionnaire’s efficacy to track changes. Cronbach’s alpha of 0.948 signifies the questionnaire’s excellent internal consistency. Pearson’s correlation coefficient (r) between the care recipient’s pain score and caregiver’s burden score was 0.41 (P=0.04), and between the care recipient’s disability score and caregiver’s burden score was 0.9 (P<0.001). @*Conclusion@#The proposed questionnaire is consistent and can track changes in a caregiver’s attitude over time. It can be adopted for clinical use to assess the burden of caregiving for functionally compromised patients.

Spontaneous Total Resolution of Severe Lumbar Disc Herniation / 전남의대학술지

No abstract available.

Factors Impacting Mortality in Geriatric Patients with Acute Spine Fractures: A 12-Year Study of 613 Patients in Singapore

STUDY DESIGN: Retrospective database analysis. PURPOSE: To identify risk factors that predict mortality following acute spine fractures in geriatric patients of Singapore. OVERVIEW OF LITERATURE: Acute geriatric spinal fractures contribute significantly to local healthcare costs and hospital admissions. However, geriatric mortality following acute spine fractures is scarcely assessed in the Asian population. METHODS: Electronic records of 3,010 patients who presented to our hospital’s emergency department and who were subsequently admitted during 2004–2015 with alleged history of traumatic spine fractures were retrospectively reviewed, and 613 patients (mean age, 85.7±4.5 years; range, 80–101 years; men, 108; women, 505) were shortlisted. Mortality rates were reviewed up to 1 year after admission and multivariate analyses were performed to identify independent risk factors correlating with mortality. RESULTS: Women were more susceptible to spine fractures (82.4%), with falls (77.8%) being the most common mechanism of injury. Mortality rates were 6.0%, 8.2%, and 10.4% at 3, 6, and 12 months, respectively. The most common causes of death at all 3 time points were pneumonia and ischemic heart disease. Based on the multivariate analysis at 1-year follow-up, elderly women had a lower mortality rate compared to men (p<0.001); mortality rates increased by 6.3% (p=0.024) for every 1-year increase in the patient’s age; and patients with an American Spinal Injury Association (ASIA) score of A–C had a much higher mortality rate compared to those with an ASIA score of D–E (p<0.001). CONCLUSIONS: An older age at presentation, male sex, and an ASIA score of A–C were identified as independent factors predicting increased mortality among geriatric patients who sustained acute spine fractures. The study findings highlight at-risk groups for acute spine fractures, thereby providing an opportunity to develop strategies to increase the life expectancy of these patients.

Utilization of Spinal Navigation to Facilitate Hassle-Free Rod Placement during Minimally-Invasive Long-Construct Posterior Instrumentation

During minimally-invasive long-construct posterior instrumentation, it may be challenging to contour and place the rod as the screw heads are not visualized. To overcome this, we utilized the image data merging (IDM) facility of our spinal navigation system to visualize a coherent whole image of the construct throughout the procedure. Here, we describe this technique that was used for a patient in whom L1–L5 posterior instrumentation was performed. Using an IDM facility, screws are color coded and after placement, the final image is saved. Saved images of all previous screws are displayed and observed while placing the subsequent screws. Therefore, the entry point, depth, and mediolateral alignment of subsequent screws can be adjusted to fall in line with previous screws such that the rod can be placed without hassle. Moreover, final adjustments to the construct are kept to a minimum. The possibility of screw pullout due to force engaging the rod on poorly aligned screws is thus avoided.

Revalidating Pfirrmann's Magnetic Resonance Image-Based Grading of Lumbar Nerve Root Compromise by Calculating Reliability among Orthopaedic Residents

BACKGROUND: Intervertebral disc herniations lead to subsequent compromise of the nerve root. The root can either have a mere contact with the disc material or be pushed aside or compressed. This was earlier graded by Pfirrmann and colleagues. We intend to revalidate this grading system by performing a reliability analysis among orthopaedic residents. METHODS: Fifty axial cut magnetic resonance (MR) images of the affected lumbar disc level that belonged to different patients (age, 37.8 ± 10.4 years; 33 males and 17 females) were chosen and given to five orthopaedic residents for grading according to the Pfirrmann's MR image-based grading of lumbar nerve root compromise. Responses were received in the form of categorical variables and reliability was assessed. RESULTS: On doing percentage statistics, we found that 14 images had 100% agreement, 22 had 80% agreement and 14 had 60% agreement. We inferred an overall agreement of 80% ± 15.1%. In addition, interrater reliability was determined by calculating the Fleiss' kappa, which was found to be 0.521, signifying moderate agreement. Intrarater reliability was determined by calculating Cohen's kappa, which was found to be 0.696, signifying substantial agreement. CONCLUSIONS: Our residents took only a short time to learn and reproduce this grading system as ratings that proved to be moderately reliable. Even though the value of kappa was slightly lower, reliability was similar to that of the original authors. We think that this grading system can be adopted in day-to-day practice by framing appropriate rules to interpret MR images where the nerve roots are not visible.

Assessment of Anteroposterior Subpedicular Approach and Oblique Scotty Dog Subpedicular Approach for Selective Nerve Root Block

BACKGROUND: The technique used to administer a selective nerve root block (SNRB) varies depending on individual expertise. Both the anteroposterior (AP) subpedicular approach and oblique Scotty dog subpedicular approach are widely practiced. However, the literature does not provide a clear consensus regarding which approach is more suitable. Hence, we decided to analyse the procedural parameters and clinical outcomes following SNRBs using these two approaches. METHODS: Patients diagnosed with a single lumbar herniated intervertebral disc (HIVD) refractory to conservative management but not willing for immediate surgery were selected for a prospective nonrandomized comparative study. An SNRB was administered as a therapeutic alternative using the AP subpedicular approach in one group (n = 25; mean age, 45 ± 5.4 years) and the oblique Scotty dog subpedicular approach in the other group (n = 22; mean age, 43.8 ± 4.7 years). Results were compared in terms of the duration of the procedure, the number of C-arm exposures, accuracy, pain relief, functional outcome and the duration of relief. RESULTS: Our results suggest that the oblique Scotty dog subpedicular approach took a significantly longer duration (p = 0.02) and a greater number of C-arm exposures (p = 0.001). But, its accuracy of needle placement was 95.5% compared to only 72% using the AP subpedicular approach (p = 0.03). There was no significant difference in terms of clinical outcomes between these approaches. CONCLUSIONS: The AP subpedicular approach was simple and facile, but the oblique Scotty dog subpedicular approach was more accurate. However, a brief window period of pain relief was achieved irrespective of the approaching technique used.

Intramedullary splinting of femoral shaft fractures in children with flexible nails: early results

<p><b>INTRODUCTION</b>Indications for flexible intramedullary nailing, as well as advancements in this technique, have evolved considerably with time and individual experience. We implemented and studied a simplified version of the technique. Functional outcome, osseous union and related issues are discussed.</p><p><b>METHODS</b>A total of 15 patients aged 5-15 years with diaphyseal femur fracture were selected for the study. The patients' fractures were stabilised with flexible intramedullary nails through lateral entry alone. After a minimum follow-up period of six months, the outcomes were analysed.</p><p><b>RESULTS</b>The mean patient age was 8.7 years, and patients were followed up for a mean duration of 12 months. Radiological union was achieved within a mean duration of 7.5 weeks. The outcomes were excellent in most of the cases.</p><p><b>CONCLUSION</b>Adequate fixation was achieved through the use of flexible nails as intramedullary splints. The results were comparable to that of the original technique. Further study is obligatory.</p>