Isthmic Lumbar Spondylolisthesis.

Lumbar isthmic spondylolisthesis is the anterior translation of one lumbar vertebra relative to the next caudal segment as a result of an abnormality in the pars interarticularis. Although it is most often an asymptomatic radiographic finding, symptomatic patients may present with low back and/or radicular leg pain. In the setting of persistent symptoms, despite nonoperative treatment, surgery can be considered. Successful arthrodesis and neurologic decompression, when necessary, are the chief goals of surgical treatment, which has demonstrated reasonable long-term outcomes. A variety of surgical treatment options are available and the relative efficacy of them based on patient-specific factors continue to be investigated.

Critical analysis of trends in lumbar fusion for degenerative disorders revisited: influence of technique on fusion rate and clinical outcomes.

PURPOSE: Lumbar fusion for degenerative disorders is among the most common spine surgical procedures performed. The purpose of this study was to analyze fusion, complications, and clinical success for lumbar fusion performed with various surgical techniques as reported in the literature from 2000 to 2015 and compare with previous critical analysis of outcomes from 1980 to 2000. METHODS: A systematic review of the literature to identify all studies of adult lumbar fusion for degenerative disorders published between January 1, 2000, and August 31, 2015, was performed adhering to PRISMA guidelines. Studies were included if they enabled analysis of outcomes of individual fusion techniques. RESULTS: Data from 8599 patients extracted from 160 studies were recorded. Posterior and transforaminal lumbar interbody fusion (PLIF and TLIF) had significantly higher fusion rates compared to instrumented posterolateral fusion (PLF) (OR 3.20 and 2.46, respectively). Clinical success rate was statistically higher with MIS versus non-MIS fusion (OR 2.44). While methodological quality was higher in studies from 2000 to 2015 than prior decades, the outcomes of comparable procedures were about the same. CONCLUSIONS: Lumbar fusions for degenerative disorders from 2000 to 2015 demonstrate a trend toward more interbody fusions and MIS techniques than prior decades. Clinical success with MIS appears more likely than with non-MIS fusions, despite equivalent fusion and complication rates. While these data are intriguing, they should be interpreted cautiously considering the level of heterogeneity of the studies available. Further, high-quality comparative studies are warranted to better understand the relative benefits of more complex interbody and MIS fusions for these conditions. These slides can be retrieved under Electronic Supplementary Material.

Decompressive surgery for lumbar spinal stenosis across the Atlantic: a comparison of preoperative MRI between matched cohorts from the US and Norway.

BACKGROUND: There are no uniform guidelines regarding when to operate for Lumbar Spinal Stenosis (LSS). As we apply findings from clinical research from one population to the next, elucidating similarities or differences provides important context for the validity of extrapolating clinical outcomes. The aim of this study was to compare the morphological severity of lumbar spinal stenosis on preoperative MRI in patients undergoing decompressive surgery in Boston, USA, and Trondheim, Norway. METHODS: In this observational retrospective study, we compared morphological severity on MRI before surgical treatment between two propensity score-matched patient populations with single or two-level symptomatic LSS. We assessed the radiographic severity of LSS utilizing the Schizas classification (grade A to D). RESULTS: Following propensity score matching, demographics are balanced. In the Trondheim cohort, two levels decompression were present in 36.2% of the patients vs. 41.9% in Boston, (p = 0.396). There was no significant difference in grades A to D concerning central stenosis (p = 0.075). When dichotomized in mild/moderate (A/B) and severe /extreme (C/D), there were no significant differences in the rate of levels operated for high-grade stenosis (C/D), 67.6% in the Boston group compare to 78.1% in the Trondheim group (p = 0.088). CONCLUSIONS: Trondheim, Norway, and Boston, US, have similar radiographic thresholds of LSS for offering surgery.

The influence of subgroup diagnosis on radiographic and clinical outcomes after lumbar fusion for degenerative disc disorders revisited: a systematic review of the literature.

BACKGROUND CONTEXT: Understanding the influence of preoperative diagnosis on outcomes for lumbar fusion surgery improves the quality of research and outcomes data, and helps guide treatment decisions. PURPOSE: We sought to perform a systematic review of the literature published between 2000 and 2014 regarding lumbar fusion outcomes for degenerative disorders. An assessment of the influence of subgroup diagnosis on outcomes as well as the quality of this body of literature was performed. STUDY DESIGN: Systematic review PATIENT SAMPLE: The 100 studies ultimately included involved adult patients (n=8,706) undergoing fusion surgery for degenerative disorders of the lumbar spine. OUTCOME MEASURES: Visual analog scale (VAS) pain scores, complication rates, and determination of successful fusion METHODS: With adherence to the PRISMA guidelines, electronic searches were performed through PubMed, Scopus, and Web of Science to identify all studies involving lumbar fusion for degenerative disc disorders from January 2000 to August 2014. Studies were eligible for inclusion if they addressed adult patients treated with lumbar fusion for one of the following: stable degenerative disc disease, unstable degenerative disc disease, degenerative disc disease not specified (DDDns), herniated disc (DH), degenerative spondylolisthesis (DDDsp), and adult degenerative scoliosis (DDDsc). Abstracted data included the number of patients, preoperative diagnosis, fusion technique, complications, fusion rate, and clinical outcomes. RESULTS: One hundred articles met inclusion criteria and yielded data for 8,706 patients. Forty-three studies included data for clinical improvement (VAS scores). The mean clinical improvement in VAS scores was significantly different among the diagnoses (p<.001), with DDDsp demonstrating the highest improvement (60%) and DDDns having the lowest (45%). Eighty-five studies included data for complication rates. Complication rates differed significantly (p<.001), with the highest rate seen in the DDDsc group (18%), followed by DDDsp (14%). Seventy-eight studies included data for fusion. The pooled odds of fusion for prospective studies were 6.93 (95% CI 4.75, 10.13). There was no evidence of publication bias. CONCLUSIONS: A relationship between outcomes and subgroup diagnosis was demonstrated. This review demonstrated a higher quality of evidence in the literature, and greater overall fusion rates compared to similar studies published in the 1980s and 1990s.

Surgical Management of Civilian Gunshot-Induced Spinal Cord Injury: Is It Overutilized?

STUDY DESIGN: Retrospective chart review. OBJECTIVE: Assess appropriate utilization of surgery for civilian gunshot-induced spinal cord injuries (CGSWSCI) according to literature standards in a large cohort. SUMMARY OF BACKGROUND DATA: CGSWSCI are mechanically stable injuries that rarely require surgery. Nonetheless, we continue to see high numbers of these patients undergo surgical treatment. This study compares indications for surgeries performed in a large cohort of CGSWSCI patients to established indications for surgical management of such injuries. The rate of over-utilization of surgical management was calculated. METHODS: Four hundred eighty-nine CGSWSCI patients transferred for rehabilitation to our institution between 2000 and 2014 were identified. Retrospective chart review was performed to identify patients who underwent initial surgical treatment, the specific surgeries performed, and indications given. We assessed appropriateness of surgery according to literature standards. Patients treated surgically were followed to assess for complications and the need for additional intervention and compared to nonsurgical patients. Secondarily, visual analog scale pain scores (0-10) and patient perceived improvement were compared between surgical and nonsurgical patients after telephone survey of both groups. RESULTS: Of 489 patients, 91 (18%) underwent initial surgery. Of 91 surgeries, 69 (75%) were not indicated by literature standards. Five of 91 (5.5%) of initially operated patients required a secondary surgery compared with two of 398 (0.5%) of the nonoperative group (P = 0.003). Over-utilization rate of the entire cohort was 14.1%. No difference was seen for pain scores or patient perceived improvement between operative and nonoperative patients. CONCLUSION: We report a high overutilization rate (14%) of surgery for CGSWSCI in our cohort. Surgical management was associated with higher infection and secondary surgery rates compared to nonsurgical management. Surgery done without a clear, demonstrable benefit poses unnecessary risk to patients and accumulates unwarranted healthcare costs. LEVEL OF EVIDENCE: 3.

Inadequate Surgical Decompression in Patients with Cervical Myelopathy: A Retrospective Review.

STUDY DESIGN: Retrospective study. OBJECTIVE: We reviewed cases of surgically treated cervical spondylotic myelopathy (CSM) or chronic, degenerative myelopathy of the subaxial cervical spine to study the incidence of inadequate surgical decompression. METHODS: We included all persons treated at our institution after a first surgical decompression for CSM over a 3-year period. Inadequate original surgical decompression was defined as neurologic decline within 12 months postoperatively and ongoing impingement of the spinal cord with <1-mm change in anteroposterior canal dimension from pre- to postoperative magnetic resonance imaging (MRI) leading to revision decompressive surgery. Revisions for other reasons were not counted as inadequate. RESULTS: Of 50 patients, 5 (10%) required revision decompression for neurologic decline and inadequate change in space available for the cord on postoperative imaging; 4 patients declined within the first 6 months and 1 patient at 8 months postoperatively. None of the 5 declined further after posterior revision, but none recovered from the interval loss. All 5 had undergone anterior approaches, for an anterior inadequacy rate of 23% (5 of 22). None of the 28 patients having posterior or combined approach declined at 2 years or had <1-mm change on postoperative MRI. The difference between anterior and posterior approaches was statistically significant (p = 0.018). CONCLUSIONS: The rate of inadequate surgical decompression for CSM was greater than expected in this series and directly associated with an anterior approach. No cases of inadequacy occurred for posterior or combined approaches. Postoperative neuroradiographic imaging such as MRI should be entertained routinely for this entity or at least for anterior-only approaches.

Academic productivity and contributions to the literature among spine surgery fellowship faculty.

BACKGROUND CONTEXT: No previous study has considered academic productivity and contributions to the literature among the faculty members of spine fellowship programs. PURPOSE: We sought to evaluate the total number of publications and measures of academic impact among faculty at spine surgical fellowship programs between 2011 and the present. STUDY DESIGN: This study is based on a review of data publicly available on PubMed and Scopus. PATIENT SAMPLE: Physicians listed as faculty at a spine fellowship program in the directory of the North American Spine Society (NASS). OUTCOME MEASURES: The outcome measures were the number of publications between January 1, 2011 and August 31, 2014 and the h-index for 1996 to present (h-tot) and 2011 to present (h-pres) for faculty members. METHODS: Fellowship programs and their characteristics were obtained from the directory of the NASS. Program-specific features, including academic affiliation, number of participating faculty, location, number of fellowship positions, dedicated research time, and presence of a research requirement for fellows, were abstracted. The number of publications for faculty at each program between January 1, 2011 and August 31, 2014 and the h-tot and h-pres were obtained from Scopus. Multivariable linear regression was used to identify statistically significant factors associated with increased academic productivity. RESULTS: Among 75 fellowship programs, with 282 faculty members, there were 55 (73%) with academic affiliation. The average number of publications per faculty member (2011-2014) was 5.5 (standard deviation, 8.4; range, 0-54). The mean h-tot for programs was 13.6 (8.7, 0-37), and mean h-pres was 3.0 (2.2, 0-8.2). Academic affiliation (regression coefficient, 22.1; 95% confidence interval: 7.2, 37.0), and the number of fellows in a program (7.0, 0.9-13.2) was significantly associated with the total number of publications. Similar findings were encountered for average h-tot and h-pres. CONCLUSIONS: The descriptive statistics presented can help surgeons benchmark their performance and that of their fellowship, compared with others in the field. Determinations regarding characteristics associated with academic productivity may also help programs' fashion future strategic initiatives.

Subscapularis tendon rupture in an 8-year-old boy: a case report.

Since falling off a motorcycle 2 years earlier, an 8-year-old, right-hand-dominant boy reported anterior shoulder pain and weakness. After being evaluated by his family physician and completing a course of physical therapy with no symptomatic improvement, he was seen at our institution. Physical examination was remarkable for diminished strength with internal rotation (4/5). In addition, bellypress and lift-off tests were positive, suggesting a lesion of the subscapularis. Magnetic resonance imaging of the shoulder showed a full-thickness subscapularis tendon tear and a supraspinatus tendon signal that could have represented a partial-thickness tear vs supraspinatus tendinosis. The patient underwent right shoulder diagnostic arthroscopy with debridement of a partial-thickness articular-sided tear of the supraspinatus tendon followed by open repair of the subscapularis tendon rupture. This case illustrates a traumatic subscapularis tendon injury that is rare in this age group. A few other traumatic subscapularis injuries have been reported in children, but they all demonstrated bony avulsion of the lesser tuberosity.

Neck pain from a spine surgeon's perspective.

Through the myriad of abnormalities encountered by spine surgeons, neck pain is one of the most perplexing. The nature, onset, and location of the pain all provide information as to what the potential pain generator may be. By synthesizing data garnered from the physical examination, imaging studies, and history, a spine surgeon must formulate a differential diagnosis and treatment plan. The surgeon must determine whether the patient has cervical radiculopathy, myelopathy, or simply cervical spondylosis because the treatment of each of these is vastly different.

What questions do patients undergoing lower extremity joint replacement surgery have?

BACKGROUND: The value of the Internet to deliver preoperative education would increase if there was variability in questions patients want answered. This study's goal was to have patients consulting an orthopedic surgeon about undergoing either a total hip arthroplasty (THA) or a total knee arthroplasty (TKA) rate the importance of different questions concerning their care. METHODS: We assembled questions patients might have about joint replacement surgery by analyzing the literature and querying a pilot group of patients and surgeons. Twenty-nine patients considering undergoing THA and 19 patients considering TKR completed a written survey asking them to rate 30 different questions, with a 5 point Likert scale from 1 (least important)--5 (most important). RESULTS: For patients considering THA or TKR, the 4 highest rated questions were: Will the surgery affect my abilities to care for myself?, Am I going to need physical therapy?, How mobile will I be after my surgery?, When will I be able to walk normally again? The mean percentage disagreement was 42% for questions answered by TKR patients and 47% for the THA group. Some patients gave a high rating to questions lowly rated by the rest of the group. CONCLUSIONS: Although there was enough agreement to define a core set of questions that should be addressed with most patients considering THA or TKA, some of the remaining questions were also highly important to some patients. The Web may offer a flexible medium for accommodating this large variety of information needs.