Three-dimensional lumbar spine vertebral motion during running using indwelling bone pins.

STUDY DESIGN: Eight healthy volunteers participated in this observational study. OBJECTIVE: Quantify 3-dimensional motions of the lumbar vertebrae during running via direct in vivo measurement and compare these motions to walking data from the same technique and running data from a skin-mounted technique. SUMMARY OF BACKGROUND DATA: Lumbar spine motions in running are only reported in 1 series of articles using a skin-mounted technique subject to overestimation and only instrumented a single vertebra. METHODS: Reflective marker triads were attached to Kirschner wires inserted into the spinous processes of L1-S1. Anatomic registration between each vertebra and attached triad was achieved using spinal computed tomographic scans. Skin-mounted trunk markers were used to assess thoracic motions. Subjects ran several times in a calibrated volume at self-selected speed while 3-dimensional motion data were collected. RESULTS: Lumbar spine flexion and pelvic rotation patterns in running were reversed compared with walking. Increased lumbar spine motions during running occurred at the most inferior segments. Thoracic spine, lumbar spine and pelvis exhibited significantly greater range of sagittal plane motion with running. The pelvis had significantly greater range of frontal plane motion, and the thoracic spine had significantly greater range of transverse plane motion with running. Skin-mounted studies reported as much as 4 times the motion range determined by the indwelling bone pin techniques, indicating that the skin motion relative to the underlying bone during running was greater than the motion of the underlying vertebrae. CONCLUSION: The lumbar spine acts as a distinct functional segment in the spine during running, chiefly contributing lateral flexion to balance the relative motions between the trunk and pelvis. The lumbar spine is also shown to oppose thoracic spine sagittal flexion. While the lumbar spine chiefly contributes to frontal plane motion, the thoracic spine contributes the majority of the transverse plane motion. LEVEL OF EVIDENCE: N/A.

Assessment of three-dimensional lumbar spine vertebral motion during gait with use of indwelling bone pins.

BACKGROUND: This study quantifies the three-dimensional motion of lumbar vertebrae during gait via direct in vivo measurement with the use of indwelling bone pins with retroreflective markers and motion capture. Two previous studies in which bone pins were used were limited to instrumentation of two vertebrae, and neither evaluated motions during gait. While several imaging-based studies of spinal motion have been reported, the restrictions in measurement volume that are inherent to imaging modalities are not conducive to gait applications. METHODS: Eight healthy volunteers with a mean age of 25.1 years were screened to rule out pathology. Then, after local anesthesia was administered, two 1.6-mm Kirschner wires were inserted into the L1, L2, L3, L4, L5, and S1 spinous processes. The wires were clamped together, and reflective marker triads were attached to the end of each wire couple. Subjects underwent spinal computed tomography to anatomically register each vertebra to the attached triad. Subjects then walked several times in a calibrated measurement field at a self-selected speed while motion data were collected. RESULTS: Less than 4° of lumbar intersegmental motion was found in all planes. Motions were highly consistent between subjects, resulting in small group standard deviations. The largest motions were in the coronal plane, and the middle lumbar segments exhibited greater motions than the segments cephalad and caudad to them. Intersegmental lumbar flexion and axial rotation motions were both extremely small at all levels. CONCLUSIONS: The lumbar spine chiefly acts to contribute abduction during stance and adduction during swing to balance the relative motions between the trunk and pelvis. The lumbar spine acts in concert with the thoracic spine. While the lumbar spine chiefly contributes coronal plane motion, the thoracic spine contributes the majority of the transverse plane motion. Both contribute flexion motion in an offset phase pattern. CLINICAL RELEVANCE: This is a valid model for measuring the three-dimensional motion of the spine. Normative data were obtained to better understand the effects of spine disorders on vertebral motion over the gait cycle.

Culturally competent care pedagogy: what works?

BACKGROUND: In its 2002 publication Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine reported American racial and ethnic minorities receive lower-quality health care than white Americans. Because caregiver bias may contribute to disparate health care, the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education have issued specific directives to address culturally competent care education. QUESTIONS/PURPOSES: We discuss the general approaches to culturally competent care education, the tools used in evaluating such endeavors, and the impact of such endeavors on caregivers and/or the outcomes of therapeutic interventions from three perspectives: (1) Where are we now? (2) Where do we need to go? (3) How do we get there? METHODS: We summarized information from (1) articles identified in a PubMed search of relevant terms and (2) the authors' experience in delivering, evaluating, and promoting culturally competent care education. WHERE ARE WE NOW?: Considerable variation exists in approaches to culturally competent care education; specific guidelines and valid evaluation methods are lacking; and while existing education programs may promote changes in providers' knowledge and attitudes, there is little empirical evidence that such efforts reduce indicators of disparate care. WHERE DO WE NEED TO GO?: We must develop evidence-based educational strategies that produce changes in caregiver attitudes and behaviors and, ultimately, reduction in healthcare disparities. HOW DO WE GET THERE?: We must have ongoing dialog about, development in, and focused research on specific educational and evaluation methodologies, while simultaneously addressing the economic, political, practical, and social barriers to the delivery of culturally competent care education.

Acute tibial compartment syndrome following spine surgery.

This article presents a case of a patient with popliteal artery occlusion following anterior and posterior instrumented fusion of the lumbar spine. No previous study has reported acute anterior tibial compartment syndrome due to popliteal artery occlusion and restricted venous return following spine surgery. A 53-year old female, with a twice failed fusion of L5-S1, underwent L3-S1 anterior interbody and posterior L3-S1 instrumented fusion. Due to postoperative continuous analgesia, the patient was sleepy and confused on postoperative day 1. On the postoperative day 2, the right calf and anterolateral tibia manifested clinical signs of compartment syndrome and both thighs exhibited pressure ecchymoses from the antiembolism stockings. Fasciotomies of the right tibial compartments were undertaken and necrosis of the anterior compartment muscles was found. Intraoperative arteriogram revealed occlusion of the right popliteal artery and thrombectomy was performed. Lupus anticoagulant was found to be responsible for patient's coagulopathy. During postoperative year 1, the patient still had weakness and recurrent edema of the right foot. Unrecognized limb ischemia and possibly restricted venous return were the causes of the compartment syndrome. Surgeons should be aware of this devastating complication of spine surgery.

Salvage procedures for pseudarthrosis after transforaminal lumbar interbody fusion (TLIF)-anterior-only versus anterior-posterior surgery: a clinical and radiological outcome study.

A retrospective review was performed to analyze the radiographic and functional outcomes of two different surgeries to repair a pseudarthrosis following a transforaminal lumbar interbody fusion (TLIF) procedure. Although there are several published reports on the results of the TLIF procedure, there are no reports on how to salvage a failed TLIF. A total of 38 consecutive patients with failed TLIF procedures (at 50 levels) were repaired by either a direct anterior approach only (21 patients) or by a combined direct anterior approach coupled with a posterior exploration and pseudarthrosis repair (17 patients). The minimum follow-up after revision was 24 months. Clinical outcome was measured by Oswestry Disability Index, Roland Morris Questionnaire, SF-36, and the authors' own centers' satisfaction questionnaire in 17 of the 38 patients. The fusion rate for the anterior-alone group was 81% (17/21) and 88% (15/17) for the anterior-posterior group, not a statistically significant difference. The Oswestry scores averaged 56.4 for the anterior lumbar interbody fusion (ALIF) group and 51.4 for the anterior-posterior fusion (APF) group. The Roland-Morris scores averaged 18.9 for the ALIF group and 20.0 for the APF group. The SF-36 showed similar outcomes in both groups. The authors' center's satisfaction questionnaire also showed similar results. The outcomes, both radiologic and functional, were equal in both groups. There was very little improvement in functional outcomes comparing prerepair to postrepair based on the authors' questionnaire.

Getting to equal: strategies to understand and eliminate general and orthopaedic healthcare disparities.

The 2001 Institute of Medicine report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care pointed out extensive healthcare disparities in the United States even when controlling for disease severity, socioeconomic status, education, and access. The literature identifies several groups of Americans who receive disparate healthcare: ethnic minorities, women, children, the elderly, the handicapped, the poor, prisoners, lesbians, gays, and the transgender population. Disparate healthcare represents an enormous current challenge with substantial moral, ethical, political, public health, public policy, and economic implications, all of which are likely to worsen over the next several decades without immediate and comprehensive action. A review of recent literature reveals over 100 general and specific suggestions and solutions to eliminate healthcare disparities. While healthcare disparities have roots in multiple sources, racial stereotypes and biases remain a major contributing factor and are prototypical of biases based on age, physical handicap, socioeconomic status, religion, sexual orientation or other differences. Given that such disparities have a strong basis in racial biases, and that the principles of racism are similar to those of other "isms", we summarize the current state of healthcare disparities, the goals of their eradication, and the various potential solutions from a conceptual model of racism affecting patients (internalized racism), caregivers (personally mediated racism), and society (institutionalized racism).

Perioperative complications in revision anterior lumbar spine surgery: incidence and risk factors.

STUDY DESIGN: This is a retrospective review of 129 consecutive anterior lumbar revision surgeries in 108 patients. It is a single-center, multi-surgeon study. OBJECTIVE: To determine occurrence rates and risk factors for perioperative complications in revision anterior lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: Although complication rates from large series of primary anterior fusion procedures have been reported, reports of complication rates for revision anterior fusion procedures are relatively rare. Concern exists chiefly about the risk to vascular and visceral structures because of scar tissue formation from the original anterior exposure. METHODS: This was a retrospective review of 129 consecutive anterior revision lumbar surgeries in 108 patients operated between 1998 and 2003. There were 40 men and 68 women. The age of patients ranged from 25 to 83 (average 50.6 years). Patients were excluded if surgery was for tumor or infection. Patients were divided into 2 groups; those with revision surgery at the same level and those with revision surgery at an adjacent level. Outcome measures included all perioperative complications. Statistical analysis included Student t test and nonparametric sign-rank. RESULTS: The number of surgical levels treated for revision was similar between the 2 groups (1 level 69%; 2 levels 19%; 3 or more levels 12%). Revision cases at the same operative level had a higher overall complication rate (42%) compared with extensions (20%; P = 0.007). This difference was primarily because of vein lacerations (23.7% vs. 3.6%, P = 0.002). There were 2 ureteral problems, both successfully salvaged. There were no arterial injuries or deaths. CONCLUSION: Complication rates for revision lumbar surgery in this series were 3 to 5 times higher than reported for primary lumbar exposures. Complication rates were significantly higher for revision anterior lumbar fusions at the same segment, which were typically in the lower lumbar spine, compared with cases involving extensions, which were typically in the upper lumbar spine.

Therapy of spinal wound infections using vacuum-assisted wound closure: risk factors leading to resistance to treatment.

STUDY DESIGN: This study retrospectively reviewed spine surgical procedures complicated by wound infection and managed by a protocol including the use of vacuum-assisted wound closure (VAC). OBJECTIVE: To define factors influencing the number of debridements needed before the final wound closure by applying VAC for patients with postoperative spinal wound infections. SUMMARY OF BACKGROUND DATA: VAC has been suggested as a safe and probably effective method for the treatment of spinal wound infections. The risk factors for infection resistance and need for debridement revisions after VAC placement are unknown. METHODS: Seventy-three consecutive patients with 79 wound infections after undergoing spine surgery were studied (6 of them had recurrence of infection). All patients were taken to the operating room for irrigation and debridement under general anesthesia followed by placement of the VAC with subsequent delayed closure of the wound. Linear regression and t test were used to identify if the following variables were risk factors for the resistance of infection to VAC treatment: timing of clinical appearance of infection, depth of infection (deep or superficial), presence of instrumentation, positive culture for methicillin-resistant Staphylococcus aureus (MRSA) or more than 1 microorganism, age of the patient, and presence of other comorbidities. RESULTS: There were 34 males and 39 females with an average age of 58.4 years (21 to 82). Once the VAC was initiated, there was an average of 1.4 procedures until and including closure of the wound. The wound was closed an average of 7 days (range 5 to 14) after the placement of the initial VAC on the wound. The average follow-up was 14 months (range 12 to 28). All of the patients but 2 achieved a clean, closed wound without removal of instrumentation at a minimum follow-up of 1 year. Sixty patients had implants (instrumentation or allograft) within the site of wound infection. Thirteen patients had a decompression with exposed dura. Sixty-four infections (81%) presented with a draining wound within the first 6 weeks postoperatively. Sixty-nine infections (87.3%) were deep below the fascia. There was no statistical significance (P>0.05) of all tested risk factors for the resistance of infection to treatment with the VAC system. The parameter more related to repeat VAC procedures was the culture of MRSA or multiple bacteria. CONCLUSIONS: VAC therapy may be an effective adjunct in closing spinal wounds even after the repeat procedures. The MRSA or multibacterial infections seem to be most likely to need repeat debridements and VAC treatment before final wound closure.

The in vivo three-dimensional motion of the human lumbar spine during gait.

Lumbar spine pathology accounts for billions of dollars in societal costs each year. Although the symptomatology of these conditions is relatively well understood, the mechanical changes in the spine are not. Previous direct measurements of lumbar spine mechanics have mostly been performed on cadavers. The methods for in vivo studies have included imaging, electrogoniometry, and motion capture. Few studies have directly measured in vivo lumbar spine kinematics with in-dwelling bone pins. This study tracked the in vivo three-dimensional motion of the entire lumbar spine (L1 [corrected] to S1) in 10 healthy, young-adult subjects. Two 1.55 mm (0.062 in.) diameter Kirshner wires were inserted into each vertebra's spinous process under anesthesia. Motion capture cameras were used to track a triad of passive markers attached to the wires. Offsets between anatomical landmarks and tracking markers were established with a CT scan for each individual vertebra. Subjects were asked to perform various exercises including walking and voluntary range of motion. Subjects were able to complete all of the exercises. All subjects reported being adequately informed of all of the procedures and there were no neurological or orthopaedic complications. The range of the average inter-segmental range of motion was 4.26 degrees -4.38 degrees in the sagittal plane, 2.61 degrees -4.00 degrees in the coronal plane, and 4.11 degrees -5.24 degrees in the transverse plane. Using a direct (pin-based) in vivo measurement method, the motion of the human lumbar spine during gait was found to be triaxial. This appears to be the first three-dimensional motion analysis of the entire lumbar spine using indwelling pins. The results were similar to previously published data derived from a variety of experimental methods.

Prospective study of postoperative lumbar epidural hematoma: incidence and risk factors.

STUDY DESIGN: Prospective clinical series. OBJECTIVE: To determine the incidence, volume, and extent of postoperative epidural hematoma resulting in thecal sac compression, and to identify risk factors correlated with measured hematoma volumes. SUMMARY OF BACKGROUND DATA: Risk factors for postoperative hematoma development have been retrospectively determined in small populations of symptomatic patients. A prospective study of hematoma characteristics and associated risk factors in a consecutive series of patients could significantly enhance our understanding of postoperative hematoma. METHODS: Preoperative magnetic resonance imaging and clinical data on 13 pre- and intraoperative risk factors were prospectively collected on 50 consecutive patients undergoing lumbar decompression surgery with or without fusion. Postoperative magnetic resonance imagings were performed within 2 to 5 days of surgery. Thecal sac cross-sectional area was calculated at each disc space. Relative thecal sac compression due to hematoma was calculated at all levels where postoperative cross-sectional area was smaller than preoperative. Hematoma volumes were calculated. Multivariate analysis identified risk factors associated with postoperative hematoma volume. RESULTS: After decompression, 58% of patients developed epidural hematoma of sufficient magnitude to compress the thecal sac beyond its preoperative state at one or more levels. None developed new postoperative neurologic deficits. A mean of 1.4 levels were decompressed. Hematoma extended over a mean of 1.9 levels. Maximal thecal sac compression due to hematoma occurred at an adjacent, nondecompressed level in 28% of patients. Multivariate analysis found age greater than 60, multilevel procedures, and preoperative international normalized ratio to be associated with larger hematoma volumes. CONCLUSION: Lumbar decompression surgery results in a 58% incidence of asymptomatic compressive postoperative epidural hematoma. Adjacent level compression by hematoma occurs in 28% of patients. Advanced age, multilevel procedures, and international normalized ratio are independently associated with postoperative hematoma volume.

Postoperative lumbar epidural hematoma: does size really matter?

STUDY DESIGN: Prospective clinical series with comparison to retrospectively collected data. OBJECTIVE: To compare direct measures of postoperative hematoma volume against a new measure of hematoma effect on the thecal sac: the critical ratio. SUMMARY OF BACKGROUND DATA: Asymptomatic epidural hematoma is common after lumbar surgery. Symptomatic patients demonstrate a typical progression from sharp peri-incisional pain to bilateral neurologic deficits. Little is known about what differentiates symptomatic and asymptomatic patients. Magnetic resonance imaging (MRI) measures of hematoma size or mass effect may correlate with postoperative symptoms. METHODS: The study population consisted of 3 patient groups evaluated by MRI 2 to 5 days after lumbar decompression with or without fusion. Fifty-seven consecutive prospectively enrolled patients comprised the asymptomatic group. No patient developed severe postoperative pain or neurologic deficit. Search of our institutional database identified 4978 surgical patients within the last 24 months. Seventeen developed new postoperative symptoms. The painful group included 12 patients with severe peri-incisional pain without neurologic deficit. The cauda equina (CE) group included 5 patients with postoperative CE syndrome. Digital imaging software was used to calculate thecal sac cross sectional area on pre- and postoperative MRI at each level, hematoma volume, volume per level decompressed, and critical ratio for each patient. Critical ratio was defined as the smallest ratio of postoperative to preoperative cross sectional area within the lumbar spine. RESULTS.: The critical ratio was the only measure found to differ significantly (P < 0.05) among all 3 groups. Mean critical ratios were asymptomatic (0.8), painful (0.5), and CE (0.2). CONCLUSION: The critical ratio correlates more closely with the presence or absence of postoperative symptoms than measures of hematoma volume, and is consistent with the clinical expectation that greater thecal sac compression may result in more severe symptoms. Few guidelines exist for postoperative lumbar MRI interpretation. The critical ratio is an important contribution.

Degenerative lumbar scoliosis: radiographic correlation of lateral rotatory olisthesis with neural canal dimensions.

STUDY DESIGN: A radiographic review of 78 consecutive patients with degenerative rotatory lumbar scoliosis. OBJECTIVE: To assess the correlation between rotary olisthesis and neural canal dimensions using radiographic indexes and to establish a gradation system of lateral rotatory olisthesis. SUMMARY OF BACKGROUND DATA: Degenerative scoliosis is a three-dimensional deformity often associated with spinal stenosis, although the association is not well defined. METHODS: A total of 78 consecutive patients (average age, 69 years) with de novo degenerative scoliosis (79% lumbar, 21% thoracolumbar; average curve, 25 degrees) were studied with plain radiographs and MRI at presentation. Radiographic measurements included lateral translation, anteroposterior olisthesis, Cobb angle, and intervertebral rotation (Nash-Moe grade difference). Computerized measurements of MRI included dural sac cross-sectional area and anteroposterior diameter, minimum subarticular height, and foramen cross-sectional area bilaterally (convexity and concavity). Measurements were conducted twice on each lumbar level (total, 312) and the average was recorded. RESULTS: Lateral translation 5 mm or less (Grade I) was associated with Nash-Moe change 0 (23%) or I (77%), lateral translation 6-10 mm (Grade II) was coupled with Nash-Moe change 0 (20%) or I (80%) and lateral deviation more than 11 mm (Grade III) was associated with I (76%) or II (24%) Nash-Moe change. Maximum intervertebral rotation tended to be at either L2-L3 (48%) or L3-L4 (39%). Increased lateral translation was associated with increased intervertebral rotation (r = 0.37, P < 0.001). Increased anteroposterior olisthesis was associated with decreased anteroposterior diameter (r = -0.18, P < 0.001) and cross-sectional area (r = -0.11, P < 0.05) of the dural sac. Larger segmental Cobb angles were associated with greater foraminal cross-sectional area in the convexity (r = 0.12, P < 0.05). In the concavity, there was no significant correlation (P > 0.05) between indexes of rotary olisthesis and foraminal area or subarticular height. Cross-sectional foraminal area and subarticular height were significantly larger in the convexity than in the concavity of the scoliotic levels. CONCLUSIONS: In degenerative scoliotic curves, lateral translation is associated with rotation. Increased rotary olisthesis does not lead to decreased dural sac area. Anteroposterior olisthesis is inversely correlated to the dural sac anteroposterior diameter and cross-sectional area. With increased segmental Cobb angle, foraminal cross-sectional area enlarges in the convexity and does not decrease in the concavity. Presence of intervertebral rotation alone does not appear to be associated with reduced neural canal dimensions. Ligamentum flavum hypertrophy, posterior disc bulging, and bony overgrowth are more likely to contribute to stenosis irrespective of scoliosis.

Functional outcome after revision hip arthroplasty: a metaanalysis.

The current study systematically reviews the literature describing patient outcomes after revision total hip arthroplasties using conventional global hip score ratings. Two thousand one hundred thirty-seven English-language articles published from 1966 through 2000 were identified through a computerized literature search and bibliography review. A three-step filter process was used to identify articles to be included in the metaanalysis. Forty-two articles with 2578 patients had data abstracted for the analysis. Metaanalysis of global hip scores was done using a fixed effects model with the assumption that the variances of each measurement were identical across studies. Thirty-nine articles reporting on 46 cohorts progressed through three filters and went to data extraction and analysis. Revision total hip arthroplasty is a reasonably safe and effective procedure for failed hip replacement Based on this exploratory analysis revision hip procedures seem to have comparable longevity, to primary hip replacement but appear to have slightly lower functional outcome (as measured by global hip scores), and slightly higher morbidity and mortality rates than primary procedures. Inconsistent reporting in the original studies limited exploration of other factors that may have affected outcomes.

Functional outcome after total knee arthroplasty revision: a meta-analysis.

The objective of this study was to perform a systematic literature review to describe patient outcome after total knee arthroplasty revision procedures using various global knee score ratings. English language articles published from 1966 through 2000 were identified through a computerized literature search and bibliography review. A multistage assessment was used to determine the articles containing data that could meet our objective. Meta-analyses of global knee scores were undertaken using a fixed effects model with the assumption that the variances of each individual measurement were identical across studies. The initial inclusion criteria were met by 58 articles with a total of 1965 patients. There were 42 articles comprising 45 unique patient cohorts and a total of 1515 patients that had sufficient global knee score data for analysis and were used in the meta-analyses. Revision total knee arthroplasty is an effective procedure for failed knee arthroplasties based on global knee rating scales.