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1.
Spine (Phila Pa 1976) ; 26(10): E207-12, 2001 May 15.
Article in English | MEDLINE | ID: mdl-11413440

ABSTRACT

STUDY DESIGN: Prospective randomized comparison of anterior lumbar interbody fusion (ALIF) plus transpedicular instrumentation plus posterolateral fusion (PLF) (360 degrees fusion) to ALIF plus transpedicular instrumentation without PLF (270 degrees fusion). OBJECTIVES: To compare the clinical outcomes, costs, and utilization of health resources of 360 degrees versus 270 degrees fusions. BACKGROUND: The 360 degrees fusion is effective, but its costs and utilization of health resources are high. The PLF often resorbs and may not be necessary. METHODS: Before and after surgery pain was measured by the Numerical Rating Scale (NRS), and function was measured by the Oswestry Low Back Disability Index (OSI). Costs were calculated by billing records. Operating times, blood loss, and hospital stays were measured at the time of hospital discharge. RESULTS: There were 48 patients: 21 women and 27 men. Mean age was 42 years. Follow-up averaged 35 months (range 24-45 months). In both 360 degrees and 270 degrees fusions, there were significant improvements in NRS and OSI, and the percentage of solid ALIF was high. Only 14% of PLF appeared solid bilaterally and 18% appeared solid on one side only. There were no significant differences in changes in NRS, changes in OSI, or percentage solid ALIF between the 360 degrees and 270 degrees fusions. However, the 270 degrees fusion group had significantly less blood loss, shorter operative times, shorter hospital stays, and lower professional fees, and although hospital charges were lower, this difference was not significant. CONCLUSION: Both the 360 degrees and 270 degrees fusions significantly reduce pain and improve function, and there are no significant clinical differences between them. However, there were shorter operating times, less blood loss, lower costs, and less utilization of health care resources associated with the 270 degrees fusions.


Subject(s)
Spinal Diseases/surgery , Spinal Fusion/methods , Adult , Female , Health Care Costs , Health Resources/statistics & numerical data , Humans , Male , Middle Aged , Orthopedic Fixation Devices , Palliative Care , Prospective Studies , Spinal Diseases/physiopathology , Spinal Fusion/economics , Treatment Outcome
2.
Spine (Phila Pa 1976) ; 25(7): 853-7, 2000 Apr 01.
Article in English | MEDLINE | ID: mdl-10751297

ABSTRACT

STUDY DESIGN: A descriptive case review. OBJECTIVES: To assess the outcomes of anterior lumbar interbody fusion for painful discs within a solid posterolateral spinal fusion. SUMMARY OF BACKGROUND DATA: Some patients continue to have pain after posterolateral spinal fusion despite apparently solid arthrodesis. One potential etiology is pain that arises from a disc within the fused levels. METHOD: Retrospective review of 176 patients with anterior interbody fusion, which located 20 who had anterior interbody fusion levels of prior posterolateral spinal fusion. All had low back pain, solid posterolateral spinal fusion, and painful disc(s) at the posterolateral spinal fusion level(s) but not elsewhere. Pain was measured by the Numerical Rating Scale, function by Oswestry Disability Questionnaire, and patient satisfaction by the North American Spine Society Outcome Questionnaire. RESULTS: Follow-up data were available for 18 patients (90%). Mean follow-up was 58 months (25 to 102). There were 10 men and 8 women. Mean age was 45 years (26 to 72). Diagnoses were degenerative discs, herniated nucleus pulposus, spondylolisthesis, and spinal stenosis. Eight patients had injuries after the previous posterolateral spinal fusion that precipitated new symptoms. Two patients had one level fusion, 14 had two levels, and 1 each had three and four levels. Four patients had one prior surgery, 5 had two, and 9 had three or more. All patients had solid anterior interbody fusion by radiograph. Mean Numerical Rating Scale improved from 7.9 before surgery to 4.7 after (P< 0.001). Mean Oswestry Disability Questionnaire improved from 56.3 before surgery to 47.9 after (P = 0.04). Of 15 patients unable to work before anterior interbody fusion, 5 returned to work. Sixteen patients (89%) were satisfied with their results. CONCLUSION: Low back pain that continues or recurs after apparently solid posterolateral spinal fusion may be caused by painful disc(s) at motion segment(s) within the fusion. A solid posterolateral spinal fusion may not protect the residual disc(s) from injury. Anterior interbody fusion can provide significant improvements in pain and function and a high degree of patient satisfaction in this clinical setting.


Subject(s)
Intervertebral Disc Displacement/surgery , Lumbar Vertebrae/surgery , Spinal Fusion , Disability Evaluation , Female , Follow-Up Studies , Humans , Intervertebral Disc Displacement/physiopathology , Male , Middle Aged , Pain Measurement , Patient Satisfaction , Recurrence , Reoperation , Retrospective Studies , Time Factors
3.
Spine (Phila Pa 1976) ; 25(6): 722-6, 2000 Mar 15.
Article in English | MEDLINE | ID: mdl-10752105

ABSTRACT

STUDY DESIGN: A review of 141 consecutive patients who underwent instrumented circumferential lumbar fusions. Outcome was assessed by an independent third party after a minimum follow-up of 2 years. OBJECTIVES: To evaluate clinical outcomes and assess patient satisfaction with circumferential lumbar fusions. SUMMARY OF BACKGROUND DATA: Circumferential lumbar fusion has been used as a salvage procedure for revision spine surgery. METHODS: Data were collected from patient interviews, patient satisfaction questionnaire, and review of records and radiographs of 141 consecutive patients who underwent circumferential lumbar fusion under a single anesthetic. RESULTS: There were follow-up data in 133 of the 141 patients (92%). Mean duration of follow-up was 37.2 months. There were 41 (31%) primary and 92 (69%) revision surgeries. There were 73 (55%) workers' compensation and 60 (45%) non-workers' compensation patients. There were radiographs available at 12-month follow-up in 86 patients (65%). There was solid radiographic fusion in 85 (99%) of the 86 patients. The overall complication rate was 20%. Clinical outcome was determined by the patient satisfaction questionnaire. There were 14 (11%) who chose the statement, "surgery met my expectations"; 68 (51%) who chose, "surgery improved my condition enough that I would go through it again for the same outcome"; 26 (20%) who chose, "surgery helped me but I would not go through it again for the same outcome"; and 25 (19%) who chose, "I am the same or worse compared with before surgery." There was no statistical difference in patient satisfaction between primary and revision surgeries or between workers' compensation versus non-workers' compensation groups. CONCLUSIONS: Circumferential lumbar fusion is a useful procedure for a patient with difficult reconstructive disease. There is a very high fusion rate. Overall, 62% of patients are satisfied with the result, especially those with a diagnosis of pseudarthrosis or spondylolisthesis with stenosis. Patients who are working before surgery and patients who are not injured workers also tended to progress well.


Subject(s)
Low Back Pain/surgery , Lumbar Vertebrae , Patient Satisfaction , Spinal Fusion/methods , Adult , Chi-Square Distribution , Female , Humans , Interviews as Topic , Male , Middle Aged , Surveys and Questionnaires , Treatment Outcome
4.
Spine (Phila Pa 1976) ; 24(21): 2224-8, 1999 Nov 01.
Article in English | MEDLINE | ID: mdl-10562988

ABSTRACT

STUDY DESIGN: Data were collected prospectively on 38 patients who underwent anterior cervical discectomy and fusion for neck pain with no symptoms or signs of radiculopathy or myelopathy. OBJECTIVES: To determine the changes in pain and function after anterior cervical discectomy and fusion for nonradicular neck pain. SUMMARY OF BACKGROUND DATA: There is considerable controversy regarding the role of anterior cervical discectomy and fusion for neck pain in the absence of radiculopathy or myelopathy. Although no studies have addressed this specific and common problem, it is known that anterior cervical discectomy and fusion for radiculopathy or myelopathy may also provide relief of neck pain for many patients. METHODS: Thirty-eight patients who underwent anterior cervical discectomy and fusion for neck pain were evaluated. Before and after surgery, the authors measured pain with a numerical rating scale, function with the Oswestry Disability Questionnaire, and final patient satisfaction. Final evaluation was done by a disinterested third party. RESULTS: All 38 patients were available for follow-up study. Mean age was 42.4 years, and mean duration of follow-up study was 53 months. All patients had painful disc(s) proven by discography. No patients had nerve root compression. Anterior cervical discectomy and fusion was performed at one level in 21 patients, two levels in 16 patients, and three levels in one patient. The mean score on the numerical rating scale for neck pain before surgery was 8.3 (range, 3-10) versus 4.1 (range, 0-10) after surgery. This difference is significant (P < 0.001). The mean score on the Oswestry Disability Questionnaire was 57.5 (range, 0-89) before surgery versus 38.9 (range, 0-80) after surgery. This difference is significant (P < 0.001). There were 30 (79%) patients who were satisfied with their outcome, and 8 (21%) who were not satisfied. There was no statistical difference in change of pain or function between patients with worker's compensation and those with other insurance or between men and women. Twenty patients were not working because of neck pain before surgery, and 15 were not working at the time of follow-up examination. CONCLUSION: A significant decrease in pain, a significant increase in function, and a high degree of patient satisfaction were found with anterior cervical discectomy and fusion for neck pain. Improvements were not affected by worker's compensation status or gender.


Subject(s)
Cervical Vertebrae/surgery , Diskectomy/methods , Intervertebral Disc/surgery , Neck Pain/physiopathology , Neck Pain/surgery , Spinal Fusion/methods , Adult , Female , Humans , Male , Middle Aged , Pain Measurement , Prospective Studies , Surveys and Questionnaires
5.
Spine (Phila Pa 1976) ; 17(6 Suppl): S176-83, 1992 Jun.
Article in English | MEDLINE | ID: mdl-1631715

ABSTRACT

Prolonged structural compromise of spinal nerve roots can lead to chronic changes that surgical decompression might not be able to reverse. In this study, it was hypothesized that if there were a reversible structural pain component, a steroid injected into the patient's symptomatic nerve root should provide temporary pain relief and that these patients should have a favorable surgical outcome. It also was hypothesized that duration of radicular symptoms would correlate inversely with surgical outcome. For postoperative relief of radicular pain, the results showed that patients with pain lasting less than 1 year had a positive surgical result (89%), regardless of response to steroid. Patients with pain lasting more than 1 year and who have had a positive response to steroid injected into the symptomatic nerve root (roots) had a positive surgical outcome of 85%. Patients who did not respond to the steroid and had pain for more than 1 year (95%) generally had a poor surgical outcome. Although the poor outcome in the last group might be explained in some cases by an inadequate structural correction, inadequate stabilization, or functional reasons, the majority of these failures represented irreversible changes in the neural structures.


Subject(s)
Betamethasone/analogs & derivatives , Nerve Compression Syndromes/surgery , Radiculopathy/drug therapy , Spinal Fusion , Betamethasone/therapeutic use , Delayed-Action Preparations , Humans , Lidocaine/therapeutic use , Nerve Compression Syndromes/complications , Nerve Compression Syndromes/epidemiology , Predictive Value of Tests , Radiculopathy/epidemiology , Radiculopathy/etiology , Sensitivity and Specificity , Spinal Nerve Roots/drug effects , Treatment Outcome
6.
Spine (Phila Pa 1976) ; 16(3): 356-8, 1991 Mar.
Article in English | MEDLINE | ID: mdl-2028309

ABSTRACT

Between February 1985 and October 1987, the authors identified seven patients with occult lumbar spine infections associated with the presence of spinal fixation hardware. Six of these infections were with organisms of low virulence; four of the seven patients had polymicrobial infections. All of the polymicrobial infections contained a Diptheroid as one of the isolates. Two of the seven patients studied had normal sedimentation rates. All had white blood cell counts less than 12,000 cells. Imaging studies were not helpful with the exception of one case with a positive gallium scan. The diagnoses were supported by clinical presentation, pathologic tissue changes, positive cultures, and response to therapy. Successful therapy was obtained by removal of hardware and treatment with antibiotics.


Subject(s)
Corynebacterium Infections/diagnosis , Internal Fixators , Lumbar Vertebrae/surgery , Spinal Fusion , Staphylococcal Infections/diagnosis , Surgical Wound Infection/microbiology , Anti-Bacterial Agents , Corynebacterium Infections/drug therapy , Drug Therapy, Combination/therapeutic use , Humans , Staphylococcal Infections/drug therapy , Staphylococcus epidermidis/isolation & purification , Surgical Wound Infection/drug therapy
7.
Spine (Phila Pa 1976) ; 15(7): 674-8, 1990 Jul.
Article in English | MEDLINE | ID: mdl-2218714

ABSTRACT

Inflammation of neural elements is frequently mentioned clinically in association with lumbar radiculopathy. Mechanical embarrassment of neural elements by definable structural abnormalities is inadequate as a sole explanation of nerve injury in this condition. The purpose of this study was to demonstrate whether an enzymatic marker for inflammation (phospholipase A2) could be identified in human disc samples removed at surgery for radiculopathy due to lumbar disc disease. Samples were assayed for phospholipase A2 activity. The level of activity in the disc samples was compared with values obtained from other human tissues using the same assay. Specific activity (percent hydrolysis radiolabelled substrate) ranged from 238 to 1,014.5 nmol/min/mg. Mean activity for the human disc material was 568.7 nmol/min/mg, compared with 0.006 nmol/min/mg for human PMN, and 12.1 nmol/min/mg for inflammatory human synovial effusion. The pH and cation-related activity were identical to those demonstrated for phospholipase A2 inflammatory conditions. Human lumbar disc phospholipase A2 activity is from 20- to 100,000-fold more active than any other phospholipase A2 that has been described. As the enzyme responsible for the liberation of arachidonic acid from cell membranes, phospholipase A2 is the rate-limiting step in the production of prostaglandins and leukotrienes. These data establish biochemical evidence of inflammation at the site of lumbar disc herniations.


Subject(s)
Intervertebral Disc Displacement/enzymology , Intervertebral Disc/enzymology , Lumbar Vertebrae , Phospholipases A/analysis , Biomarkers , Humans , Hydrogen-Ion Concentration , Intervertebral Disc Displacement/complications , Phospholipases A2 , Radiculopathy/etiology
8.
Spine (Phila Pa 1976) ; 14(4): 417-9, 1989 Apr.
Article in English | MEDLINE | ID: mdl-2524111

ABSTRACT

Occult infections caused by indolent organisms may produce persistent back pain that may be difficult to diagnose. The usual findings considered indicative of spinal infection are not reliable in these cases. The authors describe nine patients who presented with occult infections of the lumbar spine. Two of the nine had no antecedent lumbar surgeries nor open wounds. The predominant organisms were diptheroids and coagulase-negative staphylococci. The diagnosis was established by the clinical course, pathologic tissue changes at surgery, cultures, and response to antibiotic therapy. Normal Westergren sedimentation rates were noted in seven of nine patients, and normal white blood cell counts in six of nine patients. With the exception of two positive computed tomography (CT) scans, one positive gallium scan, and one positive magnetic resonance imaging (MRI) scan, all remaining imaging studies were negative for infection. In many cases, the infection neither was limited to nor involved the disc space.


Subject(s)
Abscess/complications , Back Pain/etiology , Discitis/complications , Lumbar Vertebrae , Staphylococcal Infections/complications , Surgical Wound Infection/complications , Humans , Laminectomy , Time Factors
9.
Spine (Phila Pa 1976) ; 13(12): 1355-9, 1988 Dec.
Article in English | MEDLINE | ID: mdl-2975063

ABSTRACT

In degenerative lumbar spine disease, recent studies have supported the clinical usefulness of discography, especially when used with computed tomography (CT) scanning. The role and capabilities of magnetic resonance imaging (MRI) scanning are currently evolving and being defined. This study reviews a series of patients with prolonged disabling symptoms who had normal MRI scans and abnormal discography. Discograms and discogram-CT scans may at times allow detection of clinically correlative and significant pathology (usually annular disruptions) not suggested by MRI scanning. This fact should be considered in patients with normal MRI scanning and continuing unexplained symptomatology.


Subject(s)
Intervertebral Disc/pathology , Magnetic Resonance Imaging , Adult , Back Pain/diagnosis , Back Pain/diagnostic imaging , Contrast Media/administration & dosage , Female , Humans , Injections, Spinal , Intervertebral Disc/diagnostic imaging , Male , Middle Aged , Pain Measurement , Tomography, X-Ray Computed
10.
Spine (Phila Pa 1976) ; 13(1): 76-8, 1988 Jan.
Article in English | MEDLINE | ID: mdl-2967995

ABSTRACT

Of the 692 discs injected during lumbar discograms, end-plate disruptions with leakage of contrast material into the vertebral bodies were noted in 14 discs. Although gentle pressure was applied during the injections, severe fully concordant pain was reproduced in four (28.3%) discs, moderately severe and fully concordant pain in nine (64.3%) discs, and mild discordant pain in one (7.4%) disc. This is compared to 11.2% of the remaining 678 discs without end-plate disruption that reproduced severe concordant pain, 31.1% with moderately severe concordant pain, 17.1% with mild pain, and 40.6% without any pain reproduction. The difference between pain frequency in discs with end-plate disruption and those without is statistically significant (P less than .001). This suggests that end-plate disruptions may be related to painful segments.


Subject(s)
Back Pain/etiology , Intervertebral Disc Displacement/diagnostic imaging , Adolescent , Adult , Aged , Female , Humans , Intervertebral Disc Displacement/complications , Male , Middle Aged , Radiography
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