Are Guidelines Important? Results of a Prospective Quality Improvement Lumbar Fusion Project.

BACKGROUND: United States (U.S.) healthcare is a volume-based inefficient delivery system. Value requires the consideration of quality, which is lacking in most healthcare disciplines. OBJECTIVE: To assess whether patients who met specific evidence-based medicine (EBM)-based criteria preoperatively for lumbar fusion would achieve higher rates of achieving the minimal clinical important difference (MCID) than those who did not meet the EBM indications. METHODS: All elective lumbar fusion cases, March 2018 to August 2019, were prospectively evaluated and categorized based on EBM guidelines for surgical indications. The MCID was defined as a reduction of ≥5 points in Oswestry Disability Index (ODI). Multiple logistic regression identified multivariable-adjusted odds ratio of EBM concordance. RESULTS: A total of 325 lumbar fusion patients were entered with 6-mo follow-up data available for 309 patients (95%). The median preoperative ODI score was 24.4 with median 6-mo improvement of 7.0 points (P < .0001). Based on ODI scores, 79.6% (246/309) improved, 3.8% (12/309) had no change, and 16% (51/309) worsened. A total of 191 patients had ODI improvement reaching the MCID. 93.2% (288/309) cases were EBM concordant, while 6.7% (21/309) were not.In multivariate analysis, EBM concordance (P = .0338), lower preoperative ODI (P < .001), lower ASA (American Society of Anesthesiologists) (P = .0056), and primary surgeries (P = .0004) were significantly associated with improved functional outcome. EBM concordance conferred a 3.04 (95% CI 1.10-8.40) times greater odds of achieving MCID in ODI at 6 mo (P = .0322), adjusting for other factors. CONCLUSION: This analysis provides validation of EBM guideline criteria to establish optimal patient outcomes. The EBM concordant patients had a greater than 3 times improved outcome compared to those not meeting EBM fusion criteria.

Posterior tibial vein aneurysm presenting as tarsal tunnel syndrome.

Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve within the tarsal tunnel. Its etiology varies, including space occupying lesions, trauma, inflammation, anatomic deformity, iatrogenic injury, and idiopathic and systemic causes. Herein, we describe a 46-year-old man who presented with left foot pain. Work up revealed a venous aneurysm impinging on the posterior tibial nerve. Following resection of the aneurysm and lysis of the nerve, his symptoms were alleviated. Review of the literature reveals an association between venous disease and tarsal tunnel syndrome; however, this report represents the first case of venous aneurysm causing symptomatic compression of the nerve.

Gremlin is a novel VTA derived neuroprotective factor for dopamine neurons.

Parkinson's disease and its characteristic symptoms are thought to arise from the progressive degeneration of specific midbrain dopamine (DA) neurons. In humans, DA neurons of the substantia nigra (SN) and their projections to the striatum show selective vulnerability, while neighboring DA neurons of the ventral tegmental area (VTA) are relatively spared from degeneration. Recent studies from our laboratory have shown that the VTA exhibits a unique transcriptional response when exposed to MPTP (Phani et al., 2010), a neurotoxin able to mimic the selective cell loss observed in PD (Schneider et al., 1987). In this study, we focus on gremlin, a peptide that is transcriptionally increased in the VTA in response to MPTP. We describe a novel role for gremlin as a neuroprotective agent both in vitro and in vivo and show that gremlin is capable of protecting SN DA neurons and several DA cell lines against MPP+/MPTP. We propose that this protection is mediated by VEGFR2, and by the MAP kinase signaling pathway downstream of the receptor. Our data indicate that gremlin may be a key factor in protecting the VTA against MPTP-induced cell death, and that exogenous application of gremlin is capable of protecting SN DA neurons, and therefore may provide an opportunity for the development of novel PD therapeutic compounds.