Modified technique of transforaminal lumbar interbody fusion for segmental correction of lumbar kyphosis: a safe alternative to osteotomies?

BACKGROUND: Sagittal rebalancing of a fixated lumbar hypolordosis (kyphosis) is very important to gain satisfactory results. To correct a misalignment vertebral column resection or pedicle subtraction osteotomies are favored, disregarding the relatively high complication rates. The aim of this study was to evaluate the efficiency and safety of a new modified transforaminal lumbar fusion technique as an alternative. METHODS: We conducted a retrospective review (06/2011-06/2015 ) of a prospective database at an University hospital. Inclusion criteria were adult patients with a fixated lumbar hypolordosis and the need of monosegmental correction of more than 10° with an mTLIF. Exclusion criteria consisted of minor aged patients and polysegmental corrections. Study parameters were the perioperative complications and the achieved postsurgical lordosis. The follow up period was 6 months. RESULTS: A total of 11 patients could be included. The mean segmental lordosis was -2.3° ± 12.4° (range -22° to 14°) preoperative and 15.5° ± 10.5° (range 0° to 29°) postoperative. The degree of correction was 17° ± 5.7° in mean per treated segment (range 12° to 29°). No neurologic or vascular complications occurred. No substantial loss of correction or implant failure was noted during the 6-month follow-up. CONCLUSION: The modified transforaminal lumbar fusion technique is a safe method to correct a fixated lumbar kyphosis. The potential of segmental correction is comparable to pedicle subtraction osteotomies but sparing potentially healthy segments.

Is pelvic fixation the only option to provide additional stability to the sacral anchorage in long lumbar instrumentation? A comparative biomechanical study of new techniques.

BACKGROUND: Supplementary iliac screws have the highest potential to protect S1-pedicle-screws from loosening in long fusion constructs. However, this technique bridges the iliosacral joint with potential disadvantages for the patient. This study aimed to evaluate if two different established fixation techniques can be used in addition to pedicle screws as alternative to iliac screws, and if these two techniques can provide similar stability when S1-pedicle-screws are loosened. METHODS: Flexibility testing with pure moments of 7.5Nm was performed with six human osteopenic/osteoporotic L4-pelvis specimens. The following conditions were investigated: 1. Intact; 2. Destabilization L5/S1; 3. Fixation with rigid L4-S1 pedicle-screw-system; 4. Condition 3- loosening of S1-screws; 5. Condition 4- L5-S2-lamina-hooks; 6. Condition 4- L5/S1-translaminar-screws; 7. Condition 4- S2-ala-ilium screws. FINDINGS: Application of compressive L5-S2-lamina-hooks or L5/S1-translaminar-screws next to pedicle screws in L5 and S1 was feasible in all specimens. L4-S1-pedicle-screw-instrumentation reduced the Range of Motion significantly compared to the destabilized condition. After simulation of S1 screw loosening, lamina hooks only reduced the Range of Motion in flexion/extension significantly. L5/S1-translaminar-screws had a higher stabilizing effect in lateral bending and axial rotation, but the effect of both systems was smaller than with an instrumentation extension to the os ilium. INTERPRETATION: In long lumbar pedicle screw instrumentations including L5/S1, additional ilium screws have the highest potential to protect the S1-anchorage. Additional L5/S1-translaminar-screws can increase stability of the lumbosacral junction without bridging the iliosacral joint, whereas lamina hooks showed no significant biomechanical benefit.

A survey on patients' knowledge and expectations during informed consent for spinal surgery: can we improve the shared decision-making process?

BACKGROUND: The informed medical consent in surgery requires to some point basic medical knowledge. The treating physicians while explaining the details and risks of the recommended procedure often imply this. We hypothesized, that patients do not have adequate medical understanding to decide about the ongoing therapy and its potential complications based on knowledge jeopardizing the patients' safety. METHODS: We conducted a retrospective analysis of a prospective database using a multiple choice questionnaire with 10 basic questions about anatomy, clinical symptoms and therapies of spinal diseases in our spine clinic at a German university hospital. Included were all patients at the spine clinic who agreed to the study and to fill in the questionnaire. Furthermore the patients age, mother tongue, the past spinal surgical history, the length of duration of symptoms and the patients education were inquired. The data were analyzed descriptive. RESULTS: Included were 248 patients with an average age of 59 years (16-88 a). 70 % of all patients used German as their mother tongue. 30 % of the included patients already had spinal surgery and suffered on average for 13.4 years because of their spinal disorder. Overall 32.6 % of all questions were answered correctly (range 0.8-68 %). A correlation of correctly answered questions and the patients' age, duration of symptoms, mother tongue, education and past surgical history could not be described. CONCLUSION: The percentage of correctly answered questions is almost as low as the likelihood of nearness in guessing. Having this in mind the patients do not choose any treatment option based on knowledge. The physicians need to provide more basic knowledge to the patients. This would increase the amount of successful therapies, content patients and the patients safety.

Treatment of Early-Onset Spinal Deformity (EOSD) With VEPTR: A Challenge for the Final Correction Spondylodesis-A Case Series.

STUDY DESIGN: Case Series. OBJECTIVE: To describe the post-VEPTR (vertical expandable prosthetic titanium rib) treatment changes in early-onset spinal deformity (EOSD), which may influence the final correction spondylodesis. SUMMARY OF BACKGROUND DATA: The VEPTR device, originally developed for the treatment of congenital rib cage malformation, is nowadays more widely used in the treatment of EOSD. At present, only a few reports describe the possible complications that may occur with repeated lengthening procedures of the VEPTR, thereby making the final spondylodesis more complicated and less satisfactory. METHODS: X-rays of 5 children treated for EOSD with 2 unilateral VEPTR (each rib to rib and rib to lumbar lamina) were analyzed for curve patterns and Cobb angles before, during, and at the end of VEPTR treatment, and after the final spondylodesis. Intraoperative observations during the spondylodesis, which influenced the possibilities of the curve correction, were documented. RESULTS: All patients showed a marked decompensation of the frontal balance and a high degree of rigidity of the main curve and the compensatory curves after treatment with the VEPTR device. Because of this spontaneous autofusion of spinal segments, migration of the rib cradles and/or the laminar hook, and a change in the curve patterns, the final fusion had to be longer in all patients than the primary deformity would have intended. CONCLUSIONS: If an EOSD is treated with VEPTR, the curve progression and, in particular, the development of a high thoracic hyperkyphosis or rotation of the main curve should be critically observed. Autofusion of ribs and vertebral bodies may make the final correction spondylodesis even more challenging and risky for the patient and the end result less satisfactory.

Lumbar facet joint effusion on MRI as a sign of unstable degenerative spondylolisthesis: should it influence the treatment decision?

STUDY DESIGN: Retrospective study. OBJECTIVE: To examine whether the outcomes of decompression alone (D) or decompression with fusion (D&F) differed depending on the presence or absence of the facet effusion sign in degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: There is ongoing discussion as to whether D&F is superior to D in the surgical treatment of patients with lumbar degenerative spondylolisthesis (LDS) and symptoms of spinal or radicular claudication. Previous studies have shown that a positive facet joint effusion sign on magnetic resonance imaging correlates with the spontaneous reduction of slip when comparing upright and supine postures and might represent a sign of instability, guiding treatment decisions. PATIENTS AND METHODS: One hundred sixty patients [age 69 (SD 10) y; 119 women, 41 men] with a diagnosis of LDS were identified retrospectively from our Spine Center Registry (linked to the Eurospine, Spine Society of Europe Spine Tango Registry). They were categorized based on the presence/absence of the facet effusion sign and the type of treatment received. Forty-four patients had effusion and underwent D; 76 effusion and D&F; 19 no effusion and D; and 21 no effusion and D&F. Before surgery and 3, 12, and 24 months after surgery, patients completed the multidimensional Core Outcome Measures Index questionnaire. At follow-up, they rated the global treatment outcomes (1-5 scale). Multiple regression analyses evaluated the factors influencing the outcomes. RESULTS: When age and sex was controlled for, there was no significant difference in outcomes dependent on the presence of the facet effusion sign and/or the treatment received (D vs. D&F). CONCLUSIONS: Although mindful of the limitations of this retrospective study, we conclude that the effusion sign alone does not seem to be an indication for adding fusion to decompression in the treatment of LDS. Hence, the presence of the facet effusion sign should not, in itself, deter the surgeon from performing decompression alone. However, the phenomenon should be investigated in larger samples of patients, ideally within a randomized trial.

The assessment of complications after spine surgery: time for a paradigm shift?

BACKGROUND CONTEXT: Recent years have witnessed a shift in the assessment of spine surgical outcomes with a greater focus on the patient's perspective. However, this approach has not been widely extended to the assessment of complications. PURPOSE: The present study sought to quantify the patient-rated impact/severity of complications of spine surgery and directly compare the incidences of surgeon-rated and patient-reported complications. STUDY DESIGN: Prospective study of patients undergoing surgery for painful degenerative lumbar disorders, being operated in the Spine Center of an orthopedic hospital. PATIENT SAMPLE: A total of 2,303 patients (mean [standard deviation] age, 61.9 [15.1] years; 1,136 [49.3%] women and 1,167 [50.7%] men). PATIENTS: Core Outcome Measures Index, self-rated complications, bothersomeness of complications, global treatment outcome, and satisfaction. Surgeons: Spine Tango surgery and follow-up documentation forms registering surgical details and complications. METHODS: PATIENTS completed questionnaires before and 3 months after surgery. Surgeons documented complications before discharge and at the first postoperative follow-up, 6 to 12 weeks after surgery. RESULTS: In total, 615 out of 2,303 (27%) patients reported complications, with "bothersomeness" ratings of 1%, not at all; 22%, slightly; 26%, moderately; 34%, very; and 17%, extremely bothersome. PATIENTS most commonly reported sensory disturbances (35% of those reporting a complication) or ongoing/new pain (27%) followed by wound healing problems (11%) and motor disturbances (8%). The surgeons documented complications in 19% of patients. There was a minimal overlap regarding the presence or absence of complications in any given patient. CONCLUSIONS: Most complications reported by the patient are perceived to be at least moderately bothersome and are, hence, not inconsequential. Surgeons reported lower complication rates than the patients did, and there was only moderate agreement between the ratings of the two. As with treatment outcome, complications and their severity should be assessed from both the patient's and the surgeon's perspectives.

Prevalence of sleep deprivation in patients with chronic neck and back pain: a retrospective evaluation of 1016 patients.

BACKGROUND: Chronic low back pain (CLBP) and chronic neck pain (CNP) have become a serious medical and socioeconomic problem in recent decades. Patients suffering from chronic pain seem to have a higher prevalence of sleep disorders. PURPOSE: To calculate the prevalence of sleep deprivation in patients with CLBP and CNP and to evaluate the factors that may contribute to sleep impairment. METHODS: This study was a retrospective evaluation of 1016 patients with CNP and CLBP who consulted an orthopedic department at a university hospital. Factors assessed were gender, age, diagnosis, grade of sleep deprivation, pain intensity, chronification grade, and migrational background. Pearson's chi-squared test was performed to calculate the relationship between these factors and the grade of sleep deprivation. Regression analysis was performed to explore the correlation between the grade of sleep deprivation and age, pain intensity, and chronification grade. RESULTS: A high prevalence of sleep deprivation (42.22%) was calculated in patients with CNP and CLBP, even when analgesics had been taken. About 19.88% of the patients reported serious sleep impairments (ie, <4 hours of sleep per night). The grade of sleep deprivation did not correlate with the gender or age distribution. A significant relationship was found between the grade of sleep deprivation and pain intensity, failed back surgery syndrome, and patients with a migrational background. There was a moderate relationship with intervertebral disc disease and no relationship with spinal stenosis. CONCLUSION: Sleep disturbance should be assessed when treating patients with CNP or CLBP, especially in patients with higher pain intensity, failed back surgery syndrome, and a migrational background. Further research is needed to explore the complex relationship of sleep disturbance and chronic pain.

A comparison of patient and surgeon preoperative expectations of spinal surgery.

STUDY DESIGN: Cross-sectional study of agreement between patients' and surgeons' expectations of the outcome of spinal surgery. OBJECTIVE: Patients' satisfaction after spinal surgery depends, in part, on whether their expectations of surgery are fulfilled. Whether the patient always fully understands the key messages conveyed by the surgeon, to formulate realistic expectations, is not known. This study evaluates the level of agreement in expectations declared preoperatively by the patient and the surgeon. SUMMARY OF BACKGROUND DATA: Previous studies have investigated the importance of realistic expectations for the patients' satisfaction with surgical treatments, but there is still a need for a more detailed analysis in the field of spinal surgery. METHODS: The study included 225 German-speaking patients (92 men and 133 women; mean ± SD [range] age, 62 ± 15 [15-90] yr) and their treating spinal surgeons (N = 7). Following the preoperative informed consent consultation, the patient and the surgeon independently completed a questionnaire about baseline neurological status and realistic expectations regarding various patient-orientated outcomes (axial pain (back/neck), radiating pain (leg/arm), pain medication usage, sensory and motor function, and the ability to work, do household activities, and play sports). Concordance was given by percent agreement and κ coefficients. RESULTS: Agreement between the patient and the surgeon about the existence of spine-related neurological deficits occurred in 75% (sensory) and 61% (motor) cases. The patient but not the surgeon reported a sensory deficit in 20% cases and motor deficit in 35% cases; for 4% to 5% cases, the physician reported such a deficit that the patient was seemingly unaware of. The patients consistently had higher expectations than the surgeons, especially for back or neck pain and function (work, household activities, and sports); weighted κ values for agreement were low, ranging from 0.097 to 0.222. CONCLUSION: The findings demonstrate wide discrepancies between the patient and the surgeon regarding the expected result of surgery. They highlight the need for clearer explanations of the association between the spinal problem and neurological deficits and the improvement that can be expected in pain and function after surgery. Systematic, routine evaluation of outcomes should assist in deriving the information necessary to document the improvement achieved and to formulate realistic expectations of surgery.

Radiation dose reduction in CT-guided sacroiliac joint injections to levels of pulsed fluoroscopy: a comparative study with technical considerations.

BACKGROUND: The sacroiliac (SI) joint is frequently the primary source of low back pain. Over the past decades, a number of different SI injection techniques have been used in its diagnosis and therapy. Despite the concerns regarding exposure to radiation, image-guided injection techniques are the preferred method to achieve safe and precise intra-articular needle placement. The following study presents a comparison of radiation doses, calculated for fluoroscopy and CT-guided SI joint injections in standard and low-dose protocol and presents the technical possibility of CT-guidance with maximum radiation dose reduction to levels of fluoroscopic-guidance for a precise intra-articular injection technique. OBJECTIVE: To evaluate the possibility of dose reduction in CT-guided sacroiliac joint injections to pulsed-fluoroscopy-guidance levels and to compare the doses of pulsed-fluoroscopy-, CT-guidance, and low-dose CT-guidance for intra-articular SI joint injections. STUDY DESIGN: Comparative study with technical considerations. METHODS: A total of 30 CT-guided intra-articular SI joint injections were performed in January 2012 in a developed low-dose mode and the radiation doses were calculated. They were compared to 30 pulsed-fluoroscopy-guided SI joint injections, which were performed in the month before, and to five injections, performed in standard CT-guided biopsy mode for spinal interventions. The statistical significance was calculated with the SPSS software using the Mann-Whitney U-Test. Technical details and anatomical considerations were provided. RESULTS: A significant dose reduction of average 94.01% was achieved using the low-dose protocol for CT-guided SI joint injections. The radiation dose could be approximated to pulsed-fluoroscopy- guidance levels. CONCLUSION: Radiation dose of CT-guided SI joint injections can be decreased to levels of pulsed fluoroscopy with a precise intra-articular needle placement using the low-dose protocol. The technique is simple to perform, fast, and reproducible.

Effective Dose of CT-Guided Epidural and Periradicular Injections of the Lumbar Spine: A Retrospective Study.

Spinal injection procedures can be performed blindly or, more accurately, with fluoroscopic or computed tomography (CT) guidance. Radiographic guidance for selective nerve root blocks and epidural injections allows an accurate needle placement, reduces the procedure time and is more secure for the patient, especially in patients with marked degenerative changes and scoliosis, resulting in a narrowing of the interlaminar space. Limiting factors remain the availability of scanners and the radiation dose. Interventional CT scan protocols in axial CT-acquisition mode for epidural and periradicular injections help to limit the radiation dose without a significant decrease of image quality. The purpose of this retrospective study was to analyze the effective radiation dosage patients are exposed during CT-guided epidural lumbar and periradicular injections. A total amount of n=1870 datasets from 18 months were analyzed after multiplying the dose length product with conversion factor k for each lumbar segment. For lumbar epidural injections (n=1286), a mean effective dose of 1.34 mSv (CI 95%, 1.30-1.38), for periradicular injections (n=584) a mean effective dose of 1.38 mSv (CI 95%, 1.32-1.44) were calculated.

Does the diagnosis influence the outcome in a multimodal outpatient pain management program for low back pain and sciatica? A comparative study.

The literature describes multimodal pain-management programs as successful therapy options in the conservative treatment of chronic low back pain. Yet, the intensity and inclusion criteria of such programs remain debatable. In many studies, the pain originating from spinal structures is described as nonspecific low back pain - a diffuse diagnosis without serious implications. The purpose of this study is to compare the short-term outcomes between patients suffering from sciatica due to a discus intervertebralis herniation and those suffering from low back pain caused by facet joint disease after 3 weeks of treatment in an intense multimodal outpatient program in the Department of Orthopaedic Surgery at the university hospital.

Radiation dose reduction in CT-guided periradicular injections in lumbar spine: Feasibility of a new institutional protocol for improved patient safety.

BACKGROUND: Image guided spinal injections are successfully used in the management of low back pain and sciatica. The main benefit of CT-guided injections is the safe, fast and precise needle placement, but the radiation exposure remains a serious concern. The purpose of the study was to test a new institutional low-dose protocol for CT-guided periradicular injections in lumbar spine to reduce radiation exposure while increasing accuracy and safety for the patients. METHODS: We performed a retrospective analysis of a prospective database during a 4-month period (Oct-Dec 2011) at a German University hospital using a newly established low-dose-CT-protocol for periradicular injections in patients suffering from lumbar disc herniation and nerve root entrapment. Inclusion criteria were acute or chronic nerve root irritation due to lumbar disc hernia, age over 18, compliance and informed consent. Excluded were patients suffering from severe obesity (BMI > 30), coagulopathy, allergy to injected substances, infection and non-compliant patients. Outcome parameters consisted of the measured dose length product (mGycm2), the amount of scans, age, gender, BMI and the peri-interventional complications. The results were compared to 50 patients, treated in the standard-interventional CT-protocol for spinal injections, performed in June-Oct 2011, who met the above mentioned inclusion criteria. RESULTS: A total amount of 100 patients were enrolled in the study. A significant radiation dose reduction (average 85.31%) was achieved using the institutional low-dose protocol compared to standard intervention mode in CT-guided periradicular injections in lumbar spine. Using the low-dose protocol did not increase the complications rate in the analyzed cohort. CONCLUSIONS: Low-dose-CT-protocols for lumbar perineural injections significantly reduce the exposure to radiation of non-obese patients without an increase of complications. This increases long-time patient safety of stochastic radiation effects.

Intensive interdisciplinary outpatient pain management program for chronic back pain: a pilot study.

BACKGROUND: Chronic back pain is relatively resistant to unimodal therapy regimes. The aim of this study was to introduce and evaluate the short-term outcome of a three-week intensive multidisciplinary outpatient program for patients with back pain and sciatica, measured according to decrease of functional impairment and pain. METHODS: The program was designed for patients suffering from chronic back pain to provide intensive interdisciplinary therapy in an outpatient setting, consisting of interventional injection techniques, medication, exercise therapy, back education, ergotherapy, traction, massage therapy, medical training, transcutaneous electrical nerve stimulation, aquatraining, and relaxation. RESULTS: Based on Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) scores, a significant improvement in pain intensity and functionality of 66.83% NRS and an ODI of 33.33% were achieved by our pain program within 3 weeks. CONCLUSION: This paper describes the organization and short-term outcome of an intensive multidisciplinary program for chronic back pain on an outpatient basis provided by our orthopedic department, with clinically significant results.

Effective radiation dose reduction in computed tomography-guided spinal injections: a prospective, comparative study with technical considerations.

Despite the good general patient acceptance, high patient comfort, safety and precision in the needle placement, exposure to radiation in computed tomography (CT)-guided spinal interventions remains a serious concern, and is often used to argue against its use. The aim of this study was to determine the technical possibilities of reducing the radiation dose in CT-guided epidural and periradicular injections in lumbar spine. We evaluated the possibilities of reducing radiation dose to the patient and operator during CT-guided injections on the lumbar spine using the following steps: significant reduction of the tube current and energy used for the topogram-acquisition, narrowing the area of interest in spiral CT-mode and reduction of tube current and radiation energy in the final intervention mode. Fifty-three CT-guided spinal injections were performed in the lumbar spine (34 epidural lumbar, 19 lumbar periradicular) using a low-dose protocol in non-obese patients and compared with 1870 CT-guided injections from the year 2010, when a standard dose protocol was used. Technical considerations on radiation dose reduction were provided. An average dose reduction of 85% was achieved using the low-dose protocol in CT-guided epidural and periradicular injections in lumbar spine without showing any effect on safety or precision.

Lumbar facet joint effusion in MRI: a sign of instability in degenerative spondylolisthesis?

PURPOSE: The term "segmental instability" of the lumbar spine is not clearly defined, especially as it relates to degenerative spondylolisthesis (DS) and rotational translation (RT). We investigated whether facet joint effusion on conventional supine MRI indicated increased abnormal motion in DS and RT. METHODS: 160 patients (119 female, 41 male, mean age 68.8 years, range 38.8-89.3 years) who had undergone decompression only or decompression with instrumented fusion for degenerative spondylolisthesis with different degrees of narrowing of the spinal canal were identified retrospectively from our spine surgery database. All had preoperative upright X-rays in AP and lateral views as well as supine MRI. The imaging studies were assessed for the following parameters: percent of slippage, absolute value of facet joint effusion, facet angles, degree of facet degeneration and spinal canal central narrowing, disc height, presence of facet cysts and the presence of rotational translation in the AP X-ray. RESULTS: 40/160 patients showed no facet joint effusion, and in these the difference in the values for the % slip on upright X-ray and % slip on supine MRI was ≤3%. A further 12 patients also showed a difference ≤3%, but had some fluid in the joints (0.44 ± 0.38 mm). In 108 patients, the difference in the % slip measured on X-ray and on MRI was >3% (mean 10.6%, range 4-29%) and was associated with a mean facet effusion size of 2.15 ± 0.85 mm. The extent of effusion correlated significantly with the relative slippage difference between standing and supine positions (r = 0.64, p < 0.001), and the extent of the left/right difference in effusion was associated with the presence of rotational translation (RT 1.31 ± 0.8 mm vs. no-RT 0.23 ± 0.17 mm, p < 0.0001). CONCLUSIONS: Facet joint effusion is clearly correlated with spontaneous reduction of the extent of slippage in the supine position compared to the upright position. Also, the greater the difference in right and left facet effusion, the higher the likelihood of having a RT. Future studies should assess whether analysis of facet joint effusion measured on routine MRI can help in decision-making regarding the optimal surgical treatment to be applied (decompression alone or combined with fusion).

Comparison of patient and surgeon ratings of outcome 12 months after spine surgery: presented at the 2009 Joint Spine Section Meeting.

OBJECT: The contemporary assessment of spine surgical outcome primarily relies on patient-centered reports of symptoms and function. Such measures are considered to reduce bias compared with traditional surgeon-based outcome ratings. This study examined the agreement between patients' and surgeons' ratings of outcome 1 year after spine surgery. METHODS: The study involved 404 patients (mean age 56.6 +/- 16.4 years; 259 women, 145 men) and their treating surgeons. At baseline and 12 months postoperatively patients completed the Core Outcome Measures Index (COMI) rating pain, function, quality of life, and disability. At 12 months postoperatively, they also rated the global outcome of surgery and their satisfaction with treatment. The surgeon, blinded to the patient's evaluation, rated the global outcome of surgery as excellent, good, fair, or poor. RESULTS: Seventy-six percent of the patients who were considered by the surgeon to have an excellent or good outcome achieved the minimum clinically important difference (MCID) of a 2.2-point reduction on the COMI; 24% achieved less than the MCID. There was a significant correlation between the surgeons' and patients' global outcome ratings (Spearman rho = 0.56; p < 0.0001). The degree of absolute agreement between them was significantly influenced by surgeon seniority: senior surgeons "overrated" the outcome in 24.5% of cases (compared with patients' ratings) and "underrated" it in 17.5% of cases. Junior surgeons overrated in 7.8% of cases and underrated in 43.8% of cases (p < 0.0001). Surgeon overrating occurred significantly more frequently for patients with a poor self-rated outcome (measured as global outcome, COMI score, or satisfaction with treatment). In a multivariate model, the independent variables "senior surgeon" and "patient dissatisfaction with care" were the most significant unique predictors of surgeon overrating of the global outcome (p < 0.0001; adjusted R(2) for the model = 0.16). CONCLUSIONS: Overall, agreement between surgeon and patient was reasonably good. The majority of patients who were rated as excellent/good by the surgeons had achieved the MCID in the prospectively measured COMI score. Discrepancies in outcome ratings were influenced by surgeon seniority and patient satisfaction. For a balanced view of the surgical result, outcomes should be assessed from the perspectives of both the patient and the surgeon.

Intraarticular atlantooccipital fusion for the treatment of traumatic occipitocervical dislocation in a child: a new technique for selective stabilization with nine years follow-up.

STUDY DESIGN: A case report of traumatic atlantooccipital dislocation (AOD) managed by intraarticular-posterior fusion from a posterior approach at the C0-C1 level with preservation of C1-C2 motion. OBJECTIVE: To present a new technique for atlantooccipital fusion with long-term follow-up. SUMMARY OF BACKGROUND DATA: There is an increasing number of patients with AOD who have preservation of neurologic function. The most frequent method used to treat this condition is occipitocervical fusion. There has been a tendency in recent years to minimize the extent of stabilization, performing occipitoatlantal fusion only. However, it is difficult to achieve a solid fusion between C0 and C1, and the long-term effect of the insufficiency of lig. alaria on C0-C2 stability is unknown. The authors present a modified technique of C0-C1 fusion that aims to enhance fusion and achieve greater stability. METHODS: A 11-year-old child with AOD was initially treated unsuccessfully with a halo device for 3 months. As instability persisted, an isolated C0-C1 fusion was performed from a posterior approach. This anatomically based intraarticular fusion technique comprises removal of the articular cartilage of the atlantooccipital joints, and cancellous bone autografting at the atlantooccipital joints and between the occiput and posterior arch of C1, supported by an occipital plate linked by rods to lateral mass screws in the atlas. RESULTS: This technique of increased bony fusion surface and internal fixation provided an excellent result with full recovery of minor neurologic deficits. At long-term follow-up, 9 years after surgery, the patient was free of signs and symptoms; solid fusion of the C0-C1 joint, and normal values for rotation of the C1-C2 segment were recorded. CONCLUSION: Intraarticular and posterior fusion of the atlantooccipital joint was able to provide an excellent long-term clinical outcome in the treatment of traumatic AOD in a child. This is the first report of an intraarticular fusion of the C0-C1 segment and the longest follow-up published on isolated C0-C1 stabilization.

A comparison of outcomes of cervical disc arthroplasty and fusion in everyday clinical practice: surgical and methodological aspects.

Randomised controlled trials (RCTs) of cervical disc arthroplasty vs fusion generally show slightly more favourable results for arthroplasty. However, RCTs in surgery often have limited external validity, since they involve a select group of patients who fit very rigid admission criteria and who are prepared to subject themselves to randomisation. The aim of this study was to examine whether the findings of RCTs are verified by observational data recorded in our Spine Center in association with the Spine Society of Europe Spine Tango surgical registry. Patients undergoing fusion/stabilisation or disc arthroplasty for degenerative cervical spinal disease were selected for inclusion. They completed a questionnaire pre-operatively and at 12 and 24 months follow-up (FU). The questionnaire comprised the multidimensional Core Outcome Measures Index (COMI; 0-10 scale) and, at FU, questions on global outcome and satisfaction with treatment (5-point scales, dichotomised to "good" and "poor"), re-operation and patient-rated complications. The surgeon completed a Spine Tango Surgery form. The outcome data from 266 (208 fusion, 58 arthroplasty) out of 284 eligible patients who had reached 12 months FU, and 169 (139 fusion, 30 arthroplasty) out of 178 who had reached 24 months FU, were included. Patients with cervical disc arthroplasty were younger [46 (SD 8) years vs 56 (SD 11) years for fusion; P < 0.05], had less comorbidity (P < 0.05), more often had only mono-segmental pathology (69% arthroplasty, 47% fusion) and only one type of degenerative pathology (69% arthroplasty, 46% fusion). Surgical complication rates were similar in each group (arthroplasty, 1.5%; fusion, 2.6%). The reduction in the COMI score was significantly greater in the arthroplasty group (at 12 months, 4.8 (SD 3.0) vs 3.7 (SD 2.9) points for fusion, and at 24 months 5.1 (SD 2.8) vs 3.8 (SD 2.9) points; each P < 0.05). In the arthroplasty group, a "good" global outcome was recorded in 90% patients (at 12 months) and 93% (at 24 months); in the fusion group the figures were 80 and 82%, respectively (group differences at each timepoint, P > 0.09). Satisfaction with treatment was similar in both groups (89-93%), at each timepoint. In multiple regression analysis, treatment group was of borderline significance as a unique predictor of the change in COMI at FU (P = 0.059 at 12 months, P = 0.055 at 24 months) in a model in which known confounders (age, comorbidity, number of affected levels) were controlled for. Being in the arthroplasty group was associated with an approximately 1-point greater reduction in the COMI score at FU. The results of this observational study appear to support those of the RCTs and suggest that, in patients with degenerative pathology of the cervical spine, disc arthroplasty is associated with a slightly better outcome than fusion. However, given the small size of the difference, its clinical relevance is questionable, especially in view of the a priori more favourable outcome expected in the arthroplasty group due to the more rigorous selection of patients.

Bone cement augmentation in the prevention of adjacent segment failure after multilevel adult deformity fusion.

STUDY DESIGN: Prospective case report series and detailed description of technique. OBJECTIVES: To describe a surgical procedure designed to prevent fracture and cutting-through and pullout of screws in the adjacent segment after multilevel deformity correction in adults. SUMMARY OF BACKGROUND DATA: Surgery of adult deformities has a high complication rate. One of the potential late complications is the development of fracture at the first mobile segment above a multilevel lumbar or thoracolumbar spinal fusion that necessitates further surgical intervention with extension of the instrumentation. Augmentation with bone cement of the last instrumented vertebra and the first mobile vertebra has the potential to prevent this pathology. METHODS: Three patients with degenerative thoracolumbar kyphoscoliosis and 3 with adjacent segment failure after correction surgery were treated. Cannulated and perforated pedicle screws were placed in the uppermost-instrumented vertebra. A vertebroplasty tube was inserted from 1 side at the center of the first mobile vertebra. Under C-arm control, vertebroplasty was performed in both vertebrae. RESULTS: Intraoperatively, there were no cement-related complications. Follow-ups at 6 and 12 (+/-2) months revealed there was no loss of correction, fracture or screw loosening in the augmented vertebrae. CONCLUSIONS: Bone cement augmentation of the uppermost screws and the first mobile vertebra in multilevel adult deformity and revision surgery seems to be a safe and potentially effective method of preventing adjacent segment failure.

The influence of preoperative back pain on the outcome of lumbar decompression surgery.

STUDY DESIGN: Prospective study with 12-month follow-up. OBJECTIVE: To examine how the relative severity of low back pain (LBP) to leg/buttock pain (LP) influences the outcome of decompression surgery for spinal stenosis. SUMMARY OF BACKGROUND DATA: Decompression surgery is a common treatment for lumbar spinal canal stenosis, with generally good outcome. However, concomitant LBP at presentation can make it difficult to decide whether decompression alone will result in a good overall outcome. METHODS: The Spine Society of Europe Spine Tango system was used to acquire the data from 221 patients. Inclusion criteria were lumbar degenerative spinal stenosis, first-time surgery, maximum 3 affected levels, and decompression as the only procedure. Before and 12 months after surgery, patients completed the multidimensional Core Outcome Measures Index (COMI; includes 0-10 LP and LBP scales); at 12 months, global outcome was rated on a Likert-scale and dichotomized into "good" and "poor" groups. RESULTS: There was a low but significant positive correlation between baseline LP-minus-LBP scores and both improvement in the multidimensional COMI score after 12 months (r = 0.21, P = 0.003) and the score on the 12-month global outcome scale (r = 0.19, P = 0.007). In the good outcome group, mean baseline LP was 2.3 (+/-3.7) points higher than LBP; in the poor group, the corresponding value was 0.8 (+/-3.4) (P = 0.01 between groups). In multivariate regression analyses (controlling for age, gender, comorbidity), baseline LBP intensity was the most significant predictor of the 12-month COMI score, and preoperative LP-minus-LBP score of the global outcome (each P < 0.05). CONCLUSION: Overall, greater back pain relative to LP at baseline was associated with a significantly worse outcome after decompression. This finding seems intuitive, but has rarely been quantified in the many predictor studies conducted to date. Consideration of relative LBP and LP scores may assist in clinical decision-making and in establishing realistic patient expectations.