Assessing Foraminal Stenosis in the Cervical Spine: A Comparison of Three-Dimensional Computed Tomographic Surface Reconstruction to Two-Dimensional Modalities.

STUDY DESIGN: Retrospective radiographic study. OBJECTIVE: The optimal radiographic modality for assessing cervical foraminal stenosis is unclear. Determination on conventional axial cuts is made difficult due in part to the complex, oblique orientation of the cervical neuroforamen. The utility of 3-dimensonal (3D) computed tomography (CT) reconstruction in improving neuroforaminal assessment is not well understood. The objective of this study is to determine inter-rater variability in grading cervical foraminal stenosis using 3 different CT imaging modalities: 3D CT surface reconstructions (3DSR), 2D sagittal oblique multiplanar reformations (2D-SOMPR), and conventional 2D axial CT imaging. METHODS: Pretreatment CT scans of 25 patients undergoing surgery for cervical spondylotic radiculopathy were analyzed at 2 levels: C5-C6 and C6-C7. Simple interrater agreement and kappa-Fleiss coefficients were calculated for each imaging modality and stenosis grade. Image reviewers (attending spine surgeon, attending neuroradiologist, spine fellow) interpreted each CT scan in 3 different formats: axial, 2D-SOMPR, and 3DSR. Four cervical foramina at 2 spinal levels were graded as normal (no stenosis), mild (≤25% stenosis), moderate (25%-50% stenosis), or severe (>50% stenosis). RESULTS: Across all imaging modalities, interrater reliability was fair when grading foraminal stenosis (κ < 0.4). Agreement was lowest for the axial images (κ = 0.119) and highest for the 3D CT reconstructions (κ = 0.334). 2D-SOMPR images also led to improved interrater reliability when compared with axial images (κ = 0.255). CONCLUSION: Grading cervical foraminal stenosis using conventional axial CT imaging is difficult with low interrater reliability. CT modalities that provide a circumferential view of the cervical foramen, such as 2D-SOMPR and 3D CT reconstruction, had higher rates of interobserver reliability in grading foraminal stenosis than conventional axial cuts, with 3D having the highest. As these 3D reconstructions can be obtained at no additional cost or radiation exposure over a conventional CT scan, and because they can provide useful information in determining levels being considered for surgical decompression, we recommend they be utilized when evaluating cervical foramina.

Posterolateral Lumbar Arthrodesis With and Without Interbody Arthrodesis for L4-L5 Degenerative Spondylolisthesis: A Comparative Value Analysis.

STUDY DESIGN: Independent retrospective review of prospectively collected data, comparative cohort study. OBJECTIVE: The objective of this study was to compare the clinical, radiographical, and cost/value of the addition of an interbody arthrodesis (IBA) to a posterolateral arthrodesis (PLA) in the surgical treatment of L4-L5 degenerative spondylolisthesis (DS). The authors hypothesized that the addition of IBA to PLA would produce added value while incurring minimal additional costs. SUMMARY OF BACKGROUND DATA: Many lumbar surgical advances have been made during the past several decades, yet there is a paucity of strong evidence-based validation, let alone comparative value analyses. The addition of an IBA to a PLA has become increasingly popular during the past 2 decades, yet the potential added value for the patient has not been carefully defined. METHODS: Patients undergoing single-level arthrodesis for L4-L5 DS performed at our institution from 2004 to 2012 were identified. Exclusion criteria included multilevel arthrodesis, spinal stenosis requiring decompression at or above L2-L3, previous L4-L5 spinal fusion, spondylolisthesis of greater than 33% of the vertebral body, and use of minimally invasive surgery. Radiographical fusion status, epidemiological, surgical, and functional outcomes, and cost/value data were recorded or calculated. RESULTS: A total of 179 patients with follow-up meeting inclusion criteria were identified: 68 with PLA alone and 111 with PLA + IBA. No statistical differences were noted in Oswestry Disability Index, 36-item Short-Form Health Survey scores, fusion rates, or cost/value at 6 months and at more than 3 years despite the PLA cohort being significantly older with more medical comorbidities. When length of stay was normalized across cohorts, the addition of an IBA increased hospital costs ranging from $577 to $5276, but this did not reach statistical significance. CONCLUSION: This single-center review of open surgical treatment of L4-L5 DS demonstrated that the addition of IBA to PLA added cost while producing equivalent results in fusion rates, Oswestry Disability Index, and 36-item Short-Form Health Survey scores when compared with PLA alone. LEVEL OF EVIDENCE: 3.

Long-term outcomes of allograft reconstruction of the anterior cruciate ligament.

Recent studies have found higher rates of failed reconstruction of the anterior cruciate ligament (ACL) with use of allograft when compared with autograft reconstruction. To evaluate the long-term outcomes of allograft ACL reconstruction, we retrospectively reviewed the cases of all patients who underwent allograft (n=99) or autograft (n=24) ACL reconstruction by 2 senior surgeons at a single institution over an 8-year period. Seventeen (17%) of the 99 allograft reconstructions required additional surgery. Reoperation and revision ACL reconstruction rates (30.8% and 20.5%, respectively) were much higher for patients 25 years of age or younger than for patients older than 25 years. In our cohort of NCAA (National Collegiate Athletic Association) Division I athletes, the revision ACL reconstruction rate was 62% for allograft ACL reconstruction and 0% for autograft reconstruction. Our study found that reoperation and revision rates for irradiated soft-tissue allograft ACL reconstruction were higher than generally quoted for autograft reconstruction. Given the extremely high graft failure rates in patients younger than 25 years, we recommend against routine use of irradiated soft-tissue allograft for ACL reconstruction in younger patients.

The significance of increased fluid signal on magnetic resonance imaging in lumbar facets in relationship to degenerative spondylolisthesis.

STUDY DESIGN: Retrospective radiographic review of consecutive patients with universally applied standard. OBJECTIVES: To define MRI findings at the facet joints that may suggest abnormal sagittal plane translation seen on standing lateral flexion-extension (SLFE) radiographs. SUMMARY OF BACKGROUND DATA: MRI findings, including facet joint orientation, facet joint osteoarthritis, and the presence of synovial cysts, have all been linked with degenerative spondylolisthesis (DS). MRI can also detect facet joint effusion; however, there has not been a study specifically addressing the association of facet fluid signal to degenerative spondylolisthesis (DS). METHODS: MRI and SLFE films of all patients seen at a single institution for an orthopedic spine consultation over a 2-year period were analyzed. The presence of facet effusions, synovial cysts, increased intensity within the interspinous ligament, degenerative changes at the facets, and anterior sagittal plane translation were all recorded. The data were analyzed to determine if there was a significant association between the presence of DS and the following: facet effusion, degenerative changes of the facets, synovial cysts, increased signal in the interspinous ligament, age, and gender. RESULTS: There were 139 patients without DS at (NegDS) and 54 with DS (PosDS) on SLFE films at L4-L5 (n = 193). PosDS patients were more likely to be older (P < 0.0001), female (P = 0.0042), have synovial cysts (P < 0.0001), have higher osteoarthritis grade (P < 0.0001), and have larger facet effusion size (P < 0.0001). For both groups, facet joint effusions were also found to be significantly larger in patients with Grade 2 or less osteoarthritis, than in patients with Grade 3 osteoarthritis. Twenty-two percent of the listheses were not detectable on supine MRI. CONCLUSION: Large (> 1.5 mm) facet effusions are highly predictive of degenerative spondylolisthesis at L4-L5 in the absence of measurable anterolisthesis on supine MRI. A clinically measurable facet effusion (> or = 1 mm) suggests the need for SLFE films to diagnose degenerative spondylolisthesis that can be missed with supine positioning on MRI.

Combination of acute preoperative plateletpheresis, cell salvage, and aprotinin minimizes blood loss and requirement during cardiac surgery.

Acute preoperative plateletpheresis (APP), cell salvage (CS) technique, and the use of aprotinin have been individually reported to be effective in reducing blood loss and blood component transfusion while improving hematological profiles in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). In this prospective randomized clinical study, the efficacy of these combined approaches on reducing blood loss and transfusion requirements was evaluated. Seventy patients undergoing primary coronary artery bypass grafting (CABG) were randomly divided into four groups: a control group (group I, n = 10) did not receive any of the previously mentioned approaches. An APP and CS group (group II, n = 20) experienced APP in which preoperative platelet-rich plasma was collected and reinfused after reversal of heparin, along with the cell salvage technique throughout surgery. The third group (group III, n = 22) received aprotinin in which 5,000,000 KIU Trasylol was applied during surgery, and a combination group (group IV, n = 18) was treated with all three approaches, i.e., APP, CS, and aprotinin. Compared with group I (896+/-278 mL), the postoperative total blood loss was significantly reduced in groups II, III, and IV (468+/-136, 388+/-122, 202+/-81 mL, respectively, p < 0.05). The requirements of packed red blood cells in the three approached groups (153+/-63, 105+/-178, 0+/-0 mL, respectively) also were reduced when compared with group I (343+/-118 mL, p < 0.05). In group I, six patients (6/10) received fresh-frozen plasma and three patients (3/10) received platelet transfusion, whereas no patients in the other three groups required fresh-frozen plasma and platelet. In conclusion, both plateletpheresis concomitant with cell salvage and aprotinin contribute to the improvement of postoperative hemostasis, and the combination of these two approaches could minimize postoperative blood loss and requirement.

Myocardial protection of warm cardioplegic induction on the isolated perfused rat heart model.

Myocardial protection through different cardioplegia approaches is an important issue for successful cardiovascular surgery. The objective of this prospective randomized study was to evaluate the effect of myocardial protection of warm (37 degrees C) and cold (6 degrees C) cardioplegic induction, respectively, using a Langendorff isolated rat heart perfusion model. Twenty-eight isolated rat hearts on the Langendorff perfusion model were randomly divided into two groups: group T (n = 14) received warm (37 degrees C) cardioplegic induction, followed by cold (6 degrees C) cardioplegia after ECG showed straight line; alternatively, group C (n = 14) received only cold cardioplegic induction. After undergoing ischemia for 80 min, both group T and group C received reperfusion with Krebs-Henseleit Buffer (KHB) for 40 min. An additional group A (n = 7) received KHB continuously for 120 min and served as the control group for the assessment of Na(+)/K(+)-ATPase activity. The coronary flow, concentration of creatine kinase (CK) in coronary effluent, and cardiac function were evaluated at different time periods. Na(+)/K(+)-ATPase activity was assessed at the end of reperfusion. The coronary flow, content of CK in coronary effluent, heart rate, dp/dtmax, and left ventricular peak pressure (LVPP) were significantly greater (p < .05) in group T than group C during the reperfusion period. The negative value of -dp/dtmax and left ventricular end-diastolic pressure (LVEDP) was significantly lower (p < .05) in group T than group C, during the reperfusion period. The Na(+)/K(+)-ATPase activity assessed at the end of reperfusion period was significantly higher (p < .05) in group A and group T than group C, while no significant difference (p = .13) was found between group T and group A. Compared with cold cardioplegic induction, warm cardioplegic induction provides superior myocardial protection by enhancing coronary flow, reducing myocardial injury, improving cardiac function, and preserving Na(+)/K(+)-ATPase activity.