Intraoperative neurophysiologic monitoring in idiopathic scoliosis surgery: a retrospective observational study of new neurologic deficits.

PURPOSE: Patients with adolescent idiopathic scoliosis undergoing corrective surgery are at risk for iatrogenic spinal cord injury and subsequent new neurologic deficits (NNDs). Intraoperative neurophysiologic monitoring (IONM) has been used to identify spinal cord injury; however, available data showing that IONM leads to improved clinical outcomes are inconclusive. This exploratory study aimed to examine the incidence of NNDs after idiopathic scoliosis surgery in two pediatric institutions in Canada with a focus on IONM use. METHODS: Charts of pediatric patients (10-18 yr) with adolescent idiopathic scoliosis who underwent scoliosis correction surgery were retrospectively identified from the operating room database. Data regarding incidence and severity (mild [isolated sensory deficit] vs severe [any motor deficit]) of NNDs as well as demographic and clinical characteristics were extracted. RESULTS: Of 547 patients reviewed, 359 (66%) underwent IONM and 186 (34%) underwent wake-up test. Neuromonitoring data were missing in two patients. Total incidence of NNDs was 4.9% (95% confidence interval [CI], 3.1 to 6.8). Compared with the wake-up test, patients undergoing IONM were less likely to develop NNDs (unadjusted odds ratio, 0.39; 95% CI, 0.18 to 0.86; P = 0.02). Nevertheless, subgroup analysis did not reveal a statistical difference in severity of those deficits (mild vs severe) with IONM vs wake-up test. Combined anterior and posterior approach was also significantly associated with increased risk of such deficits. CONCLUSION: This exploratory study revealed that IONM was associated with a reduced overall incidence of NNDs in idiopathic scoliosis correction; however, its impact on the severity of those deficits is questionable. As we were unable to adjust for confounding variables, further research is needed to determine the impact of IONM on NNDs.

RéSUMé: OBJECTIF: Les patients adolescents atteints de scoliose idiopathique subissant une chirurgie corrective sont à risque de lésions médullaires iatrogéniques et de nouveaux déficits neurologiques (NDN) subséquents. Le monitorage neurophysiologique peropératoire (MNP) a été employé pour identifier les lésions médullaires; cependant, les données disponibles montrant que le MNP entraîne de meilleurs pronostics cliniques ne sont pas concluantes. Cette étude exploratoire visait à examiner l'incidence des NDN après une chirurgie de scoliose idiopathique dans deux établissements pédiatriques au Canada en se concentrant sur l'utilisation du MNP. MéTHODE: Les dossiers des patients pédiatriques (10-18 ans) atteints de scoliose idiopathique ayant subi une chirurgie de correction de scoliose ont été rétrospectivement identifiés dans la base de données de salle d'opération. Les données concernant l'incidence et la gravité (légers [déficit sensoriel isolé] vs graves [tout déficit moteur]) des NDN ainsi que les caractéristiques démographiques et cliniques ont été extraites. RéSULTATS: Parmi les 547 patients passés en revue, 359 (66 %) ont eu un MNP et 186 (34 %) ont eu un test d'éveil ('wake-up test'). Les données de monitorage neurologique manquaient pour deux patients. L'incidence totale des NDN était de 4,9 % (intervalle de confiance [IC] de 95 %, 3,1 à 6,8). Par rapport au test d'éveil, les patients subissant un MNP étaient moins susceptibles de présenter des NDN (rapport de cotes non ajusté, 0,39; IC 95 %, 0,18 à 0,86; P = 0,02). Néanmoins, l'analyse des sous-groupes n'a pas révélé de différence statistique dans la gravité de ces déficits (légers vs graves) en comparant un MNP à un test d'éveil. Une association significative a également été relevée entre une approche combinée chirurgicale antérieure et postérieure et un risque accru de tels déficits. CONCLUSION: Cette étude exploratoire a indiqué que le MNP était associé à une incidence globale réduite de NDN lors d'une chirurgie de correction de scoliose idiopathique; toutefois, son impact sur la gravité de ces déficits est discutable. Comme nous n'avons pas été en mesure d'ajuster les données aux variables confondantes, d'autres recherches sont nécessaires pour déterminer l'impact du MNP sur les NDN.

Characteristics of patients receiving long-term opioid therapy for chronic noncancer pain: a cross-sectional survey of patients attending the Pain Management Centre at Hamilton General Hospital, Hamilton, Ontario.

BACKGROUND: Characteristics of patients receiving long-term opioid therapy (≥ 6 months) for chronic noncancer pain are poorly understood. We conducted a cross-sectional survey of this patient population to explore demographic variables, pain relief, functional improvement, adverse effects and impressions of an educational pamphlet on long-term opioid therapy. METHODS: We invited 260 adult patients presenting to the Pain Management Centre at the Hamilton General Hospital, Hamilton, Ontario, with chronic noncancer pain to complete a 20-item survey. Patients who presented for procedures were not eligible for our study. We used adjusted logistic regression models to explore the association between higher morphine equivalent dose and pain relief, functional improvement, adverse events and employment. RESULTS: The survey was completed by 170 patients (a response rate of 65.4%). Most respondents (87.6%; 149 out of 170) were receiving long-term opioid therapy, and the median morphine equivalent dose was 180 mg daily (interquartile range 60-501). Most respondents reported at least modest (> 40%) opioid-specific pain relief (74.1%; 106 out of 143) and functional improvement (67.6%; 96 out of 142), and 46.5% (66 out of 142) reported troublesome adverse effects that they attributed to their opioid use. Most patients were receiving disability benefits (68.3%; 99 out of 145) and, among those respondents who were less than 65 years of age (90.3%; 131 out of 145), 10 (7.6%) were working full-time and 14 (10.7%) part-time. In our adjusted analyses, higher morphine equivalent dose was associated with greater self-reported functional improvement (odds ratio [OR] 1.45, 95% confidence interval [CI] 1.07-1.96) but not with pain relief (OR 1.38, 95% CI 1.00-1.89), troublesome adverse effects (OR 0.92, 95% CI 0.70-1.20) or employment (OR 0.80, 95% CI 0.56-1.15). INTERPRETATION: Most outpatients receiving long-term opioid therapy for chronic noncancer pain at a tertiary care chronic pain clinic reported at least moderate pain relief and functional improvement; however, adverse effects were common and few patients were engaged in competitive employment.

Presence with purpose: attitudes of people with developmental disability towards health care students.

CONTEXT: Early clinical encounters help medical and nursing students build professional competencies. However, there is a necessary emphasis on patient autonomy and appropriate consent. Although most individuals do not object to student involvement in clinical encounters, there are occasions when personal preference and health care education conflict. Many studies have evaluated patient attitudes towards students across a variety of specialties. OBJECTIVES: The purpose of this study was to identify the attitudes, comfort level and preferences of individuals with developmental disability (DD) towards the presence and involvement of medical and nursing students during clinical encounters. METHODS: Adults with DD across the Hamilton-Niagara region were invited to participate. Focus groups were moderated by two students with a health care facilitator and physician-educator. Participants were provided with focus group questions in advance and encouraged to bring communication aids or care providers. Data were analysed for emerging themes by two independent reviewers, who then compared results. RESULTS: Twenty-two individuals participated. A wide range of opinions were expressed. Some participants were positively disposed towards students and perceived better care and improved communication with the health care team. Others were indifferent to students in a clinical setting. The final group was opposed to the presence of health care students, expressing confusion over their role and purpose, uneasiness with deviation from the norm, and concerns about confidentiality. Informative introductions with confidentiality statements and the presence of a supervising clinician were seen as helpful. CONCLUSIONS: People with DD are affected by above-average health care needs. Their input into health care planning has been limited. Their opinions on health care learners varied considerably. Themes relating to attitudes, comfort and preferences about student involvement provide impetus for health care training practices that promote person-centred approaches and improvements to the quality of care received by people with DD.