Use of bone morphogenetic proteins in spinal fusion surgery for older adults with lumbar stenosis: trends, complications, repeat surgery, and charges.

STUDY DESIGN: Retrospective cohort study of Medicare claims. OBJECTIVE: Examine trends and patterns in the use of bone morphogenetic proteins (BMP) in surgery for lumbar stenosis; compare complications, reoperation rates, and charges for patients undergoing lumbar fusion with and without BMP. SUMMARY OF BACKGROUND DATA: Small, randomized trials have demonstrated higher rates of solid fusion with BMP than with allograft bone alone, with few complications and, in some studies, reduced rates of revision surgery. However, complication and reoperation rates from large population-based cohorts in routine care are unavailable. METHODS: We identified patients with a primary diagnosis of lumbar stenosis who had fusion surgery in 2003 or 2004 (n = 16,822). We identified factors associated with BMP use: major medical complications during the index hospitalization, rates of rehospitalization within 30 days, and rates of reoperation within 4 years of follow-up (through 2008). RESULTS: Use of BMP increased rapidly, from 5.5% of fusion cases in 2003 to 28.1% of fusion cases in 2008. BMP use was greater among patients with previous surgery and among those having complex fusion procedures (combined anterior and posterior approach, or greater than 2 disc levels). Major medical complications, wound complications, and 30-day rehospitalization rates were nearly identical with or without BMP. Reoperation rates were also very similar, even after stratifying by previous surgery or surgical complexity, and after adjusting for demographic and clinical features. On average, adjusted hospital charges for operations involving BMP were about $15,000 more than hospital charges for fusions without BMP, though reimbursement under Medicare's Diagnosis-Related Group system averaged only about $850 more. Significantly fewer patients receiving BMP were discharged to a skilled nursing facility (15.9% vs. 19.0%, P < 0.001). CONCLUSION: In this older population having fusion surgery for lumbar stenosis, uptake of BMP was rapid, and greatest among patients with prior surgery or having complex fusion procedures. BMP appeared safe in the perioperative period, with no increase in major medical complications. Use of BMP was associated with greater hospital charges but fewer nursing home discharges, and was not associated with reduced likelihood of reoperation.

A novel treatment approach to cholesterol granulomas. Technical note.

The authors report a novel technique for the treatment of cholesterol granulomas. An extradural middle fossa approach was used to access the granuloma, with drainage through silastic tubes into the sphenoid sinus via the anteromedial triangle between V1 and V2. Cholesterol granulomas occur when the normal aeration and drainage of temporal bone air cells is occluded, resulting in vacuum formation and transudation of blood into the air cells. This process results in anaerobic breakdown of the blood with resulting cholesterol crystal formation and an inflammatory reaction. Traditional treatment of this lesion involves extensive drilling of the temporal bone to drain the granuloma cyst and establish a drainage tract into the middle ear. Such drainage procedures can be time consuming and difficult, and potentially involve structural damage to the inner ear and facial nerve. An extradural middle fossa approach provides easy access to the granuloma and anterior petrous bone entry into the granuloma for resection. Granuloma drainage is then achieved using shunt tubing in the sphenoid sinus via a small hole in the anteromedial triangle between V1 and V2. Five patients with symptomatic cholesterol granuloma were treated without complication using this novel extradural middle fossa approach. One patient required reoperation 1-year postoperatively for cyst regrowth and occlusion of the drainage tube. At the 5-year follow-up examination, no patient reported recurrent symptoms. Extradural middle fossa craniotomy and silastic tube drainage into the sphenoid sinus is a viable alternative method for treatment of cholesterol granuloma.

Direct injection of blood into the labrum enhances the stability provided by the glenoid labral socket.

We tested the hypothesis that the stabilizing function of the labrum can be enhanced by inflating it with blood. In 6 fresh cadaveric glenoids, the anteroinferior stability provided by the glenoid was quantitated by measuring the maximal angle between the glenoid centerline and the direction of the force applied via a ball in the glenoid before the ball dislocated from the glenoid. This stability angle was measured for each of 4 different applied loads. These measurements were repeated after the anteroinferior labrum was augmented by the injection of fresh blood. Injection augmentation of the labrum significantly increased the measured stability angles in 5 of 6 specimens. The 1 outlier had a partial labral tear. The mean increase in stability for all 6 glenoids ranged from 19% to 30% for the different test loads. Labral injection with blood may be a useful adjunct in the surgical management of glenohumeral instability.