Operative Versus Nonoperative Management of Civilian Gunshot Wounds to the Spinal Cord: Novel Use of the Functional Independence Measure for Validated Outcomes.

BACKGROUND: Surgery for patients with gunshot wound spinal cord injury (GSCI) remains controversial. Few recent studies provide standardized follow-up and detailed functional outcomes. To our knowledge, the research we present in this study is unique in that we are the first to incorporate Functional Independence Measure (FIM) scores as an outcomes measure for neurologic recovery in patients with GSCI. METHODS: Patients with GSCI were divided into surgical and nonsurgical groups. Neurologic function was measured according to the American Spinal Injury Association impairment scale and defined as either complete or incomplete injury. Outcomes were then analyzed separately for complete and incomplete GSCI groups during hospitalization and rehabilitation. RESULTS: Baseline admissions characteristics were similar between surgical and nonsurgical groups except for a greater median injury severity score in the nonsurgical group (34 vs. 27; P = 0.02). For complete GSCI, total length of stay (LOS) was significantly longer in the surgical group (52 vs. 42 days; P = 0.04), and no difference was observed in overall FIM scores (58 vs. 54; P = 0.7). For incomplete GSCI, rehabilitation LOS was longer (35 vs. 21; P = 0.02) and a trend towards longer total LOS was observed in the surgical group (40 vs. 32; P = 0.07). No difference was observed in overall FIM scores (61 vs. 62; P = 0.9). CONCLUSIONS: Surgery for patients with GSCI is associated with increased LOS and is not associated with improved FIM scores for patients with either complete or incomplete spinal cord injuries.

Spondylolysis and End Plate Arthrosis at L5-S1: A Cadaveric Study.

This study examined the effect of bilateral and unilateral L5 pars defects on the degree of disk degeneration at the L5-S1 level in cadaveric specimens. An observational study was performed of 690 cadaveric specimens selected at random. These specimens represent individuals who died between 1893 and 1938. The study included 558 male and 132 female cadavers. Of the 120 specimens with L5 spondylolysis, 95 cases were bilateral and 25 were unilateral. The remaining 544 specimens were used as the control cohort. Degenerative disk disease was measured by the classification of Eubanks et al. According to this classification, degenerative disk disease was graded from no arthrosis (grade 0) to complete ankylosis (grade IV). Linear regression analysis corrected for age, sex, and race showed that subjects with bilateral spondylolysis at L5 had a statistically significant increase in the amount of disk degeneration (P=.02) compared with those with unilateral lesions. Student's t tests showed significant differences (P<.001 and P=.002, respectively) in the amount of degeneration seen with both bilateral and unilateral spondylolysis above what would be predicted in the normal control population. A positive correlation was found between the number of pars defects at L5 and the degree of disk degeneration at L5-S1. These results support the idea that individuals with spondylolysis at these levels may be at increased risk for development of low back pain and reduced quality of life. [Orthopedics. 2017; 40(1):e59-e64.].

Chronic Antiplatelet Use Associated With Increased Blood Loss in Lumbar Spinal Surgery Despite Adherence to Protocols.

There are conflicting reports regarding postoperative bleeding risks associated with discontinuation of antiplatelet therapy at least 7 days preoperatively. Most of the studies in the spine literature are based on surveys or anecdotal evidence. The majority of surgeons discontinue therapy 7 days preoperatively, but this varies widely from 5 to 21 days. The purpose of this retrospective study was to assess whether chronic antiplatelet use is associated with increased intraoperative blood loss, need for transfusion, and perioperative complications. Of 454 patients who underwent elective lumbar spinal surgery, 85 were on antiplatelet therapy and 369 were not. All patients stopped antiplatelet therapy at least 7 days preoperatively with approval from their cardiologist or primary care provider. Multiple regression analysis was performed and corrected for age, sex, antiplatelet therapy, number of levels decompressed/fused/instrumented, preoperative hematocrit, and postoperative hematocrit. Results showed that preoperative antiplatelet therapy, despite at least 7 days of discontinuation, is a statistically significant predictor (P=.04) of increased intraoperative blood loss. Blood transfusion was not associated with antiplatelet use but was associated with the number of levels fused, age, and low preoperative hematocrit (all P<.01). There were no recorded complications in either group. The authors conclude that antiplatelet therapy is associated with an increased risk of intraoperative blood loss in spine patients despite discontinuation at least 7 days preoperatively, but the clinical significance of this is unclear given the lack of association with blood transfusions and perioperative complications. [Orthopedics. 2016; 39(4):e695-e700.].

Smoking is Associated with Increased Blood Loss and Transfusion Use After Lumbar Spinal Surgery.

BACKGROUND: Little is known about the association between smoking and intraoperative blood loss and perioperative transfusion use in patients undergoing spinal surgery. However, we found that although many of the common complications and deleterious effects of smoking on surgical patients had been well documented, the aspect of blood loss seemingly had been overlooked despite data reported in nonorthopaedic sources to suggest a possible connection. QUESTIONS/PURPOSES: We asked: (1) Is smoking associated with increased estimated blood loss during surgery in patients undergoing lumbar spine surgery? (2) Is smoking associated with increased perioperative transfusion usage? METHODS: Between 2005 and 2009, 581 lumbar decompression procedures (with or without fusion) were performed at one academic spine center. Of those, 559 (96%) had sufficient chart documentation to categorize patients by smoking status, necessary intra- and postoperative data to allow analysis with respect to bleeding and transfusion-related endpoints, and who did not meet exclusion criteria. Exclusion criteria included: patients whose smoking status did not fit in our two categories, patients with underlying coagulopathy, patients receiving anticoagulants (including aspirin and platelet inhibitors), history of hepatic disease, history of platelet disorder or other blood dyscrasias, and patient or family history of any other known bleeding disorder. Smoking history in packs per day was obtained for all subjects. We defined someone as a smoker if the patient reported smoking up until the day of their surgical procedure; nonsmokers were patients who quit smoking at least 6 weeks before surgery or had no history of smoking. We used a binomial grouping for whether patients did or did not receive a transfusion perioperatively. Age, sex, number of levels of discectomies, number of levels decompressed, number of levels fused, and use of instrumentation were recorded. The same approaches were used for transfusions in all patients regardless of smoking history; decisions were made in consultation between the surgeon and the anesthesia team. Absolute indications for transfusion postoperatively were: a hemoglobin less than 7 g/dL, continued symptoms of dizziness, tachycardia, decreased exertional tolerance, or hypotension that failed to respond to fluid resuscitation. Multiple linear regression analyses correcting for the above variables were performed to determine associations with intraoperative blood loss, while logistic regression was used to analyze perioperative transfusion use. RESULTS: After controlling for potentially relevant confounding variables noted earlier, we found smokers had increased estimated blood loss compared with nonsmokers (mean, 328 mL more for each pack per day smoked; 95% CI, 249-407 mL; p < 0.001). We also found that again correcting for confounders, smokers had increased perioperative transfusion use compared with nonsmokers (odds ratio, 13.8; 95% CI, 4.59-42.52). CONCLUSIONS: Smoking is associated with increased estimated surgical blood loss and transfusion use in patients undergoing lumbar spine surgery. Patients who smoke should be counseled regarding these risks and on smoking cessation before undergoing lumbar surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.

Bilateral Pars Defects at the L4 Vertebra Result in Increased Degeneration When Compared With Those at L5: An Anatomic Study.

BACKGROUND: Cadaveric studies have examined disc degeneration at the L4-L5 and L5-S1 motion segments; however, we are not aware of another study that has examined the relationship between bilateral spondylolysis and its effect on degenerative disc disease at those levels. This may have been overlooked by researchers owing to the majority of spondylolysis occurring at the L5 vertebra. QUESTIONS/PURPOSES: Using osteologic specimens from a collection that included individuals who died in one city in the USA between 1893 and 1938, we asked: (1) do specimens with bilateral spondylolysis (bilateral pars defects) have increased levels of disc degeneration, at their respective motion segments, when compared with matched controls without spondylolysis, and (2) is the finding of a bilateral pars defect associated with more severe arthritis at L4-L5 than at L5-S1? METHODS: An observational study was performed on 665 skeletal lumbar spines from the Hamann-Todd Osteologic Collection at the Cleveland Museum of Natural History (Cleveland, OH, USA). The specimens included 534 males and 131 females ranging from 17 to 87 years old, with a nearly bell-shaped distribution of ages for males and a larger proportion of younger ages in the female specimens. Of those with spondylolysis, 81 had a defect at L5 and 14 had a defect at L4. The gross specimens were examined subjectively for evidence of arthrosis. At the time of examination, specific attention was not paid to the coexisting presence or absence of spondylolysis nor was the examiner blinded to the age of the specimens. Disc degeneration was measured by the classification of Eubanks et al., a modified version of the Kettler and Wilke classification. Linear regression was performed to derive a formula that would predict the amount of disc degeneration at L4-L5 and L5-S1 for the normal control population given a specimen's age, sex, and race. We then used this formula to evaluate the difference in disc degeneration at the corresponding level of the pars defect that is greater than the predicted amount for a control without spondylolysis. This allowed us to conclude that any significant differences found between the L4-L5 and L5-S1 cohorts were attributable to factors not simply inherent to their functional position in the spine of an individual without a bilateral pars defect. RESULTS: L4 spondylolysis and L5 spondylolysis showed greater amounts of degeneration compared with that of matched controls (L4 controls: mean = 1.52, SD = 0.74; L4 spondylolysis: mean = 3.21, SD = 0.87; p < 0.001; L5 controls: mean = 0.97, SD = 0.48; L5 spondylolysis: mean = 2.06, SD = 0.98; p < 0.001). When we controlled for the expected amount of degenerative disc disease at each level in controls, the observed degeneration was more severe at L4-L5 than at L5-S1 (p = 0.008, R-squared = 18.6). CONCLUSIONS: L4-L5 and L5-S1 bilateral spondylolysis groups had increased presence of degenerative disc disease compared with those without bilateral spondylolysis. For the same degree of spondylolysis, the observed amount of disc degeneration was greater at the L4-5 motion segment compared with L5-S1. CLINICAL RELEVANCE: Although not as common as the spondylolysis at L5-S1, we believe that our findings support that patients with L4-L5 spondylolysis can expect a greater degree of degenerative disc disease and increasing clinical symptoms. Multiple factors in the sacropelvic geometry of an individual, facet morphologic features at L4-L5, and the absence of the iliolumbar ligament at this level are possible contributing factors to the findings of this study.

Arthroscopic validation of the clinical exam for the detection of the symptomatic synovial-plical complex by relief from surgical excision.

PURPOSE: The goal is to introduce a reproducible exam technique that allows clinical diagnosis of symptomatic plical bands and associated synovium about the knee. We then aimed to assess the accuracy of the exam technique through arthroscopic confirmation of these tissues. Lastly, we hope to determine whether arthroscopic plicectomy and partial synovectomy is an effective treatment for alleviating the pain associated with symptomatic plica. METHODS: This retrospective study evaluated 80 consecutive symptomatic knees under the care of a single physician diagnosed with symptomatic plica and associated painful synovium from 2001-2011. These patients underwent diagnostic and therapeutic arthroscopy to verify the presence of a plica and painful synovium with plicectomy and partial synovectomy if necessary. Statistical analysis was performed to determine the sensitivity and positive predictive value of the exam. RESULTS: The medial parapatellar region was the most common location for symptomatic plica and associated synovial tissue. The exam technique described in this study had a sensitivity of 83.8% with a positive predictive value of 98.6% in the specific patient population described. CONCLUSIONS: This study suggests that while the medial plical band is the most common, there is frequently sensitive synovial tissue found in multiple locations about the knee. This study also suggests that a thorough exam technique can accurately diagnose both the plical bands as well as the sensitive synovial tissue. LEVEL OF EVIDENCE: Level II, Diagnostic Study. See the Guidelines for Authors for a complete description of levels of evidence.