Assessment of an Opioid Stewardship Program on Perioperative Opioid Prescribing in a Safety-Net Health System.

This quality improvement study involves comparison of opioid prescription data before and after implementation of an opioid stewardship program in a safety-net medical system.

Perioperative major neurologic deficits as a complication of spine surgery.

STUDY DESIGN: Retrospective review of spine surgery patients with new major neurologic complication. OBJECTIVE: To define the causes and severity of new neurologic damage to the spinal cord or cauda equina caused by spinal surgery. MATERIALS AND METHODS: Consult records were reviewed for all postoperative spine surgery patients referred to a tertiary spinal cord injury rehabilitation center over a 12-year period. Any patients with a new perioperative surgery-related decrement in American Spinal Injury Association (ASIA) Impairment Scale (AIS), loss of bowel or bladder function, or loss of ability to ambulate were examined and final 1-year gaps for neurologic loss reported. RESULTS: 64 patients had a new perioperative major neurologic event with: 41% thoracic, 39% cervical, and 20% lumbar; 61% intraoperative, 31% in the immediate 2-week postoperative period, 8% unknown. Chronic myelopathy (44%) was the most common indication. The causes of neurologic injury were postoperative fluid collection (25%), malposition of instrumentation (14%), traumatic decompression (14%), cord infarct (11%), deformity correction (2%), and unknown (34%). Overall, 87% lost the ability to ambulate and 66% lost volitional bowel-bladder control. AIS decrement and loss of ambulation and bowel-bladder function did not differ statistically significantly by surgical indication. However, among the main root causes, traumatic decompressions and cord infarcts had significantly worse neurologic deterioration than fluid collections or malposition of instrumentation. CONCLUSION: The relative rate of major neurologic injury in spine surgery is higher in thoracic and cervical cases at spinal cord levels, especially when done for myelopathy, even though lumbar surgeries are most common. The most common causes of neurologic injury were potentially avoidable postoperative fluid collections, malposition of instrumentation, and traumatic decompression.

Combined Motor and Sensory Intraoperative Neuromonitoring for Cervical Spondylotic Myelopathy Surgery Causes Confusion: A Level-1 Diagnostic Study.

STUDY DESIGN: Level-1 diagnostic study. OBJECTIVE: The purpose of this study was to evaluate the sensitivity and specificity of combined motor and sensory intraoperative neuromonitoring (IONM) for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Intraoperative neuromonitoring during spine surgery began with sensory modalities with the goal of reducing neurological complications. Motor monitoring was later added and purported to further increase sensitivity and specificity when used in concert with sensory monitoring. Debate continues, however, as to whether neuromonitoring reliably detects reversible neurologic changes during surgery or simply adds set-up time, cost, or mere medicolegal reassurance. METHODS: Neuromonitoring data using combined motor and sensory evoked potentials for 540 patients with CSM undergoing anterior or posterior decompressive surgery were collected prospectively. Patients were examined postoperatively to determine the clinical occurrence of new neurologic deficit which correlated with monitoring alerts recorded per established standard criteria. RESULTS: The overall incidence of positive IONM alerts was 1.3% (N = 7) all of which were motor alerts. All were false positives as no patient had clinical neurological deterioration post-operatively. The false-positive rate was 1.4% (N = 146) for anterior surgeries and 1.3% (N = 394) for posteriors with no statistical difference between them (P = 1.0, Fisher exact test). There were no false-negative alerts, and all negatives were true negatives (N = 533). The overall sensitivity of detecting a new neurologic deficit was 0%, overall specificity 98.7%. CONCLUSION: Combined motor and sensory neuromonitoring for CSM patients created a confusing choice between the motor or sensory data when in disagreement in 1.3% of surgical patients. Criterion standard clinical examinations confirmed all motor alerts were false positives. Surgical plan was negatively altered by following false motor alerts early on, but disregarded in later cases in favor of sensory data. Neuromonitoring added set-up time and cost, but without clear benefit in this series.Level of Evidence: 4.

Patterns of spinal cord injury in automobiles versus motorcycles and bicycles.

STUDY DESIGN: Retrospective case series. OBJECTIVES: To examine the patterns and relative rates of occurrence of spinal cord injury (SCI) in automobiles compared to motorcycles and bicycles. SETTING: Los Angeles County, California. METHODS: A retrospective chart review of SCI consults at Rancho Los Amigos National Rehabilitation Center in Los Angeles County, California between 2003 and 2013 were selected and screened for a mechanism of injury involving a vehicular accident. Chart review was performed to determine neurological levels and extent of impairment, which were graded according to the International Standards for Neurological Classification of Spinal Cord Injury. RESULTS: We identified 398 cases of SCI from 2003 to 2013 that fit the inclusion criteria. Overall, the relative percentages of ASIA impairment scale (AIS) A/B/C/D did not differ statistically across automobiles, motorcycles, or bicycles. When stratified by spinal region, motorcycles had a higher percentage of thoracic SCIs compared to automobiles. Automobiles resulted in more cervical SCIs with few injuries in the lumbar region. Bicycle patterns followed automobiles, not motorcycles. Thoracic SCIs were more likely graded motor complete than cervical or lumbar injuries, regardless of the mechanism. CONCLUSIONS: Automobile, motorcycle, and bicycle related SCIs occur primarily in the cervicothoracic region. SCIs due to motorcycle accidents have a higher predilection for the thoracic region, and there is a statistically higher percentage of motor complete injuries. A higher percentage of cervical SCIs occur as a result of automobile and bicycle accidents. Extrapolations from motor vehicle usage data suggest that the relative rate of occurrence of SCI for motorcycles is higher than for automobiles.

Non-locality and the misdiagnosis of Spinal Cord Injury Without Radiographic Abnormality: proof of concept.

Study Design: This is a retrospective review. Objectives: To validate the concept of "non-locality" to explain cases of Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) previously deemed inexplicable. To investigate and challenge the source data for the SCIWORA hypothesis which has the built-in assumption that a traumatic spinal cord injury (SCI) can only be caused by a local or adjacent spinal column injury and which, therefore, postulates that the pediatric spinal column is inherently more flexible than the spinal cord to explain SCI whenever a local spinal column injury is not detected. Setting: A National Rehabilitation Center, one of fourteen which reports to the Spinal Cord Injury Model System. Methods: We examined all residual SCIWORA cases over a 5-year period. In addition, we performed an extensive literature search to trace the evidence supporting the SCIWORA hypothesis that children's spinal columns are inherently lax and may stretch more than the spinal cord prior to disruption. Results: Six SCI patients with a residual diagnosis of SCIWORA were identified, 3 pediatric and 3 adult. All had injuries fitting non-locality. None were an actual SCIWORA. Source data do not appear to support the SCIWORA hypothesis. Conclusion: Borrowing from quantum mechanics, we reveal non-locality as a real entity in the spine. The assumption of locality-only is invalid and likely contributed to the SCIWORA hypothesis for the pediatric spine. Misdiagnosis and misunderstanding of SCIWORA may lead to improper treatment and increased cost. Awareness may facilitate search for adequate explanations for difficult cases rather than mere assignment as SCIWORA.

Paraplegic patients: how to measure balance and what is normal or functional?

PURPOSE: To review the current understanding and data of sagittal balance and alignment considerations in paraplegic patients. METHODS: A PubMed literature search was conducted to identify all relevant articles relating to sagittal alignment and sagittal balance considerations in paraplegic and spinal cord injury patients. RESULTS: While there are numerous studies and publications on sagittal balance in the ambulatory patient with spinal deformity or complex spine disorders, there is paucity of the literature on "normal" sagittal balance in the paraplegic patients. Studies have reported significantly alterations of the sagittal alignment parameters in the non-ambulatory paraplegic patients compared to ambulatory patients. The variability of the alignment changes is related to the differences in the level of the spinal cord injury and their differences in the activations of truncal muscles to allow functional movements in those patients, particularly in optimizing sitting and transferring. Surgical goal in treating paraplegic patients with complex pathologies should not be solely directed to achieve the "normal" radiographic parameters of sagittal alignment in the ambulatory patients. The goal should be to maintain good coronal balance to allow ideal sitting position and to preserve motion segment to optimize functions of paraplegia patients. CONCLUSION: Current available literature data have not defined normal sagittal parameters for paraplegic patients. There are significant differences in postural sagittal parameters and muscle activations in paraplegic and non-spinal cord injury patients that can lead to differences in sagittal alignment and balance. Treatment goal in spine surgery for paraplegic patients should address their global function, sitting balance, and ability to perform self-care rather than the accepted radiographic parameters for adult spinal deformity in ambulatory patients.

American Spinal Injury Association A (sensory and motor complete) is not different from American Spinal Injury Association B (sensory incomplete, motor complete) in gunshot-related spinal cord injury.

BACKGROUND CONTEXT: We receive a large number of patients with spinal cord injury (SCI) due to penetrating gunshot wounds (GSW) at our national rehabilitation center. Although many patients are labeled American Spinal Injury Association (ASIA) B sensory incomplete because of sensory sparing, especially deep anal pressure, with purported prognostic value, we have not observed a clinical difference from patients labeled ASIA A complete. We hypothesized that sensory sparing, if meaningful, should reduce the occurrence of pressure ulcers. PURPOSE: To determine if ASIA classifications A and B are important distinctions for patients with SCIs secondary to civilian gunshot wounds. DESIGN/SETTING: A retrospective chart review was performed on all patients with civilian gunshot-induced SCI transferred to Rancho Los Amigos Rehabilitation Center between 1999 and 2014. Outcome measures were occurrence of pressure ulcers and surgical intervention for pressure ulcers. PATIENT SAMPLE: We included a total of 487 patients who sustained civilian gunshot wounds to the spine and were provided care at Rancho Los Amigos Rehabilitation Center from 2001 to 2014. OUTCOME MEASURES: Occurrence of pressure ulcers and surgical intervention for pressure ulcers among patients who suffered civilian-induced gunshot wounds to the spine. METHODS: Retrospective chart review identified 487 SCIs due to gunshot wounds that were treated at Rancho Los Amigos from 2001 to 2014. Injury characteristics including ASIA classification, pressure ulcers, and pressure ulcer surgeries were recorded. Comprehensive surgical data were obtained for all patients. Chart reviews and telephone interviews were performed to determine the occurrence of any pressure ulcers and pressure ulcer surgeries. Statistical analysis was performed to compare data by spinal region and ASIA grade. There were no conflicts of interest from any of the authors, and there was no funding obtained for this study. RESULTS: There was no statistical difference for cervical ASIA A versus ASIA B for the occurrence of pressure ulcers or the percentage requiring surgery, nor for thoracic A versus B. When grouped, there was a statistically higher occurrence of pressure ulcers in cervical A or B classification than in thoracic A or B classification, but a higher rate of surgery for thoracic A or B classification. Lumbosacral cauda equina levels were not statistically different in occurrence of pressure ulcers or pressureulcer surgery by ASIA grades A-D. Overall, when grouped C1-T12, cord-level cervicothoracic A and B classifications were statistically equivalent. C1-T12 cord level C or D classification with motor sparing had statistically lower occurrence and need of surgery for pressure ulcers and were equivalent to lumbosacral cauda equina level A-D. CONCLUSION: ASIA A and B distinctions are not meaningful at spinal cord levels in the cervicothoracic spine due to gunshot wounds as shown by similar occurrence of pressure ulcers and pressure ulcer surgery, and should be treated as if the same. Meaningful decrease of pressure ulcers at cord levels does not occur until there is motor sparing ASIA C or D. Furthermore, cauda equina lumbosacral injuries are a lower risk, which is independent of ASIA grade A-D and statistically equivalent to cord level C or D. Motor sparing at cord levels or any cauda equina level is most determinative neurologically for the occurrence of pressure ulcers or pressure ulcer surgery.

Surgical Management of Civilian Gunshot-Induced Spinal Cord Injury: Is It Overutilized?

STUDY DESIGN: Retrospective chart review. OBJECTIVE: Assess appropriate utilization of surgery for civilian gunshot-induced spinal cord injuries (CGSWSCI) according to literature standards in a large cohort. SUMMARY OF BACKGROUND DATA: CGSWSCI are mechanically stable injuries that rarely require surgery. Nonetheless, we continue to see high numbers of these patients undergo surgical treatment. This study compares indications for surgeries performed in a large cohort of CGSWSCI patients to established indications for surgical management of such injuries. The rate of over-utilization of surgical management was calculated. METHODS: Four hundred eighty-nine CGSWSCI patients transferred for rehabilitation to our institution between 2000 and 2014 were identified. Retrospective chart review was performed to identify patients who underwent initial surgical treatment, the specific surgeries performed, and indications given. We assessed appropriateness of surgery according to literature standards. Patients treated surgically were followed to assess for complications and the need for additional intervention and compared to nonsurgical patients. Secondarily, visual analog scale pain scores (0-10) and patient perceived improvement were compared between surgical and nonsurgical patients after telephone survey of both groups. RESULTS: Of 489 patients, 91 (18%) underwent initial surgery. Of 91 surgeries, 69 (75%) were not indicated by literature standards. Five of 91 (5.5%) of initially operated patients required a secondary surgery compared with two of 398 (0.5%) of the nonoperative group (P = 0.003). Over-utilization rate of the entire cohort was 14.1%. No difference was seen for pain scores or patient perceived improvement between operative and nonoperative patients. CONCLUSION: We report a high overutilization rate (14%) of surgery for CGSWSCI in our cohort. Surgical management was associated with higher infection and secondary surgery rates compared to nonsurgical management. Surgery done without a clear, demonstrable benefit poses unnecessary risk to patients and accumulates unwarranted healthcare costs. LEVEL OF EVIDENCE: 3.

Inadequate Surgical Decompression in Patients with Cervical Myelopathy: A Retrospective Review.

STUDY DESIGN: Retrospective study. OBJECTIVE: We reviewed cases of surgically treated cervical spondylotic myelopathy (CSM) or chronic, degenerative myelopathy of the subaxial cervical spine to study the incidence of inadequate surgical decompression. METHODS: We included all persons treated at our institution after a first surgical decompression for CSM over a 3-year period. Inadequate original surgical decompression was defined as neurologic decline within 12 months postoperatively and ongoing impingement of the spinal cord with <1-mm change in anteroposterior canal dimension from pre- to postoperative magnetic resonance imaging (MRI) leading to revision decompressive surgery. Revisions for other reasons were not counted as inadequate. RESULTS: Of 50 patients, 5 (10%) required revision decompression for neurologic decline and inadequate change in space available for the cord on postoperative imaging; 4 patients declined within the first 6 months and 1 patient at 8 months postoperatively. None of the 5 declined further after posterior revision, but none recovered from the interval loss. All 5 had undergone anterior approaches, for an anterior inadequacy rate of 23% (5 of 22). None of the 28 patients having posterior or combined approach declined at 2 years or had <1-mm change on postoperative MRI. The difference between anterior and posterior approaches was statistically significant (p = 0.018). CONCLUSIONS: The rate of inadequate surgical decompression for CSM was greater than expected in this series and directly associated with an anterior approach. No cases of inadequacy occurred for posterior or combined approaches. Postoperative neuroradiographic imaging such as MRI should be entertained routinely for this entity or at least for anterior-only approaches.

Overutilization of bracing in the management of penetrating spinal cord injury from gunshot wounds.

OBJECTIVE Penetrating gunshot wounds (GSWs) to the spinal column are stable injuries and do not require spinal orthoses or bracing postinjury. Nonetheless, a high number of GSW-related spinal cord injury (SCI) patients are referred with a brace to national rehabilitation centers. Unnecessary bracing may encumber rehabilitation, create skin breakdown or pressure ulcers, and add excessive costs. The aim of this study was to confirm the stability of spinal column injuries from GSWs and quantify the overutilization rate of bracing based on long-term follow-up. METHODS This retrospective cohort study was performed at a nationally renowned rehabilitation center. In total, 487 GSW-related SCI patients were transferred for rehabilitation and identified over the last 14 years. Retrospective chart review and telephone interviews were conducted to identify patients who were braced at the initial treating institution and determine if late instability, deformity, or neurological deterioration resulted in secondary surgery or intervention. In addition, 396 unoperated patients were available for analysis after 91 patients were excluded for undergoing an initial destabilizing surgical dissection or laminectomy, thereby altering the natural history of the injury. All of these 396 patients who presented with a brace had bracing discontinued upon reaching the facility. RESULTS In total, 203 of 396 patients were transferred with a spinal brace, demonstrating an overutilization rate of 51%. No patients deteriorated neurologically or needed later surgery for spinal column deformity or instability attributable to the injury. All patients had stable injuries. The patterns of injury and severity of neurological injury did not vary between patients who were initially braced or unbraced. The average follow-up was 7.8 years (range 1-14 years) and the average age was 25 years (range 10-62 years). CONCLUSIONS The incidence of brace overutilization for penetrating GSW-related SCI was 51%. Long-term follow-up in this study confirmed that these injuries were stable and thus did not require bracing. No patients deteriorated neurologically, whether or not they were initially braced. The unnecessary use of spinal orthoses increases costs and patient morbidity. Reeducation and dissemination of this information is warranted.

Accuracy of percutaneous lumbar pedicle screw placement using the oblique or "owl's-eye" view and novel guidance technology.

OBJECT: This study was conducted to assess the in vivo safety and accuracy of percutaneous lumbar pedicle screw placement using the owl's-eye view of the pedicle axis and a new guidance technology system that facilitates orientation of the C-arm into the appropriate fluoroscopic view and the pedicle cannulation tool in the corresponding trajectory. METHODS: A total of 326 percutaneous pedicle screws were placed from L-3 to S-1 in 85 consecutive adult patients. Placement was performed using simple coaxial imaging of the pedicle with the owl's-eye fluoroscopic view. NeuroVision, a new guidance system using accelerometer technology, helped align the C-arm trajectory into the owl's-eye view and the cannulation tool in the same trajectory. Postoperative fine-cut CT scans were acquired to assess screw position. Medical records were reviewed for complications. RESULTS: Five of 326 screws breached a pedicle cortex­all breaches were less than 2 mm­for an accuracy rate of 98.47%. Five screws violated an adjacent facet joint. All were at the S-1 superior facet and included in a fusion. No screw violated an adjacent mobile facet or disc space. There were no cases of new or worsening neurological symptoms or deficits for an overall clinical accuracy of 100%. CONCLUSIONS: The owl's-eye technique of coaxial pedicle imaging with the C-arm fluoroscopy, facilitated by NeuroVision, is a safe and accurate means by which to place percutaneous pedicle screws for degenerative conditions of the lumbar spine. This is the largest series reported to use the oblique or owl's-eye projection for percutaneous pedicle screw insertion. The accuracy of percutaneous screw insertion with this technique meets or exceeds that of other reported clinical series or techniques.

Scoliosis and interspinous decompression with the X-STOP: prospective minimum 1-year outcomes in lumbar spinal stenosis.

BACKGROUND CONTEXT: The X-STOP interspinous decompression device, as a treatment for neurogenic intermittent claudication (NIC) because of lumbar spinal stenosis (LSS), has been shown to be superior to nonoperative control treatment. Current Food and Drug Administration labeling limits X-STOP use to NIC patients with a maximum of 25° concomitant lumbar scoliosis. This value was arrived at arbitrarily by the device developers and is untested. PURPOSE: To determine X-STOP utility for NIC in patients with concomitant lumbar scoliosis. STUDY DESIGN: A prospective, single institution, clinical outcome study comparing patients with scoliosis with patients without scoliosis who underwent X-STOP interspinous decompression for NIC because of LSS. PATIENT SAMPLE: A cohort of 179 consecutive patients, 63 with scoliosis (Cobb angle 11° or more) and 116 without scoliosis, with symptoms attributable to NIC treated between January 2006 and May 2007, were included in the study. OUTCOME MEASURES: All patients completed self-reported preoperative and minimum 1-year postoperative outcome forms. Functional measures included Oswestry Disability Index (ODI), visual analog scale (VAS) pain score, and maximum walking and standing times in minutes. Three questions measured patient satisfaction: How satisfied were you with the procedure (very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied); Would you have the procedure again? (yes or no); Would you recommend the procedure to a friend? (yes or no). METHODS: Before analysis, the 179 consecutive X-STOP patients were divided into three groups: Group 1 (controls without scoliosis, n=116); Group 2 (low scoliosis: 11-25°, n=41), and Group 3 (high scoliosis: 26° or more, n=22). The three groups were not statistically different for any preoperative functional scores. Groups were analyzed for pre- to postoperative functional change and level of satisfaction. Segmental scoliosis at the treated level was also analyzed. RESULTS: Fifty-six percent of Group 1 and Group 2 patients, but only 18% of Group 3 patients, achieved the success criterion of an ODI improvement of 15 or more points (Group 3 the outlier, p=.004). The satisfaction rate was Group 1, 76%; Group 2, 78%; Group 3, 59% (Group 3 the outlier, p=.0001). On average, all three groups improved for each outcome: Group 1 (ODI 17.3, VAS 2.0, standing time 39 minutes, and walking time 43 minutes), Group 2 (ODI 20.0, VAS 1.9, standing time 65 minutes, and walking time 64 minutes), Group 3 (ODI 7.2, VAS 0.9, standing time 18 minutes, and walking time 16 minutes). There was no statistical relationship between any outcome and segmental scoliosis. CONCLUSIONS: The outcome success rate for the X-STOP procedure to treat NIC is lower in patients with overall lumbar scoliosis more than 25° but is unaltered by segmental scoliosis at the affected level. Although patients and surgeons must be aware that the presence of more than 25° of scoliosis portends less favorable results with X-STOP implantation for NIC because of LSS, success in these patients is not precluded, and selection of treatment must be put into the context of individual patient risk and other treatment options.

Corrective osteotomies and osteosynthesis for supination contracture of the forearm in children.

PURPOSE: The purpose of this study was to present the authors' experience with corrective osteotomies of the forearm for supination contracture in children. METHODS: Fourteen patients with supination contracture of the forearm due to brachial plexus lesion (11), poliomyelitis residuals (2), or Monteggia fracture malunion (1) underwent distal ulnar osteotomy without fixation and subsequent midradial osteotomy with plate fixation to produce a position of greater pronation. A minimum of 6 months' follow-up was required to be included in the series. RESULTS: Ten boys and 4 girls whose mean age was 11 years underwent surgery between 1998 and 2006 to correct a supination contracture. The mean preoperative contracture measured 80 degrees of supination. The final mean postoperative correction was 104 degrees, whereas the final mean position of pronation was 24 degrees. CONCLUSIONS: Distal ulnar and midradial osteotomies are effective in the treatment of supination deformities of the forearm with little risk of complication or need for additional surgery. Radial fixation is important, but ulnar fixation is not required. Both osteotomies must be complete before plate fixation of the radius to realize maximal correction. LEVEL OF EVIDENCE: Level IV.

Identification of mitogen-activated protein kinase kinase as a chemoresistant pathway in MCF-7 cells by using gene expression microarray.

BACKGROUND: Components of the mitogen-activated protein kinase (MAPK) cascade have been implicated in apoptotic regulation. This study used gene expression profiling analysis to identify and implicate mitogen-activated protein kinase kinase (MEK5)-BMK1 (big mitogen-activated kinase-1)/extracellular signal related protein kinase (ERK5) pathway as a novel target involved in chemoresistance. METHODS: Differential gene expression between apoptotically sensitive (APO+) and apoptotically resistant (APO-) MCF-7 cell variants was determined by using microarray and confirmed by reverse transcriptase- polymerase chain reaction (RT-PCR). An apoptotic/viability reporter gene assay was used to deter-mine the effects of the transfection of a dominant-negative mutant of BMK1 (BMK1/DN) in conjunction with apoptotic-inducing agents (etoposide, tumor necrosis factor-alpha [TNF], or TNF-related apoptosis-inducing ligand [TRAIL]), with or without phorbol ester (PMA). RESULTS: Of the 1186 genes detected through microarray analysis, MEK5 was increased 22-fold in APO- cells. Overexpression of MEK5 was confirmed by using RT-PCR analysis. Expression of BMK1/DN alone resulted in a dose-dependent increase in cell death versus control (P <.05). In addition, BMK1/DN enhanced the sensitivity of MCF-7 cells to treatment-induced cell death (P <.05). The ability of PMA to partially suppress TRAIL- and TNF-induced cell death was inhibited by BMK1/DN. However, only TRAIL-induced activity suppression reached statistical significance (P <.05). CONCLUSIONS: The overexpression of MEK5 in APO- MCF-7 breast carcinoma cells shows that this MAPK signaling protein represents a potent survival molecule. Molecular inhibition of MEK5 signaling may represent a mechanism for sensitizing cancer cells to chemotherapeutic regimens.