Lumbar discectomy outcomes vary by herniation level in the Spine Patient Outcomes Research Trial.

BACKGROUND: The Spine Patient Outcomes Research Trial showed an overall advantage for operative compared with nonoperative treatment of lumbar disc herniations. Because a recent randomized trial showed no benefit for operative treatment of a disc at the lumbosacral junction (L5-S1), we reviewed subgroups within the Spine Patient Outcomes Research Trial to assess the effect of herniation level on outcomes of operative and nonoperative care. METHODS: The combined randomized and observation cohorts of the Spine Patient Outcomes Research Trial were analyzed by actual treatment received stratified by level of disc herniation. Overall, 646 L5-S1 herniations, 456 L4-L5 herniations, and eighty-eight upper lumbar (L2-L3 or L3-L4) herniations were evaluated. Primary outcome measures were the Short Form-36 bodily pain and physical functioning scales and the modified Oswestry Disability Index assessed at six weeks, three months, six months, one year, and two years. Treatment effects (the improvement in the operative group minus the improvement in the nonoperative group) were estimated with use of longitudinal regression models, adjusting for important covariates. RESULTS: At two years, patients with upper lumbar herniations (L2-L3 or L3-L4) showed a significantly greater treatment effect from surgery than did patients with L5-S1 herniations for all outcome measures: 24.6 and 7.1, respectively, for bodily pain (p = 0.002); 23.4 and 9.9 for Short Form-36 physical functioning (p = 0.014); and -19 and -10.3 for Oswestry Disability Index (p = 0.033). There was a trend toward greater treatment effect for surgery at L4-L5 compared with L5-S1, but this was significant only for the Short Form-36 physical functioning subscale (p = 0.006). Differences in treatment effects between the upper lumbar levels and L4-L5 were significant for Short Form-36 bodily pain only (p = 0.018). CONCLUSIONS: The advantage of operative compared with nonoperative treatment varied by herniation level, with the smallest treatment effects at L5-S1, intermediate effects at L4-L5, and the largest effects at L2-L3 and L3-L4. This difference in effect was mainly a result of less improvement in patients with upper lumbar herniations after nonoperative treatment.

Distraction-flexion injury in a neurologically intact pediatric patient treated nonoperatively: case study.

STUDY DESIGN: A case study was conducted. OBJECTIVE: To detail the successful nonoperative management of a distraction-flexion Salter-Harris Type 1 midcervical spine injury in a young child. SUMMARY OF BACKGROUND DATA: Documented cases of neurologically intact pediatric patients with unstable flexion-distraction injuries of the midcervical spine are rare. METHODS: A case report and literature review are presented. RESULTS: A rare distraction-flexion injury was successfully treated nonoperatively. CONCLUSIONS: Although distraction-flexion cervical spine injuries are common in adults and often occur with concomitant neurologic sequelae, they also can occur in the pediatric patient. Whereas these injuries require surgery in adults, they can be managed nonoperatively in the pediatric population.

The impact of spinal problems on the health status of patients: have we underestimated the effect?

STUDY DESIGN: A prospective study of 17,774 patients who consulted spine centers in which the impact of spinal disorders and comorbidities on physical functional status were evaluated. OBJECTIVES: To quantify the effect spinal diagnoses have on patients' physical functional status (SF-36 Physical Component Summary [PCS] score) compared with other common conditions and to quantify the effects of comorbidities on physical functional status in spine patients. SUMMARY OF BACKGROUND DATA: The burden of spinal conditions on a patient's function and the role that comorbidities play in this affliction are poorly quantified in the literature. METHODS: Data from the Health Survey Questionnaire were prospectively gathered through the National Spine Network, a nonprofit consortium of spine-focused practices. Each patient's SF-36 score was summarized into a single PCS score. The correlation between diagnosis and comorbidity and PCS score was assessed using multivariate linear regression. RESULTS: The study patients were a mean of 47.5 years of age, 54.7% were female, 52.3% had lumbosacral diagnoses, and 82.0% had had 3 or more months of pain. The population had a mean PCS score of 30.4 +/- 9.95 (SD) compared with 50.0 +/- 10.00 for the general United States population. The more comorbidities in a patient, the lower the PCS score (Spearman rank correlation = -0.27). The five comorbid conditions that lowered the PCS the most included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), renal failure, rheumatoid arthritis, and lupus (all P <0.001). In multiple linear regression analysis, age, gender, diagnosis, and comorbidity explained 12.1% of the variance in PCS score. CONCLUSIONS: The PCS score is greatly affected in patients with spinal problems. The study population's PCS (30.4) was lower or similar to the PCS for patients with other illnesses reported in the literature: CHF (31.0), COPD (33.9), SLE (37.1), cancer (38.4), primary total hip arthroplasty (29.0), primary total knee arthroplasty (32.6), and glenohumeral degenerative joint disease (35.2). Further, the presence of comorbidity in spine patients adds to the burden of spinal conditions on functional status.

Giovanni Alfonso Borelli: "Father of spinal biomechanics".

The first modern textbook on spinal biomechanics was written by Giovanni Alfonso Borelli in 1680. A mathematician, astronomer, and physicist by trade, Borelli became consumed in the physical laws of nature and the human body. His work served as a monumental contribution to ascertain, in depth and with undiminished accuracy, the basic biomechanical principles of the human body.

Primary bone and metastatic tumors of the cervical spine.

Cervical spine tumors, whether primary bone tumors or metastatic tumors, are rare. The possibility of tumors existing must be considered in the differential diagnosis of patients with persistent neck pain, with or without neurologic symptoms, particularly in those with significant pain at night. The clinical presentation is extremely variable, though a history of malignancy should always raise the concern for recurrence. The evaluation and diagnostic assessment includes a thorough physical examination. Radiographic imaging is usually initiated with plain radiographs and additional advanced imaging obtained as indicated. Using appropriate biopsy principles and techniques, tissue is obtained for histologic determination of the suspected lesion before surgical intervention. Treatment options are extremely variable and depend on many factors, including tumor type, location, and patient preference. Treatment warrants a multidisciplinary approach from experienced physicians and is most successfully accomplished in referral centers. Oncologic staging using the Enneking staging system, followed by surgical staging using the Weinstein, Boriani, Biagini system, will aid in the accurate characterization of the tumor load, maximize surgical goals, assure use of appropriate terminology, and provide optimal communication among treatment centers regarding tumor characteristics, treatment efforts, and results.

Reconstructive amputation after grade IIIC open tibial fracture. One method of preserving residual limb length.

A high percentage of patients with grade IIIC open tibial fractures eventually undergo amputation. Maintaining an adequate residual limb length is advantageous with regard to biomechanics, energy expenditure, and prosthetic fitting. This case report presents new considerations for maintaining residual limb length in the presence of comminuted proximal tibial fractures. These considerations include (a) using an autogenous fibular strut graft for stabilizing the reconstructed residual limb and (b) determining the level of amputation based on soft-tissue integrity rather than on fracture level. We present one technique for preserving an adequate residual limb length in the face of significant proximal tibia comminution.

Pedicular transvertebral screw fixation of the lumbosacral spine in spondylolisthesis. A new technique for stabilization.

Controversy exists about which method is most appropriate for treating moderate- to high-grade spondylolisthesis and symptomatic pseudarthrosis. The authors report preliminary results of pedicular transvertebral screw fixation, a new technique for stabilizing the lumbosacral junction in moderate- to high-grade spondylolisthesis. Using this technique, fusion was successful in three patients, two with an established pseudarthrosis. Pedicular transvertebral screw fixation provides immediate three-column stabilization of the lumbosacral junction. The technique is safe, effective, and employs instrumentation common to spine surgery. Its use in high-grade slips makes the technique more simple to perform than other methods of lumbosacral stabilization.

Techniques of subaxial posterior cervical spine fusions: an overview.

The various methods for posterior cervical stabilization techniques allow successful fusion in almost all instances and indications. The choice is primarily dependent on the surgeon's training, experience, and preference, and is subsequently narrowed by the available intact and stable anatomy unique to each patient's injury. Despite the availability of multiple stabilization techniques and their widespread use, these techniques should be performed only by surgeons familiar and comfortable with the approach, anatomy, and stabilization techniques, and with the care of patients with mechanical and neurological injuries to the cervical spine.

Cryopreservation of platelets isolated with the IBM 2997 blood cell separator: a rapid and simplified approach.

The equivalent of 5-7 units of platelets, isolated from a single donor with the IBM Blood Cell Processor 2997 using a dual stage separation chamber, was frozen with the cryoprotectant dimethylsulfoxide (DMSO). The DMSO-saline solution was added directly to the platelets, and the platelets were frozen in a polyvinyl chloride plastic bag by storage in a -80 degrees C mechanical freezer. Washing the thawed platelets with a phosphate-buffered sodium chloride-dextrose solution, pH of 5.0, removed about 95% of the DMSO. In vitro freeze-thaw-wash recovery was 80%, and in vivo 51Cr platelet recovery was 31%. Platelet dense body granules were well maintained after freezing, thawing, and washing. This is a safe and effective method of platelet cryopreservation which can be performed in less time than other currently used methods.