Debility Among Spinal Surgeons.

BACKGROUND: As the climate of medical care continually shifts, more is expected of surgical specialists than ever before. The rate of burnout among providers appears to be increasing, whereas the career longevity of the modern physician continues to rise to meet the growing demands of our patient population. Spinal surgery is a demanding field, requiring significant amounts of mental and physical fortitude. We intend to highlight issues that cause debility in this cohort of providers. METHODS: This study surveyed the members of the North American Spine Society to better ascertain the issues that plague our profession in relation to physical and mental debility. The survey included multiple-choice questions regarding demographics, burnout, and health status, among other physical and mental health concerns. RESULTS: We achieved a 19% response rate. Eighty percent of responders highlighted physical debility, and psychological, social, and/or behavioral debility (e.g., burnout) was reported by 39% of respondents. CONCLUSIONS: This study highlights the need to improve the work environment and maintain physician health. Although this report sheds light on the problems affecting our colleagues, there is much work that is needed to improve on them. Often the medical philosophy is to ignore one's own personal discomfort in the quest to help patients. In an era in which physician career longevity is needed, these issues must be identified and addressed.

The efficacy of ketamine for postoperative pain control in adolescent patients undergoing spinal fusion surgery for idiopathic scoliosis.

The use of ketamine in conjunction with morphine to reduce postoperative pain has been explored in several different surgery subtypes with conflicting results. Ketamine has shown promise to have both opioid sparing and analgesic effects in the postoperative setting. This study aimed to elucidate ketamine's ability to reduce morphine equivalent consumption and improve patient satisfaction after spinal fusion surgery for the correction of idiopathic scoliosis. This surgery is known to be associated with significant postoperative pain which impedes the ability to improve patient satisfaction, and may complicate the recovery timeline. Currently, the standard therapeutic regimen consists of patient-controlled analgesia morphine and the use of other opioids such as hydromorphone. A prospective, randomized double-blinded, placebo-controlled trial was performed to compare the standard morphine equivalent therapy alone against a standard therapy in conjunction with ketamine. Fifty adolescent patients were enrolled and randomized. Results yielded a significant reduction in postoperative morphine equivalent consumption (p = 0.042), adjusted postoperative pain scores (p < 0.001), and incidence of nausea and vomiting (p = 0.045). The application of ketamine as an analgesic in conjunction with the current standard of morphine equivalent therapy may serve as a superior pain control regimen for spinal surgeries in young population. This regimen enhancement may be generalizable to other surgery subtypes within similar populations. LEVEL OF EVIDENCE: Level I.

Great Vessel Excursion: Prone Versus Supine Position.

BACKGROUND: It is theorized that pedicle screws could be placed into the anterior vertebral cortex to increase biomechanical strength by 20% to 25%. Although stereotactic navigational tools allow for accurate docking of spinal implants, no data exist regarding operative positioning as it relates to great vessel alignment. Our hypothesis is that the great vessels fall anteriorly, with prone positioning providing a safer margin for implantation of screws from a posterior approach. METHODS: Volunteers underwent magnetic resonance imaging of the spine. Twenty healthy volunteers, affiliated with the academic medical center performing the study, underwent magnetic resonance imaging in both the supine and prone positions. Measurements were taken of the distance (mm) from the projected tip of a pedicle screw to the neighboring great vessels.Measurements were made at every other vertebral level from T3 to L5 by bisecting the pedicle in the transverse and sagittal planes and projecting the trajectory of a screw to the anterior cortex. We then evaluated great vessel position in relationship to the tip of the projected pedicle screw at the anterior cortex in the supine and prone orientations. RESULTS: The vessels were found to lie in a range of 2 to 10 mm from the anterior cortex. The comparison between the supine and prone positions showed that the great vessels in the lumbar region are held securely by the surrounding soft tissue. However, in the thoracic spine, anterior excursion does occur, just not as we expected. The aorta moves anteriorly while prone by 1.4 to 5 mm; however, its movement causes it to slide forward along the vertebra, shortening the distance to the anterior cortex. As a result, the screw trajectory is in a riskier geographic location. In the thoracolumbar area, the inferior vena cava translates 1.7 to 2.9 mm. CONCLUSIONS: These data suggest that the risks of vascular injury from anterior cortical fixation of the vertebra using pedicle screws placed posteriorly in the prone position are apparent. In the lumbar region, the upper thoracic region around the aortic arch, and the thoracolumbar junction the great vessels remain close to the vertebra. While in the mid-thoracic region, the aorta moves closer to the area of screw penetration anteriorly when the subject is prone. CLINICAL RELEVANCE: Spine surgeons commonly attempt pedicle screw placement into the anterior cortex of the vertebral body. Our study helps elucidate the inherent risks of this technique due to vessel positioning when prone.

Preservation of Spine Motion in the Surgical Treatment of Adolescent Idiopathic Scoliosis Using an Innovative Apical Fusion Technique: A 2-Year Follow-Up Pilot Study.

BACKGROUND: This trial reports the 2-year and immediate postremoval clinical outcomes of a novel posterior apical short-segment (PASS) correction technique allowing for correction and stabilization of adolescent idiopathic scoliosis (AIS) with limited fusion. METHODS: Twenty-one consecutive female AIS patients were treated at 4 institutions with this novel technique. Arthrodesis was limited to the short apical curve after correction with translational and derotational forces applied to upper and lower instrumented levels. Instrumentation spanned fused and unfused segments with motion and flexibility of unfused segments maintained. The long concave rods were removed at maturity. Radiographic data collected included preoperative and postoperative data for up to 2 years as well as after long rod removal. RESULTS: All 21 patients are beyond 2 years postsurgery. Average age at surgery was 14.2 years (11-17 years). A mean of 10.5 ± 1 levels per patient were stabilized and 5.0 ± 0.5 levels (48%) were fused. Cobb angle improved from 56.1° ± 8.0° to 20.8° ± 7.8° (62.2% improvement) at 1 year and 20.9° ± 8.4°, (62.0% improvement) at 2 years postsurgery. In levels instrumented but not fused, motion was 26° ± 6° preoperatively compared to 10° ± 4° at 1 year postsurgery, demonstrating 38% maintenance of mobility in nonfused segments. There was no report of implant-related complications. CONCLUSIONS: PASS correction technique corrected the deformity profile in AIS patients with a lower implant density while sparing 52% of the instrumented levels from fusion through the 2-year follow-up.

Computer Assisted Cobb Angle Measurements: A novel algorithm.

BACKGROUND: The standard for evaluating scoliosis is PA radiographs using Cobb angle to measure curve magnitude. Newer PACS systems allow easier Cobb angle calculations, but have not improved inter/intra observer precision of measurement. Cobb angle and its progression are important to determine treatment; therefore, angle variability is not optimal. This study seeks to demonstrate that a performance equivalent to that achieved in the manual method is possible using a novel computer algorithm with limited user input. The authors compared Cobb angles from predetermined spinal levels in the average attending score versus the computer assisted approach. METHODS: Retrospective analysis of PA radiographs from 58 patients previously evaluated for scoliosis was collected. Predesignated spinal levels (e.g., T2-T10) were assigned for different curves and calculated by Cobb method. Four spine surgeons evaluated these Cobb angles. Their average scores were measured and compared to formulated values using the novel computer-based algorithm. Literature reports inter-observer reliability is 6.3-7.2degrees. Limits of accuracy were set at 5 degrees of average orthopedic surgeons' score. RESULTS: The computer-based algorithm calculated Cobb angles within 5 degrees of orthopedic surgeons' average with a standard deviation of 3.2 degrees. This result was based on a 95% confidence interval with p values <0.001. The computer algorithm was plotted against average angle determined by the surgeons, with individual determinations and linear regression (r2 =0.90). The average difference between surgeons' measures and computer algorithm was 0.4 degrees(SD= 3.2degrees, n=79). There was a tendency for the computer algorithm program to overestimate the angle at larger angles, but difference was small with r2 = 0.09. CONCLUSIONS: Our study showed the novel computer based algorithm was an efficient and reliable method to assess scoliotic curvature in the coronal plane with the possibility of expediting clinic visits, ensuring reliability of calculation and decreasing patient exposure to radiation. Level of Evidence: III.

Analysis of Segmental Mobility Following a Novel Posterior Apical Short-Segment Correction for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: A prospective, nonrandomized, multicenter study. OBJECTIVES: The purpose of this study was to evaluate the amount of motion present at instrumented but unfused segments and at motion segments adjacent to the instrumentation following application of a new posterior apical short-segment correction technique for correcting adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: High-density pedicle screw instrumentation and posterior arthrodesis of all instrumented levels is the most common surgical treatment for AIS stabilization. The consequence of long fusion is an abnormal load on adjacent levels with an increased risk of future adjacent segment degeneration. METHODS: This new system applied translational and derotational forces over a short apical segment. The short apical region was prepared for fusion while maintaining motion of unfused vertebral segments. Radiographic data were collected pre-operatively, at surgery, and at 3, 6, and 12 months after surgery. RESULTS: Twenty-one female patients, mean age of 14.2 years (10.6-16.9 years) with Lenke 1A/1B curves, were enrolled. The range of motion in the unfused instrumented segment was significantly higher than the apical fused segment (11 vs. 0.9, P < 0.001). The range of motion of unfused vertebral levels distal to the construct at one year did not differ significantly from their respective pre-op values. When the analysis was extended to understand the impact of lower instrumented vertebra (LIV) on motion of unfused segments distal to the construct, it appeared that (1) the change in motion from pre-op to 12 months post-op as a function of LIV is not statistically significant; and (2) The motion of the unfused distal vertebral segments at 12 months does not statistically increase with a lower LIV. CONCLUSION: Through one year, this novel technique achieved and maintained similar AIS correction to current posterior fusion techniques while maintaining the mobility of unfused motion segments with less implant density. LEVEL OF EVIDENCE: 4.

Fifteen to twenty-five year functional outcomes of twenty-two patients treated with posterior Cotrel-Dubousset type instrumentation: a limited but detailed review of outcomes.

BACKGROUND: Long-term outcomes of patients undergoing extensive fusions for adolescent idiopathic scoliosis (AIS) have conflicting results. Moskowitz found uninstrumented scoliosis fusion patients had similar back pain as a normal age matched population. Recently, long-term outcomes of patients with Harrington rod instrumentation were reviewed and found similar functional outcome scores to non-scoliosis patients, with trending toward worse outcomes when fusions extended to L4. Our study examined long-term functional outcomes of patients treated with Cotrel-Dubousset (CD) instrumentation and determined whether distal level of instrumented fusion (L4 and L5) correlate with increased back pain or lower functional level. METHODS: Retrospective review of AIS surgeries from 1986 to 1996 was undertaken. Patient demographics and surgical data were collected via case-note audit. Patients were contacted and asked to complete a series of functional outcome questionnaires including visual analog scales (VAS) for pain, Short-Form 36 (SF-36), Scoliosis Research Society 22 (SRS-22) and Oswestry Disability Index (ODI) for function. ANOVA technique categorically compared outcome scores to most distal levels of fusion. Linear regression compared patient reported outcomes to time elapsed since surgery. Statistical significance was p < 0.05. RESULTS: One hundred twelve patients were identified, 50 patients were contacted, and 22 agreed to participation and completed a full assessment. Follow-up time since surgery ranged from 15 to 26 years and age ranged from 30 to 43 years. Six patients reported daily VAS back pain of ≥5; with a mean of 2.5. Back pain was not associated with level of distal fusion (p = 0.92). ODI was 15.36, with six patients' ODI >20. No relationship was shown between ODI and distal level of fusion (p = 0.72). SF-36 and SRS 22 values were also not related to distal level of instrumentation. Patient reported VAS back pain scores (r(2) = 0.18, p = 0.05), ODI (r(2) = 0.09, p = 0.17), and SF-36 and SRS-22 were not worse in patients with longer follow-up over time. Back pain and certain functional score subcategories of the SF-36 and SRS-22 trended toward improved results over time. CONCLUSIONS: Most patients who underwent multi-segment spinal fixation appeared to do well long-term, with minimal back pain. Lowest instrumented segment did not appear to be associated with increased back pain after 15 to 25 years follow-up.

Spinal cord compression in pseudohypoparathyroidism.

BACKGROUND CONTEXT: Spinal cord compression associated with pseudohypoparathyroidism (PHP) is an increasingly reported sequelae of the underlying metabolic syndrome. The association of neurologic dysfunction with PHP is not well appreciated. We believe this to be secondary to a combination of underlying congenital stenosis, manifest by short pedicles secondary to premature physeal closure, and hypertrophic ossification of the vertebral bony and ligamentous complexes. PURPOSE: The purpose of this case report is to review the case of spinal stenosis in a child with PHP Type Ia. We are aware of only eight published reports of patients with PHP Type Ia and spinal stenosis-there are only two previously known cases of pediatric spinal stenosis secondary to PHP. STUDY DESIGN/SETTING: This is a case report detailing the symptoms, diagnosis, interventions, complications, and ultimate outcomes of a pediatric patient undergoing spinal decompression and fusion for symptomatic stenosis secondary to PHP Type Ia. Literature search was reviewed regarding the reports of spinal stenosis and PHP, and the results are culminated and discussed. PATIENT SAMPLE: We report on a 14-year-old obese male with PHP and progressive lower extremity weakness secondary to congenital spinal stenosis. Examination revealed functional upper extremities with spastic paraplegia of bilateral lower extremities. The patient's neurologic function was cautiously monitored, but he deteriorated to a bed-bound state, preoperatively. METHODS: The patient's chart was reviewed, summarized, and presented. Literature was searched using cross-reference of PHP and the terms "spinal stenosis," "myelopathy", "myelopathic," and "spinal cord compression." All relevant case reports were reviewed, and the results are discussed herein. RESULTS: The patient underwent decompression and instrumented fusion of T2-T11. He improved significantly with regard to lower extremity function, achieving unassisted ambulation function after extensive rehabilitation. Results from surgical decompression in previously reported cases are mixed, ranging from full recovery to iatrogenic paraplegia. CONCLUSIONS: The association of neurologic dysfunction with PHP is not well appreciated. It is important to highlight this rare association. Surgical decompression in patients with PHP yields mixed results but may be of greatest efficacy in younger patients who receive early intervention.

Complications in spinal deformity surgery: issues unrelated directly to intraoperative technical skills.

STUDY DESIGN: Literature review of complications unrelated directly to surgical skills involved in spinal deformity surgery. OBJECTIVE: Highlight complications associated with perioperative issues. SUMMARY OF BACKGROUND DATA: Complications can arise from mundane events that arise during the operative experience, but are not directly related to surgical skills. METHODS: Literature reviews that touches on the more common potential complication events that do not involve direct surgical expertise. RESULTS: The topics of positioning, nutrition, blood loss, comorbidities, OR time, and pulmonary and GI concerns are discussed as basics that could derail a surgical outcome even with an otherwise uneventful surgical technique. The need for vigilance is stressed and the nuances of understanding these are discussed. CONCLUSION: Mundane events can derail a perfectly executed surgical undertaking. Attention to detail, team work, close monitoring, and checklist type focus will help to improve, focus, and avoid these preventable complications that have nothing to do with direct surgical skills.

Small intestinal submucosa for anular defect closure: long-term response in an in vivo sheep model.

STUDY DESIGN: After undergoing anulotomy, lumbar intervertebral discs from sheep were treated with small intestinal submucosa (SIS) and assessed functionally at 24 weeks after surgery. OBJECTIVE: To determine the efficacy of an SIS-based patch and plug scaffold to facilitate anular defect closure and anular functional recovery after anulotomy and partial discectomy. SUMMARY OF BACKGROUND DATA: The incidence of reherniation following discectomy remains high and mechanical means of anular closure have met with limited success. SIS is a naturally occurring collagen-based material, which acts as a resorbable scaffold in vivo that promotes soft tissue regeneration. METHODS: Twelve sheep underwent retroperitoneal exposure of the lumbar spine. Three levels were assigned to either: no additional procedure, box anulotomy alone, or box anulotomy followed by placement of an SIS "patch and plug" anchored by titanium bone screws. At 26 weeks after surgery, 18 motion segments underwent pressure-volume testing to assess the competency of the anulus. High resolution MRI images were taken of the remaining 18 segments. Undecalcified histology was conducted on all specimens. RESULTS: Radiographs, MRI images, and histology indicate that there was an exuberant tissue response at SIS-treated levels. New tissue formation in SIS-treated specimens was integrated well with the native anulus, but did not resemble the organization of native anulus. The extent of anular closure was substantial enough to allow the disc a functional recovery to a mean 66% of its capacity to develop internal pressure. MRI images indicate that SIS-treated levels did not maintain signal intensity comparable to exposure-only (intact) levels, but SIS-treated discs were statistically significantly higher than anulotomy-only levels. CONCLUSION: SIS-treated discs were better able to maintain hydration and resulted in a functional recovery relative to anulotomy alone levels. The SIS patch and plug reduced the cascade of functional degeneration that an intervertebral disc undergoes following anulotomy.

The Huichol offering: a shamanic healing journey.

An American transcultural psychiatrist, and a Mexican engineer deeply involved with the Huichol Indians, build a team that heals a decade-long epidemic caused by sorcery. Huichol children in boarding schools became possessed by demonic witchcraft that transformed them into aggressive animals. Many local shaman had been called in to treat the illness but had been unsuccessful. The team found a way to incorporate traditional belief and ritual, with modern psychological principles to weave a healing story. This article represents the ultimate integration of mind/body/spirit medicine to heal across cultures.

Epidural granuloma arising from epidural catheter placement.

Indwelling epidural catheter placement for prolonged drug delivery or is commonplace. Epidural catheter placement leading to a subsequent epidural mass is infrequently symptomatic and thus not often sought after or uncovered. Such masses can mimic lesions causing tumor, infection, and inflammation, and when found, the etiology of granuloma formation is unclear. This article describes a case of a benign epidural granuloma masquerading as an epidural tumor thought to be caused by epidural catheter placement for postoperative total hip replacement pain control. After symptoms of mechanical and radiculopathic pain arose, the patient underwent an open biopsy, spinal decompression, and intradural exploration as an MRI evaluation identified a mass in the spinal canal. Pathologic examination identified a benign fibrous granuloma. At 36-month follow-up, there was no evidence of symptom or tumor recurrence.

Pregnancy after anterior spinal surgery: fertility, cesarean-section rate, and the use of neuraxial anesthesia.

BACKGROUND CONTEXT: Previous publications have reported results with respect to functional outcome and sexual function in young women after traumatic injuries to the pelvis. It is well known that anterior spinal surgery has the possibility of causing reproductive dysfunction in men. Little has been described concerning deleterious effects of anterior spinal surgery in women of childbearing age. PURPOSE: The purpose of the study was to determine the fertility, cesarean section rate, and the use of neuraxial anesthesia in a population of women of childbearing age who have undergone anterior spinal surgery. STUDY DESIGN/SETTING: This was a retrospective chart review combined with a telephone questionnaire of the patients who had undergone anterior spinal surgery by a single orthopedic surgeon. METHODS: Demographic data were collected from hospital and office records. Patients were asked if they had tried to become pregnant, if their pregnancy had come to term, the use of spinal or epidural anesthesia for that labor and delivery, and the type of delivery. RESULTS: Seventy-nine potential subjects were identified and 67 patients were contacted to determine their fertility status. Ninteen patients had tried to become pregnant after their anterior spinal surgery. All patients who reported that they tried to become pregnant were successful at having a child. Seven of the 19 women had children who were born by cesarean section (37%). Only two patients received an epidural as analgesia for their delivery. CONCLUSIONS: Although the cesarean-section rate appears high, it is consistent with the current obstetrical trends. Anesthesiologists appear less inclined to offer neuraxial anesthesia to a population which has undergone anterior spinal surgery.

Effect of kyphoplasty on survival after vertebral compression fractures.

BACKGROUND: A growing population of patients with osteoporosis and fragility fractures has developed. Fragility fractures, including vertebral compression fractures, have been associated with increased mortality. Early operative interventions for patients sustaining hip fractures have been found to reduce mortality. PURPOSE: To determine if kyphoplasty improves survival after vertebral compression fractures. STUDY DESIGN: A retrospective chart review of all kyphoplasty procedures performed by the same orthopedic surgeon between June 2000 and June 2004 and a review of patients receiving nonoperative care consisting of oral analgesia and an orthosis during the same time period were conducted. PATIENT SAMPLE: Patients seen by a single surgeon for an osteoporotic vertebral body fracture. OUTCOME MEASURES: The primary outcome measured was patient death within the study time period. METHODS: Data from both groups were tabulated and analyzed for statistical differences by Student t test and chi-squared analysis. Kaplan-Meier curves comparing age, medical comorbidity, and surgical intervention were constructed. Log-rank test was used to analyze the survival curves. RESULTS: Of the 94 patients who elected for kyphoplasty, 38 patients were deceased at the close of the current study which ended in September 2006, whereas 26 of the 90 patients who elected for conservative therapy had died. Student t test revealed a significant age difference between patients treated with kyphoplasty and those who were treated nonoperatively (p=.0002). Chi-squared analysis revealed a significant difference between the two populations with respect to Charlson score (p=.050) but no statistical difference between the two populations with respect to ASA (p=.81) or gender (p=.1207). Kaplan-Meier curves were constructed to independently assess the influence of age, medical comorbidity, and kyphoplasty on survival. A significant relationship was detected by log-rank test for age (p=.0172), ASA (p=.0497), and Charlson score (p=.0015) but not treatment with kyphoplasty (p=.1037). An age-adjusted mortality rate was calculated and was found to be 35.3 per 1,000 patient-years for the conservative treatment population and 40.1 for the surgical population. A multivariate analysis comparing age, comorbidity, and surgical treatment with survival did not detect a statistical relationship. CONCLUSION: Kyphoplasty did not seem to effect the survival of patients with a vertebral compression fracture.

Invasive and minimally invasive surgical techniques for back pain conditions.

This article summarizes current issues related to invasive and minimally invasive surgical techniques for back pain conditions. It describes pain generators and explains theories about how discs fail. The article discusses techniques for treating painful sciatica, painful motion segments, and spinal stenosis. Problems related to current imaging are also presented. The article concludes with a discussion about physical therapy.

Vertebroplasty and kyphoplasty.

Vertebral compression fractures occur more frequently than hip and ankle fractures combined. These fragility fractures frequently result in both acute and chronic pain, but more importantly are a source of increased morbidity and possibly mortality. Percutaneous veretebral augmentation offers a minimally invasive approach for the treatment of vertebral compression fractures. The history, technique, and results of vertebroplasty and kyphoplasty are reviewed. Both methods allow for the introduction of bone cement into the fracture site with clinical results indicating substantial pain relief in approximately 90% of patients.

Invasive and minimally invasive surgical techniques for back pain conditions.

Back pain is a ubiquitous problem for developed countries. It is a source of disability for society and is a financial drain through lost wages and productivity. The treatment of spine-related pain has changed over the years: minimally invasive approaches are now favored. Despite this trend, surgeons still rely on decompressions of compressed neurological structures and the fusion of painful motion segments. The history of treatments of spine-related pain as well as modern and minimally invasive techniques are reviewed.