The 9-Item Patient Health Questionnaire (PHQ-9): an aid to assessment of patient-reported functional outcomes after spinal surgery.

BACKGROUND CONTEXT: Preoperative depression is increasingly understood as an important predictor of patient outcomes after spinal surgery. In this study, we examine the relationship between depression and patient-reported functional outcomes (PRFOs), including disability and pain, at various time points postoperatively. PURPOSE: The objective of this study was to analyze the use of depression, as measured by the 9-Item Patient Health Questionnaire (PHQ-9), as a means of assessing postoperative patient-reported disability and pain. STUDY DESIGN/SETTING: This study includes an analysis of prospective non-randomized spine registry compiled through an academic multispecialty group practice model. PATIENT SAMPLE: A total of 1,000 spinal surgery patients from an affiliated surgical registry, enrolled from January 2010 onward, were included in this study. OUTCOME MEASURES: Pain was assessed via the visual analog scale (VAS) for leg or back pain. Disability was measured by the Oswestry Disability Index (ODI). Depression was measured by the PHQ-9. METHODS: Patient data were collected preoperatively and at 1, 4, 10, and 24 months postoperatively. Data were analyzed via analysis of variance and Pearson correlation coefficient. RESULTS: All patient stratifications analyzed experienced improvements in pain and ability postoperatively, as measured by the VAS and the ODI, respectively. Moderately and severely depressed patients (as measured by preoperative PHQ-9) experienced decreases in the mean PHQ-9 score of -6.00 and -7.96 24 months after surgery, respectively. CONCLUSIONS: In all groups, spinal surgery was followed by relief of pain and improved PRFO. Preoperative depression, as measured by the PHQ-9, predicted postoperative PRFO. Patients with moderate to severe depression as measured by the PHQ-9 experienced large mean decreases in the PHQ-9 score postoperatively. As a psychosocial metric, the PHQ-9 is a useful method of assessing value-added service of a spinal surgery.

Early failure of metal-on-metal artificial disc prostheses associated with lymphocytic reaction: diagnosis and treatment experience in four cases.

STUDY DESIGN: Report of four collected cases. OBJECTIVE: The purpose of this report is to describe the presentation, diagnostic workup, treatment, and pathologic findings in four cases of lymphocytic reaction in patients receiving a metal-on-metal total disc replacement (TDR). SUMMARY OF BACKGROUND DATA: Metal-on-metal designs in hip arthroplasty have gained popularity because of decreased volumetric wear rates and theoretically increased implant longevity. Systemic metal ions produced have not been associated with adverse clinical sequelae, although there have been reports of local soft-tissue reactions leading to early prosthetic failure. Histologic evaluation in these cases suggested a cell-mediated delayed-type hypersensitivity reaction. Metal-on-metal bearings have also emerged in lumbar and cervical TDR. METHODS: This report is on four patients, from three centers, who underwent TDR, using a metal-on-metal implant, and later presented with symptoms that were determined to be due to lymphocytic reaction. Details of their symptoms, diagnostic work-up, treatment, and outcomes were compiled. RESULTS: All four patients initially had a good surgical outcome, followed by the onset and worsening of axial pain, and/or radicular symptoms months later. All patients had imaging findings of a mass lesion with neurologic impingement. All three of the lumbar patients underwent a decompressive posterior procedure before the eventual device removal and fusion. Intraoperatively, in all the lumbar cases, a thick, yellowish, avascular soft-tissue mass was found to be responsible for an epidural-mass effect on the thecal sac. In the cervical case, there was a gray-tinged soft-tissue response around the implant, suggestive of metallosis. Independent laboratory analysis confirmed a lymphocytic reaction to the implant. Three of the patients had a good outcome after the explant and revision surgery. The remaining patient continued to have residual symptoms related to the neural compression caused by the mass. CONCLUSIONS: In this group of patients from three centers, a metal-on-metal TDR resulted in a lymphocytic reaction causing subsequent failure of the surgery. This phenomenon has previously been recognized with metal bearings in hip arthroplasty. Surgeons using metal-on-metal TDRs should be aware of this possible occurrence.

Direct lateral lumbar interbody fusion for degenerative conditions: early complication profile.

STUDY DESIGN/SETTING: A community hospital prospective, nonrandomized chart review. March 2004 to December 2006, 58 patients were treated. Adverse events: new complaints and increasing length of stay limit early mobilization and require consultation with other physicians or reoperation. These formed the focus of the study. OBJECTIVE: Assess patient demographics and adverse events related to direct lateral lumbar approach. SUMMARY OF BACKGROUND DATA: Clinicians advocate anterior column support for lumbar conditions. Minimally invasive stabilization of lumbar spine via direct lateral approach gained popularity owing to perceived decrease in patient morbidity. METHODS: Mild or major adverse events during hospital stay or within 6 weeks of discharge were considered early complications and designated as medical, approach, or implant related. A historical cohort of open posterior spinal fusion patients was used for comparison. RESULTS: Forty-three female and 15 male patients with a mean age of 61 years formed the study group. Surgery performed included 38 single level, 19 2-level, and 1 3-level case. Adverse events occurred in 13 patients (22.4%); 8 events were approach, 3 medical, and 1 implant bone interface related. Major complications occurred in 5 patients (8.6%). Two patients (3.4%) with L4 nerve injury showed residual motor effects, at 1 year postoperatively. Significant differences were noted between single and 2-level cases; Estimated blood loss (EBL) and operative time. Open posterior fusion patients experienced greater operative time and increased EBL compared with minimally invasive cases. CONCLUSIONS: Major adverse events approximated 8.6% with approach-related complaints of nerve irritation nearing 3.4%. Mild complications occurred in 13.7% of patients. Meralgia paresthetica was a primary approach-related complaint. Most complaints significantly reduced by first postoperative visit. One patient (1.7%) had symptoms lasting over a year that did not adversely affect function. Significant finding related to exposure, that is, 1-versus 2-level cases. Overall morbidity reduction noted by EBL is considerably less compared with the historical cohort. Direct lateral lumbar interbody fusion has proven to be of value.

Interobserver reliability in the interpretation of diagnostic lumbar MRI and nuclear imaging.

BACKGROUND CONTEXT: Assessment of patients with complaints of low back or leg pain varies with the subspecialty of the treating physician. The evaluation of the spine patient may include magnetic resonance imaging (MRI), bone scan, or single-photon emission computed tomography (SPECT) imaging. The interpretation of these tests and the examiner's biases will impact the outcome of patient treatment and the cost to the health-care system. PURPOSE: To evaluate interobserver reliability of MRI and nuclear imaging studies and determine the predictability of nuclear medicine results based upon MRI findings. STUDY DESIGN/SETTING: Retrospective radiographic review for patients with low back pain. MRI, planar bone scan imaging, and SPECT imaging techniques were evaluated. PATIENT SAMPLE: Seventeen patients (80 lumbar levels) who presented to an orthopedic spine specialist with a complaint of mechanical low back or leg pain were randomly selected. Inclusion criteria were age greater than 21 years and a workup that included MRI, bone scan, and SPECT scan images. OUTCOME MEASURES: Interobserver reliability was determined using kappa values (0.6 to <0.8=substantial; 0.8-1=perfect). Interobserver reliability was evaluated for all studies and compared with a "group consensus." METHODS: A team of orthopedists and radiologists of varying experience levels were assembled to interpret the imaging studies. All readings were performed independently followed by group interpretation and discussion. The reviewers were asked to assess each lumbar level (L1-L2 through L5-S1). Phase one: Is the level degenerative? Is there a spondylolisthesis present? Does the level have Modic changes on MRI? Phase two: Based on the MRI, will the planar bone scan be positive? After this prediction, was the planar scan positive? Identify the lesion location (anterior column vs. posterior column). Phase three: Based on their assessment and predicted results on planar bone scan, was the SPECT scan able to improve this assessment? RESULTS: High kappa values were demonstrated in the identification of a degenerative disc, spondylolisthesis, and Modic change (0.773, 0.728, and 0.669, respectively). Bone scan and SPECT scan yielded poorer kappa results (0.539 and 0.460, respectively). Reviewer-predicted bone scan results demonstrated a positive predictive value of 68% and a negative predictive value of 84%. Predicated SPECT results were similar (positive predictive value 66% and negative predictive value 84%). SPECT identified 24% more lesions in the lumbar spine when compared with bone scan. CONCLUSIONS: MRI interpretation of the lumbar spine is comparable between specialties. Nuclear imaging studies (bone scan/SPECT) demonstrated a poorer correlation between examiners. The presence of MRI changes enables an accurate prediction of bone scan or SPECT scan findings. SPECT scan demonstrates an increased sensitivity in the detection of spinal abnormalities and the ability to localize a lesion when compared with planar bone scan.

Arthroscopic treatment of gunshot wounds to the shoulder.

Two cases are presented that demonstrate the utility of arthroscopic intervention for the management of gunshot wounds to the shoulder. The first report involves a 24-year-old man with a retained bullet in his glenohumeral joint after a drive-by shooting The intra-articular bullet was retrieved arthroscopically avoiding chondral injury from the mechanical effects of a loose body as well as the potential local and systemic effects of lead toxicity. Irrigation and debridement was performed to evacuate joint debris, which could have served as a nidus for infection or inflammation. The other case describes a 19-year-old man who sustained a gunshot wound to the lateral portion of his upper arm resulting in a proximal humerus fracture along with a retained bullet in his subacromial space. The bullet was successfully removed arthroscopically avoiding a traditional exposure, which would have complicated his fracture care.