A prospective randomized comparison of 270 degrees fusions to 360 degrees fusions (circumferential fusions).

STUDY DESIGN: Prospective randomized comparison of anterior lumbar interbody fusion (ALIF) plus transpedicular instrumentation plus posterolateral fusion (PLF) (360 degrees fusion) to ALIF plus transpedicular instrumentation without PLF (270 degrees fusion). OBJECTIVES: To compare the clinical outcomes, costs, and utilization of health resources of 360 degrees versus 270 degrees fusions. BACKGROUND: The 360 degrees fusion is effective, but its costs and utilization of health resources are high. The PLF often resorbs and may not be necessary. METHODS: Before and after surgery pain was measured by the Numerical Rating Scale (NRS), and function was measured by the Oswestry Low Back Disability Index (OSI). Costs were calculated by billing records. Operating times, blood loss, and hospital stays were measured at the time of hospital discharge. RESULTS: There were 48 patients: 21 women and 27 men. Mean age was 42 years. Follow-up averaged 35 months (range 24-45 months). In both 360 degrees and 270 degrees fusions, there were significant improvements in NRS and OSI, and the percentage of solid ALIF was high. Only 14% of PLF appeared solid bilaterally and 18% appeared solid on one side only. There were no significant differences in changes in NRS, changes in OSI, or percentage solid ALIF between the 360 degrees and 270 degrees fusions. However, the 270 degrees fusion group had significantly less blood loss, shorter operative times, shorter hospital stays, and lower professional fees, and although hospital charges were lower, this difference was not significant. CONCLUSION: Both the 360 degrees and 270 degrees fusions significantly reduce pain and improve function, and there are no significant clinical differences between them. However, there were shorter operating times, less blood loss, lower costs, and less utilization of health care resources associated with the 270 degrees fusions.

The axial cage. a pilot study for interbody fusion in higher-grade spondylolisthesis.

BACKGROUND CONTEXT: The surgical treatment of high-grade spondylolisthesis is challenging. Posterolateral fusion alone has a high rate of pseudarthrosis. Surgical stabilization of higher-grade lumbar spondylolisthesis with a fibula strut graft is an effective technique but is associated with harvest site morbidity and graft fractures. PURPOSE: We hypothesized that a lumbar interbody fusion with a long, threaded titanium cage, packed with cancellous bone, inserted across the center of the spondylolisthesis, would provide the rigid immobilization necessary for successful arthrodesis. This would, therefore, eliminate the need for fibula harvest and possibly reduce the need for posterior instrumentation. STUDY DESIGN/SETTING: Prospective, study cohort of 11 consecutive patients with a minimum follow-up of 1 year. PATIENT SAMPLE: Patients with higher-grade spondylolisthesis (grade II-IV) were considered eligible. OUTCOME MEASURES: Pain was measured with a 10-point Numerical Rating Score (NRS). The Oswestry Disability Index (OSI) was used to assess patient function. Patients also responded to a satisfaction scale to evaluate satisfaction with their outcome. Radiographs were reviewed 1, 3, 6, 12, and, when available, 24 months after surgery. METHODS: We reviewed our clinical results and technical outcomes in 11 consecutive patients who underwent this unique form of anterior lumbar interbody fusion with a custom axial cage. RESULTS: There were no surgical or postoperative complications. Serial x-rays revealed no implant subsidence or loosening. There have been no implant fractures or reoperation. Clinical results have been excellent with significant pain reduction and improved function. At 1 year after surgery the mean NRS was 3.5 (range, 0-7), a significant average reduction of 5.0 points. (p<.001) All patients have been satisfied with their results. CONCLUSIONS: The axial cage technique appears to be a significant improvement over the fibular strut graft for the treatment of higher-grade spondylolisthesis. It provides significant reduction in pain, significant improvement in function, high patient satisfaction, and avoids the morbidity and fracture risks associated with fibular strut grafting.

Influence of human immunodeficiency virus infection on pelvic inflammatory disease.

OBJECTIVE: To examine the influence of human immunodeficiency virus (HIV) infection on clinical and microbiologic characteristics of pelvic inflammatory disease (PID). METHODS: Forty-four HIV-infected women and 163 HIV noninfected women diagnosed with PID by standard case definition were evaluated by using clinical severity scores, transabdominal sonograms, and endometrial biopsies. After testing for bacterial infections, patients were prescribed antibiotics as recommended by the Centers for Disease Control and Prevention (CDC). RESULTS: Symptoms of PID and analgesic use before enrollment did not differ by HIV serostatus. More HIV-infected women had received antibiotics before enrollment (40.9% versus 27.2%, P =.08), a factor associated with milder signs regardless of serostatus. More HIV-infected women had sonographically diagnosed adnexal masses at enrollment (45.8% versus 27.1%, P =.08), a difference that yielded higher median severity scores (17.5 of 42 points versus 15 of 42 points, P =.07). However, those differences were not significant at the P <.05 level. Mycoplasma (50% versus 22%, P <.05) and streptococcus species (34% versus 17%, P <.05) were isolated more commonly from biopsies of HIV-infected women. Within 30 days after enrollment, HIV-infected women generally responded as well to therapy as HIV-noninfected women did, regardless of initial CD4 T-lymphocyte percentage. CONCLUSION: Among women with acute PID, HIV infection was associated with more sonographically diagnosed adnexal masses. Clinical response to CDC-recommended antibiotics did not differ appreciably by serostatus. Mycoplasmas and streptococci were isolated more commonly from HIV-infected women, but those organisms also might be associated with PID in immunocompetent women.