Analysis of injected cement volume and clinical outcomes following kyphoplasty for vertebral compression fractures.

BACKGROUND: It has been suggested that greater volumes of cement injected during kyphoplasty correlate with improved vertebral body height restoration and kyphotic angulation correction. However, there is little evidence tying cement volume to patient outcomes. Here, we analyzed the association between cement volume and outcome utilizing indices of pain, disability, and quality of life. METHODS: One hundred and thirty-six patients undergoing kyphoplasty were analyzed retrospectively. The total volume of bone cement injected was recorded intraoperatively for each patient; the average total cement volume was 5.44 cc. Pre- and postoperative outcome indices were documented, using the visual analog scale (VAS), Roland-Morris disability index (RMDI), and the EuroQol 5 Dimension instrument (EQ5D). Pearson's correlations and linear regression models were derived for the association of total cement volume with each of the patient outcome measures. This was a retrospective cohort study. RESULTS: The average change in VAS, RMDI, and EQ5D scores for all patients was -6.8, +8.3, and +0.41, respectively. For VAS, RMDI, and EQ5D improvements, neither Pearson's correlations nor multiple linear regression models revealed a correlation or an association with total cement volume. CONCLUSION: For patients undergoing kyphoplasty, outcomes were not associated with the total injected cement volume; all had a significant reduction in pain and most exhibited decreased disability with improved quality of life.

Vertebral height restoration following kyphoplasty.

BACKGROUND: Kyphoplasty is a minimally invasive surgery developed to restore height and stabilize painful vertebral compression fractures (VCFs). Only small retrospective studies have addressed the correlation between the degree of vertebral height restoration as it relates to pain relief and postoperative activity levels. No definitive correlations have been established. The objective of this analysis is to determine how height restoration correlates with improvements in pain, disability and quality of life. METHODS: We assessed outcomes following kyphoplasty in 59 Medicare-eligible patients with 1-3 painful VCFs between T5 and L5 due to osteoporosis or cancer. Pre and postoperative lateral radiographs were available for fifty-nine patients and were used to measure anterior, middle and posterior vertebral body (VB) heights. The Visual Analog Scale (VAS) [range: 0 (none) to 10 (worst)] was used to prospectively measure back pain pre and post-operatively in all patients. Pre and post-operative measurements of disability and quality of life were retrospectively collected using the Roland Morris Disability Index (RMDI) [range: 0 (no disability) to 24 (high disability)] and EuroQol5-Domain scale (EQ5D) [range: -0.11 (poor quality of life) to 1.0 (perfect health)]. Pearson correlations and linear regression models were analyzed for association of VB height improvement with outcomes. RESULTS: Neither Pearson correlations (r coefficient range: 0.001-0.152) nor linear regression models (R2 value range: 0.0002-0.1133) revealed correlation or association between VB height improvements and outcomes. CONCLUSIONS: This is one of the largest studies to date assessing associations of VB height restoration following kyphoplasty with prospective measurements of pain and retrospective evaluation of disability and quality of life using validated instruments. Although a majority of patients in this cohort demonstrated increased vertebral heights and significant improvements in outcomes, none of the outcomes showed association with height improvements. Regardless of vertebral height improvements, most patients had improved pain, function and quality of life.

Inter-rater reliability of the modified Medical Research Council scale in patients with chronic incomplete spinal cord injury.

OBJECTIVE: The aim of this study was to determine the inter-rater reliability of the modified Medical Research Council (MRC) scale for grading motor function in patients with chronic incomplete spinal cord injury (SCI). METHODS: Two neurosurgical residents and 2 faculty members performed motor examinations in 6 chronic incomplete SCI patients for a total of 156 muscle groups. Examinations were performed using the modified MRC grading scale during routine clinic visits for each patient. Informed consent was obtained prior to enrollment. Patients with American Spinal Injury Association (ASIA) Impairment Scale grade A (ASIA A) injuries were excluded. Inter-rater reliability coefficients were calculated using Kendall's coefficient of concordance (W) and intraclass correlation coefficients (ICCs). RESULTS: Sixty-four percent of the tested variables demonstrated extremely strong (W 0.71-0.9) or strong (0.51-0.7) inter-rater reliability using Kendall's coefficient of concordance and an ICC corresponding to excellent (ICC > 0.75) or fair to good (ICC 0.4-0.75) inter-rater reliability. An additional 7% showed poor inter-rater reliability (ICC < 0.4). The remaining variables tested did not reach statistical significance. CONCLUSIONS: The inter-rater reliability of the modified MRC scale was found to be high in the majority of tested variables, but the results suggest that discrepancy among trained observers does exist. Reliability was greatest in the lower-extremity muscle groups and least in the upper-extremity muscle groups in patients with chronic incomplete SCI.

Patient Expectations and Preferences in the Spinal Surgery Clinic.

BACKGROUND: Managing patient expectations is essential in the treatment of patients undergoing spinal surgery. Patient satisfaction is associated with improved clinical outcomes and can be improved when patient and surgeon expectations are aligned and patient preferences are met. METHODS: Patients presenting to clinic for management of spinal disease were asked to complete a questionnaire assessing demographics, current pain, reason for visit, and expectations and preferences surrounding the clinic experience. Variables were compared with χ2 tests to determine factors associated with patient expectations. Subsets of new patients and returning patients were compared by the use of matched pair tests. One-way analysis of variance was used to compare means of clinic expectations in patients depending on their level of education. RESULTS: A total of 240 patients were included. New patient evaluation was the most common reason for evaluation (26.6%), and pain relief was the most common chief concern (39.3%). Patients preferred their surgeon wash their hands in the room instead of before entering (P < 0.001) and wear professional attire over scrubs (P < 0.001). Patients believe their wait time will be longer than it should be (P = 0.002), they will spend longer in clinic than they should (P = 0.03), and they will get less face-to-face time with their surgeon than they should (P < 0.01) but also that the surgeon is not getting paid enough for the clinic visit (P = 0.02). CONCLUSIONS: Because spine surgery is largely elective, patients often seek treatment to improve quality of life and alleviate subjective symptoms. Understanding patient expectations is critical to ensure that patients and physicians are working toward similar goals.

The nonsurgical nature of patients with subarachnoid or intraparenchymal hemorrhage associated with mild traumatic brain injury.

OBJECT: Mild traumatic brain injury (mTBI), as defined by Glasgow Coma Scale (GCS) score of 13 or higher, is a common problem in the United States and worldwide, estimated to affect more than 1 million patients yearly. When associated with intracranial hemorrhage, it is a common reason for neurosurgical consultation and transfer to tertiary care centers. The authors set out to investigate the clinical implications of subarachnoid hemorrhage (SAH) and/or intraparenchymal hemorrhage (IPH) associated with mTBI in hopes of standardization of mTBI clinical care and optimization of resource allocation. METHODS: The authors performed a retrospective review of 500 consecutively treated patients with mTBI and SAH and/or IPH admitted to a Level I trauma center in Alabama between May 2003 and May 2013. They performed a review of medical records to confirm the diagnosis, determine neurological condition at admission, and assess for episodes of neurological decline or brain injury-related complications including altered mental status, seizures, and hyponatremia. RESULTS: Of the 500 patients for whom data were reviewed, 304 (60.8%) were male and 196 (39.2%) were female. Average age was 46.3 years. Overall, 63 patients (12.6%) had isolated IPH, 411 (82.2%) had isolated SAH, and 26 (5.2%) had radiographic evidence of both IPH and SAH. One hundred forty-five patients (29%) were transferred an average distance of 64.5 miles. The authors identified no patients who experienced neurological worsening during their hospital course. Two patients experienced hyponatremia that required treatment with sodium supplementation. CONCLUSIONS: Patients with the constellation of SAH and/or IPH and mTBI do not require neurosurgical consultation, and these findings should not be used as the sole criteria to justify transfer to tertiary referral centers.

Surgical manifestations of thoracic arachnoid pathology: series of 28 cases.

OBJECT: Various pathologies involving the thoracic arachnoid mater uniformly manifest as thoracic myelopathy and may present a significant management dilemma. The authors undertook this study to assess outcome in cases of thoracic myelopathy due to thoracic arachnoid pathology. METHODS: The authors have cared for and followed 28 patients with thoracic myelopathy from thoracic arachnoid pathology over the last 17 years. A chart review and contemporary follow-up of these patients was performed and outcomes were reported. RESULTS: Patients with thoracic myelopathy from thoracic arachnoid pathology often have improvement in their condition after surgical decompression/detethering procedures. While not universal, patients in this series had improvement in mJOA scores at 1 year after surgery (p = 0.0001) and at last follow-up (p = 0.04). Results indicated that across a wide variety of pathologies the extent of thoracic spinal cord involvement is a predictor of the disease course and outcome. Comparison of the group of patients with cord involvement limited to 2 vertebral segments (short-segment pathology) versus the group with cord tethering of more than 2 segments (long-segment pathology) showed that patients in the short-segment group more frequently had ventral or dorsal arachnoid bands (p = 0.003), more frequently had signal change in the cord on MRI (p = 0.02), and less frequently presented with a syrinx (p = 0.02), and a smaller percentage of patients in this group underwent reoperation (p = 0.02). While patients with short-segment pathology typically improved after a single operative intervention, patients with long-segment pathology typically improved after multiple operations, frequently for CSF diversion. CONCLUSIONS: Thoracic arachnoid pathology causing thoracic cord dysfunction and myelopathy is varied, has multiple etiologies, and can be difficult to treat over the long term. Surgical management, when indicated, is case specific. Serial long-term follow-up is essential to document enduring clinical and radiographic success.

Neurosurgical injuries resulting from the 2011 tornados in Alabama: the experience at the University of Alabama at Birmingham Medical Center.

OBJECT: The April 27, 2011, tornados that affected the southeastern US resulted in 248 deaths in the state of Alabama. The University of Alabama at Birmingham (UAB) Medical Center, the largest Level I trauma center in the state, triaged and treated a large number of individuals who suffered traumatic injuries during these events, including those requiring neurosurgical assessment and treatment. METHODS: A retrospective review of all adult patients triaged at UAB Medical Center during the April 27, 2011, tornados was conducted. Those patients who were diagnosed with and treated for neurosurgical injuries were included in this cohort. RESULTS: The Division of Neurosurgery at UAB Medical Center received 37 consultations in the 36 hours following the tornado disaster. An additional patient presented 6 days later, having suffered a lumbar spine fracture that ultimately required operative intervention. Twenty-seven patients (73%) suffered injuries as a direct result of the tornados. Twenty-three (85%) of these 27 patients experienced spine and spinal cord injuries. Four patients (15%) suffered intracranial injuries and 2 patients (7%) suffered combined intracranial and spinal injuries. The spinal fractures that were evaluated and treated were predominantly thoracic (43.5%) and lumbar (43.5%). The neurosurgery service performed 14 spinal fusions, 1 ventriculostomy, 2 halo placements, 1 diagnostic angiogram, 1 endovascular embolectomy, and 1 wound debridement and lavage. Twenty-two patients (81.5%) were neurologically intact at discharge and all but 4 had 1 year of follow-up. Three patients had persistent deficits from spinal cord injuries and there was 1 death in a patient with multisystem injuries in whom no procedures were performed. Two patients experienced postoperative complications in the form of 1 wound infection and 1 stroke. CONCLUSIONS: The April 27, 2011, tornados in Alabama produced significant neurosurgical injuries that primarily involved the spine. There were a disproportionate number of patients with thoracolumbar fractures, a finding possibly due to the county medical examiner's postmortem findings that demonstrated a high prevalence of fatal cervical spine and traumatic brain injuries. The UAB experience can be used to aid other institutions in preparing for the appropriate allotment of resources in the event of a similar natural disaster.

Improving wait times and patient satisfaction in primary care.

A strong and inverse relationship between patient satisfaction and wait times in ambulatory care settings has been demonstrated. Despite its relevance to key medical practice outcomes, timeliness of care in primary care settings has not been widely studied. The goal of the quality improvement project described here was to increase patient satisfaction by minimizing wait times using the Dartmouth Microsystem Improvement Curriculum (DMIC) framework and the Plan-Do-Study-Act (PDSA) improvement process. Following completion of an initial PDSA cycle, significant reductions in mean waiting room and exam room wait times (p = .001 and p = .047, respectively) were observed along with a significant increase in patient satisfaction with waiting room wait time (p = .029). The results support the hypothesis that the DMIC framework and the PDSA method can be applied to improve wait times and patient satisfaction among primary care patients. Furthermore, the pretest-posttest preexperimental study design employed provides a model for sequential repetitive tests of change that can lead to meaningful improvements in the delivery of care and practice performance in a variety of ambulatory care settings over time.

Chemical priming for spinal cord injury: a review of the literature part II-potential therapeutics.

INTRODUCTION: Spinal cord injury is a complex cascade of reactions secondary to the initial mechanical trauma that puts into action the innate properties of the injured cells, the circulatory, inflammatory, and chemical status around them, into a non-permissive and destructive environment for neuronal function and regeneration. Priming means putting a cell, in a state of "arousal" towards better function. Priming can be mechanical as trauma is known to enhance activity in cells. MATERIALS AND METHODS: A comprehensive review of the literature was performed to better understand the possible chemical primers used for spinal cord injuries. CONCLUSIONS: Taken together, many studies have shown various promising results using the substances outlined herein for treating SCI.

Chemical priming for spinal cord injury: a review of the literature. Part I-factors involved.

INTRODUCTION: There are significant differences between the propensity of neural regeneration between the central and peripheral nervous systems. MATERIALS AND METHODS: Following a review of the literature, we describe the role of growth factors, guiding factors, and neurite outgrowth inhibitors in the physiology and development of the nervous system as well as the pathophysiology of the spinal cord. We also detail their therapeutic role as well as those of other chemical substances that have recently been found to modify regrowth following cord injury. CONCLUSIONS: Multiple factors appear to have promising futures for the possibility of improving spinal cord injury following injury.

Anterior cervical approach for the treatment of cervical myelopathy.

Compression of the spinal cord by the degenerating cervical spine tends to lead to progressive clinical symptoms over a variable period of time. Surgical decompression can stop this process and lead to recovery of function. The choice of surgical technique depends on what is causing the compression of the spinal cord. This article reviews the symptoms and assessment for cervical spondylotic myelopathy (clinically evident compression of the spinal cord) and discusses the indications for decompression of the spinal cord anteriorly.

Spontaneous thoracic spinal cord herniation: three cases with long-term follow-up.

OBJECTIVE AND IMPORTANCE: Spontaneous thoracic spinal cord herniation (STSCH) is an uncommon cause of thoracic myelopathy. Fewer than 40 cases have been reported in the English language literature with a mean follow-up of less than 6 months. CLINICAL PRESENTATION: We have encountered three patients diagnosed with STSCH in the last 6 years at our institution. These patients presented with symptoms and signs localizing to the thoracic spinal cord. Magnetic resonance imaging revealed ventral thoracic spinal cord displacement in each. INTERVENTION: One patient was treated surgically, two managed expectantly. Two patients have been followed for greater than 5 years, whereas a third has been followed for 15 months. CONCLUSION: Our experience suggests that patients with neurological symptoms and signs attributable to STSCH may not progress and therefore may be followed with clinical and magnetic resonance imaging surveillance. When surgery is indicated for progressive STSCH, late retethering may occur.

Bilateral thoracoscopic sympathectomy for the treatment of palmar hyperhidrosis in the active duty population.

In an active duty population charged with handling weapons and heavy equipment, hyperhidrosis is a dangerous affliction. Surgical correction of hyperhidrosis is possible by transection of the thoracic sympathetic chain. Thoracoscopic sympathectomy should yield results similar to those of a standard open thoracotomy approach but with decreased recovery times, a more rapid return to duty, and improved job performance. Three active duty patients presented to the Naval Medical Center, San Diego, for evaluation of palmar hyperhidrosis. All patients underwent bilateral thoracoscopic sympathectomy for the treatment of palmar hyperhidrosis. They tolerated the procedure well without complications and were satisfied with their outcomes. They reported no further episodes of hyperhidrosis and have returned to full duty. This procedure is especially relevant for patients in the active duty population, whose job safety is affected by hyperhidrosis. Those treated can expect to return to full duty in a timely manner.