Surgical Approach for Cervical Myelopathy: Front or Back?
Spine surgeons have two basic approach options when performing surgery on patients with degenerative cervical myelopathy—anterior or posterior. Each approach has advantages and disadvantages, and numerous studies have attempted to elucidate which approach might be better for specific clinical situations.
In the June 21, 2017 edition of The Journal of Bone & Joint Surgery, Kato et al. add to the evidence base regarding this question. They report on results from an analysis comparing the two approaches in 80 pairs of “propensity-matched” patients who had multilevel compression myelopathy. Propensity matching allowed the authors to adjust for multiple baseline factors and MRI characteristics, thus minimizing the risk of selection bias.
After the propensity-matched analysis, there were no two-year between-group differences in mJOA score, Neck Disability Index, or SF-36 Physical Component score. The overall rates of perioperative complications were similar between the two groups, although dysphagia and dysphonia were reported only in the anterior group, while surgical site infection and C5 radiculopathy were reported only in the posterior group.
The authors claim that propensity matching helps to “reflect the ‘real-world’ clinical setting and likely has greater generalizability than a smaller, narrowly randomized controlled trial,” but they ultimately conclude that the surgical approach in such cases “should be carefully chosen by evaluating risk profiles in a shared decision-making process on a case-by-case basis.”
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What’s New in Spine Surgery
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Theodore Choma, MD, co-author of the June 21, 2017 Specialty Update on spine surgery, to select the five most clinically compelling findings from among the more than 40 studies cited in the article.
Biomaterials and Biologics
A multicenter randomized prospective trial compared osteogenic protein-1 (OP-1, also known as bone morphogenetic protein [BMP]-7) combined with local autograft to iliac crest autograft combined with local autograft in posterolateral lumbar fusion. Based on computed tomography (CT) scan assessments, the authors found a 54% fusion rate in the OP-1 group and a 74% fusion rate in the iliac crest group. OP-1 appears to be a poor substitute for iliac crest autograft for achieving posterolateral lumbar fusion.
Adult Spinal Deformity (ASD)
We continue to elucidate the risks and morbidity of adult degenerative spinal deformity surgery. The Scoli-Risk-1 study,1 a Level-III multicenter, prospective observational study, reported on 272 patients with ASD treated surgically. Twenty-two percent of the patients were discharged from the hospital with a decline in the lower-extremity motor score, while only 13% demonstrated improvement. However, by 6 months postoperatively, 21% demonstrated improvement, 69% demonstrated maintenance, and 11% continued to demonstrate lower-extremity motor decline.
Spinal Cord Injury
A Level-I, randomized, crossover trial2 examined whether the character of neuropathic pain following spinal cord injury determined the response to 300 mg/day of either pregabalin or oxcarbazepine. Both anticonvulsant medications significantly improved neuropathic pain in these patients. A subgroup analysis demonstrated that oxcarbazepine was more effective in patients without evoked pain and pregabalin was more effective in patients with evoked pain.
Lumbar Degenerative Spondylolisthesis
To address the consequences of fusion along with decompression in degenerative lumbar spondylolisthesis, a Level-I, randomized controlled trial3 specifically compared laminectomy only with laminectomy plus fusion among 66 patients with stable degenerative spondylolisthesis and symptomatic lumbar stenosis. Patients in the fusion group had significantly higher SF-36 scores at 2, 3, and 4 years, but the groups did not differ with respect to ODI scores at 2 years. The authors reported a significantly higher reoperation rate (34% compared with 14%) in the decompression-only group over the 4-year follow-up, but patients who underwent decompression with fusion began to have an increase in the probability of reoperation 36 months after surgery.
Osteoporotic Injuries
We have more evidence of the effectiveness of vertebral cement augmentation for osteoporotic thoracolumbar compression fractures. The authors of a level-I systematic review and meta-analysis examined randomized controlled trials comparing vertebroplasty with conservative treatment or placebo/sham and identified 11 relevant studies involving 1,048 subjects. The meta-analysis found that patients receiving percutaneous vertebroplasty (n = 531) had lower pain ratings at 1 to 2 weeks, 2 to 3 months, and 1 year. The effect size of vertebroplasty was significant and close to the minimal clinically important difference (MCID).
References
- Lenke LG, Fehlings MG, Shaffrey CI, Cheung KM, Carreon L, Dekutoski MB, Schwab FJ, Boachie-Adjei O, Kebaish KM, Ames CP, Qiu Y, Matsuyama Y, Dahl BT, Mehdian H, Pellis´e-Urquiza F, Lewis SJ, Berven SH. Neurologic outcomes of complex adult spinal deformity surgery: results of the prospective, multicenter Scoli-RISK- 1 study. Spine (Phila Pa 1976). 2016 Feb;41(3):204-12.
- Min K, Oh Y, Lee SH, Ryu JS. Symptom-based treatment of neuropathic pain in spinal cord-injured patients: a randomized crossover clinical trial. Am J Phys Med Rehabil. 2016 ;95(5):330–8
- Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, Coumans JV, Harrington JF, Amin-Hanjani S, Schwartz JS, Sonntag VK, Barker FG 2nd, Benzel EC. Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med. 2016 Apr 14;374(15):1424-34.
Does Hip Arthroscopy Really Help?
Over the past 15 to 20 years, the use of arthroscopic procedures for hip pathologies has rapidly increased. Leaders in sports medicine have standardized many arthroscopic techniques, including methods of joint distraction, portal location, approaches to labral repair or debridement, and management of cartilage lesions.
Many in the orthopaedic community have wondered whether this expansive use of hip arthroscopy is justified by significant improvement in patient function or is simply a first (and perhaps overused) step toward inevitable hip arthroplasty. To help answer that question, in the June 21, 2017 issue of The Journal, Menge et al. document the 10-year outcomes of arthroscopic labral repair or debridement in 145 patients who originally presented with femoroacetabular impingement (FAI).
Whether these patients were treated with debridement or repair, their functional outcomes and improvement in symptoms were excellent over the 10-year time frame, and the median satisfaction score (10) indicates that these patients were very satisfied overall. However, as seen in other similar studies in the peer-reviewed literature, the results in older patients with significant cartilage injury or radiographic joint space narrowing were inferior, and most of the patients with these characteristics ended up with a hip replacement.
The Menge et al. study helps confirm that arthroscopic repair or debridement in well-selected FAI patients yields excellent longer-term outcomes, and it provides concrete criteria for patient selection.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Chondroitin Sulfate Similar to Celecoxib in Easing Pain of Knee OA
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD, in response to a recent study in Annals of the Rheumatic Diseases.
European investigators recently reported on a trial comparing the efficacy of pharmaceutical-grade chondroitin sulfate (CS) (800 mg/day) with the NSAID celecoxib (CX) (200 mg/day) and placebo in more than 600 patients with painful knee osteoarthritis (OA).
In this well-designed, well-executed, double-blinded, 3-armed trial, investigators tracked patient pain scores at baseline and at 1-month, 3-month and 6-month intervals. This trial was characterized by strict adherence to blinded protocols, high levels of patient adherence, and meticulous review of patient diaries and adverse-event reports.
Patients in both the CS and CX groups experienced significantly greater pain relief when compared to those in the placebo group at every follow-up time point. In addition to tracking pain via the visual analogue scale (VAS), the investigators included the Lequesene index (LI)—which integrates both pain and function—along with the Minimal-Clinically Important Improvement (MCII) scale. While CX and CS were not superior/inferior to one another, both active treatments provided significant pain improvements relative to placebo according to all three measurements at all time points.
These findings showing the efficacy of pharmaceutical-grade CS are important for orthopaedic surgeons, rheumatologists, and general practitioners. Nonoperative management of knee OA remains an important modality that requires a multimodal approach, typically including NSAIDs and/or acetaminophen. These results suggest that there’s another safe medication that may prove especially helpful for OA patients who cannot tolerate NSAIDs or acetaminophen due to kidney, gastrointestinal, cardiovascular, and/or liver issues.
Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.
A Paean to Shoulder Pioneer Doug Harryman
The June 7, 2017 issue of JBJS contains one more in a series of personal essays where orthopaedic clinicians tell a story about a high-impact experience they had that altered their worldview, enhanced them personally, and positively affected the care they provide as orthopaedic physicians.
This “What’s Important” piece comes from Dr. Frederick A. Matsen, III of the University of Washington. In his moving tribute to former colleague Doug Harryman, Dr. Matsen explains how his friend and mentor’s devotion to improving patient outcomes was matched by an unwavering faith that permeated every aspect of his life. The article includes a link to a series of engaging videos that Dr. Harryman made to share his many discoveries about shoulder function with the world.
If you would like JBJS to consider your “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning of the title.
Because they are personal in nature, “What’s Important” submissions will not be subject to the usual stringent JBJS peer-review process. Instead, they will be reviewed by the Editor-in-Chief, who will correspond with the author if revisions are necessary and make the final decision regarding acceptance.
Can Only 4 Questions Yield Meaningful Patient Outcome Measures?
In today’s data-driven, evidence-based world of orthopaedics, capturing accurate information about a patient’s physical function can require patients to answer dozens of separate questions. In the June 7, 2017 edition of JBJS, Hancock et al. investigate whether the computer-based tool called PROMIS (Patient-Reported Outcomes Measurement Information System) PF CAT is more efficient than and just as reliable as the more burdensome function-evaluation instruments.
In short, the answer is yes. Among a group of otherwise healthy patients scheduled to undergo meniscal surgery, the PROMIS PF CAT scores were generally highly correlated with traditional patient-reported physical-function measures, such as the SF-36 Physical Function instrument and the KOOS Sport and Quality-of-Life scores.
In contrast to the more traditional fixed-length questionnaires, the PROMIS PF CAT presents an initial item to the patient, and uses the response to that to select the most informative next item. That process continues only until a predefined level of precision is reached, at which point the test ends. The vast majority (89%) of the patients in this study completed the PROMIS PF CAT after answering only four items.
Considering its strong correlation with other widely accepted measurement tools and its efficiency, the authors conclude that PROMIS PF CAT “may be a good alternative for evaluating physical function in meniscal injury populations,” and that it could help “reduce burnout and maintain high response rates” in a time-constrained health care environment.
Good Outcomes with After-Hours Hip Fracture Surgery
In the June 7, 2017 issue of The Journal of Bone & Joint Surgery, Pincus et al. report on a careful analysis comparing outcomes from hip fracture surgery occurring “after hours” (defined by the authors as weekday evenings between 5 PM and 12 AM) with surgeries occurring during “normal hours” (weekdays from 7 AM to 5 PM). In the busy Ontario trauma center where this study was performed, it is common for patients with blunt trauma to take precedence over seniors who are relatively stable but in need of hip fracture care.
Pincus et al. found that adverse outcomes, in terms of surgical and medical complications, were similar whether the hip surgery occurred during normal hours or after hours. Interestingly, there was a higher rate of inpatient complications in the normal-hours group, and fewer patients in the after-hours group were discharged to a rehab after surgery than in the normal-hours group.
It has been my impression that highly skilled professional surgeons and their teams are going to put forward their best efforts for all patients—no matter what time of day or night they operate. Concentration, focus, and high standards can generally overcome fatigue. However, the Pincus et al. study should not be viewed as justification for hospital decision makers to forget their commitment to optimize management of all resources, including surgical teams. After-hours care should never become “routine,” and there should be continuous attention on developing alternative solutions, such as moving elective surgery to other facilities or true shift scheduling that provides all members of the team with occasional daytime hours off for rest and management of personal lives.
The authors note that in their Canadian jurisdiction, there are hospital and surgeon-reimbursement incentives that may work to promote after-hours surgery, but the long-term focus must always put patient outcomes first. And we must always remember that good patient outcomes rely on maintaining surgical teams who are experienced and not burnt out.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
9 Tips to Excel with MIPS
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Jason Weisstein, MD, MPH, FACS.
MIPS—the Merit-based Incentive Payment System—is still a mystery to many orthopaedic surgeons. But it can have a big positive or negative impact on your practice.
MIPS is a federal improvement-incentive program consisting of Quality, Resource Use, Clinical Practice Improvement, and Advancing Care components. To demonstrate excellent performance (and reap the associated rewards), physicians can choose the activities and measures that are most meaningful for their practice. Weights are assigned to each category based on a 1 to 100 point scale. In 2017, the transition year, weights are as follows: Quality-60 percent, Cost-0 percent, Improvement Activities-15 percent and Advancing Care Information-25 percent.
I often hear a lot of grumbling from colleagues about their electronic health record (EHR) systems as one of the major causes of physician burnout. However, implementing the right technology will help you excel under this new reimbursement model.
Here are 9 MIPS tips related to EHRs:
- Choose the Quality benchmarks that best fit your practice. You need at least 20 eligible cases per Quality measure. Go to the CMS website and select benchmarks that have established measures.
- Report Quality for an entire year or over 90 days.
- Make sure your EHR has built-in dashboards that enable you to keep an eye on your composite score in near real-time, from day to day.
- Be sure that the EHR you select captures data being entered at the point of care and can enable this data to be used for multiple purposes.
- Get a head start on the Advancing Care component. Selecting an EHR vendor with successful Meaningful Use (MU) attestations is critical.
- Earn bonus points via specialty registries and Clinical Improvement Activities.
- Make sure your EHR allows you to compare your performance with that of your peers using analytical tools.
- When engaging in Clinical Improvement Activities, follow guidelines based on your specific practice size.
- Submit only the required number of Clinical Improvement Activities for the given measurement year, because the following year, you may need to pick a different activity.
With the shift to MIPS and value-based care, orthopaedic surgeons and their teams can thrive by adapting and utilizing technology that fits within their workflows and that helps them understand how they are performing in real time, both within their own practices and compared with their peers nationwide.
Jason Weisstein, MD, MPH, FACS is the Medical Director of Orthopedics at Modernizing Medicine.
JBJS Classics: Porous-Coated Hip Components
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.
In their classic 1987 publication, Drs. Charles Engh, Dennis Bobyn, and Andrew Glassman described clinical and radiographic results of a series of 307 hips with 2-year follow-up, and 89 hips with 5-year follow-up after total hip arthroplasty in which the patients had received an extensively porous-coated femoral stem. The authors also described histologic evaluation of 11 hips retrieved at autopsy or revision.
By 1987 the same authors as well as other investigators had already published observations concerning the influence of femoral stem size, shape, stiffness, and porosity on clinical and radiographic evidence of fixation and stress shielding in humans and animal models.1,2 But this study, which so far has been cited more than 1500 times, goes “above and beyond” by carefully correlating previous observations with histologic sections obtained through human femora.
Among other achievements, Engh et al. described radiographic criteria for categorizing a femoral implant as either stable by bone ingrowth, stable by fibrous tissue ingrowth, or unstable. Implants thought to be stable by fibrous ingrowth had a prominent radio-opaque line around the stem, separated from the implant by a radiolucent space up to 1 mm in thickness. This line was thought to represent a shell of bone with load-carrying capability. However, histology demonstrated that the space between the shell and the implant was composed of dense fibrous tissue. When the shell was present, there tended to be little hypertrophy or atrophy of the adjacent femoral cortex.
Engh et al. noted that radiographs and histology of hips with extensive ingrowth from the endosteum often showed parallel increased porosity of the adjacent cortex – an early manifestation of stress shielding. Overall, 259 (84%) of the femoral stems had radiographic findings suggestive of bone ingrowth, 42 (13%) had findings interpreted as stable fibrous ingrowth, and 2% were thought to be unstable (but not yet revised at the time of the study). Stress shielding was much more common in larger-diameter stems and those with good bone ingrowth compared to smaller implants or those with stable fibrous fixation.
Why do we consider this manuscript a classic? First, the authors include a careful correlation of histology with radiographic and clinical findings, helping illustrate the importance of tight press fit at the isthmus to achieve proximal fixation. The authors also document intracortical porosity as the morphologic manifestation of stress shielding and emphasize the impact of a small increase in stem diameter on axial rigidity.
Designs of femoral stems have evolved considerably since the 1980s,3 and the findings described in this paper helped validate fundamental principles related to load transmission and bone remodeling4-6 and thus helped advance that evolutionary process.
Thomas W. Bauer, MD, PhD
JBJS Deputy Editor
References
- Bobyn JD, Pilliar RM, Binnington AG, Szivek JA. The effect of proximally and fully porous-coated canine hip stem design on bone modeling. Journal of orthopaedic research : official publication of the Orthopaedic Research Society 1987;5:393-408.
- Bobyn JD, Pilliar RM, Cameron HU, Weatherly GC. The optimum pore size for the fixation of porous-surfaced metal implants by the ingrowth of bone. Clinical orthopaedics and related research 1980:263-70.
- McAuley JP, Culpepper WJ, Engh CA. Total hip arthroplasty. Concerns with extensively porous coated femoral components. Clinical orthopaedics and related research 1998:182-8.
- Huiskes R. Validation of adaptive bone-remodeling simulation models. Stud Health Technol Inform 1997;40:33-48.
- Huiskes R, Weinans H, Dalstra M. Adaptive bone remodeling and biomechanical design considerations for noncemented total hip arthroplasty. Orthopedics 1989;12:1255-67.
- Weinans H, Huiskes R, Grootenboer HJ. Effects of fit and bonding characteristics of femoral stems on adaptive bone remodeling. J Biomech Eng 1994;116:393-400.
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