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Aggressive Treatment Improves QOL in Many Cases of Spinal Metastases

swiontkowski marc colorA significant portion of metastatic disease comes with no clear identification of a primary tumor; this is unfortunately the case with many spinal metastases. In the October 4, 2017 issue of The Journal, Ma et al. evaluate the survival and patient-reported quality-of-life (QOL) outcomes for patients with spinal metastases from cancer of unknown primary origin.

Their prospective longitudinal study confirms that a more aggressive strategy that combines surgery and radiation therapy results in better QOL (as measured with the four-domain FACT-G instrument) than radiation alone. There was no significant difference in survival time between the two groups. In a subgroup analysis of patients receiving surgery, those who underwent circumferential decompression had significantly better functional and physical well-being and higher total QOL scores than those who underwent decompressive laminectomy.

These findings emphasize the critical role of shared decision making in such difficult situations. A dire diagnosis with poor statistical chances of long-term survival does not mean that patients should not be informed of treatment options and have the opportunity to opt for an aggressive surgical approach, especially if that decision is likely to result in improved QOL. Let us endeavor to compassionately provide patients with the facts, as we understand them, and let them select from among the medical and surgical options that are at their disposal. More often than not, in this sad scenario, it seems aggressive is better in terms of quality of life.

September 2017 Article Exchange with JOSPT

JOSPT_Article_Exchange_LogoIn 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of September 2017, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Assessment of Psychometric Properties of Various Balance Assessment Tools in Persons With Cervical Spondylotic Myelopathy.

This cross-sectional study concluded that a brief version of the Balance Evaluation Systems Test (BESTest) is the most-preferred tool for assessing balance among patients with cervical spondylotic myelopathy.

Longer Surgeries, Lengths of Stay Associated with More Adverse Events

Trauma Image for OBuzzThe phrase “adverse event” has been defined variably in the orthopaedic literature, which is one reason identifying the factors associated with such events can be tricky. In the August 16, 2017 edition of The Journal of Bone & Joint Surgery, Millstone et al. go a long way toward pinpointing modifiable factors that boost the risk of adverse events.

Using an institution-wide adverse-event reporting system called OrthoSAVES, the authors analyzed adverse events among 2,146 patients who underwent one of three elective orthopaedic procedures: knee replacement, hip replacement, or spinal fusion. They found an overall adverse event rate of 27%, broken down by surgical site as follows:

  • 29% for spine
  • 27% for knee
  • 25% for hip

The most common adverse events had a low severity grade (1 or 2); the authors suggest that including events typically not viewed as severe (such as urinary retention) is one reason the overall adverse event rate in this study was higher than most previously reported.

The unique finding from this study was that two modifiable factors—length of stay and increasing operative duration—were independently associated with a greater risk of an adverse event. More specifically, the authors found that, regardless of surgical site, each additional 30 minutes of surgery increased the adjusted odds for an adverse event by 13%.

The authors were quick to point out that their findings should not be interpreted as an admonition for surgeons to hurry up. “While operative duration may be a modifiable factor, operating more quickly for spinal or any other procedures may, itself, lead to increased complications,” they wrote. Rather, Millstone et al. suggest that the multiple factors comprising “procedural efficiency” during a surgical hospitalization warrant further investigation.

What’s New in Musculoskeletal Infection

PPI Image for O'BuzzEvery 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, Arvind Nana, MD, co-author of the July 19, 2017 Specialty Update on musculoskeletal infection, selected the five most compelling findings from among the more than 120 studies cited in the Specialty Update.

Periprosthetic Joint Infection

–Much of the discussion around treating periprosthetic joint infections (PJIs) centers around comparing one-stage versus two-stage exchange arthroplasty. Two-stage exchange arthroplasty requires the use of a temporary cement spacer, and one study1 found that debris from articulating spacers may induce CD3, CD20, CD11(c), and IL-17 changes, raising the possibility of associated immune modulation.

–When performing debridement to treat a PJI, instead of an irrigation solution containing antibiotics, a 20-minute antiseptic soak with 0.19% vol/vol acetic acid reduced the risk of reinfection.2

Spine

–Four studies helped bolster evidence that surgical-site infections are the leading cause of reoperations after spine surgery, both early (within 30 days)3, 4 and late (after 2 years).5, 6

Trauma

–A 100-patient prospective cohort study found that posttraumatic osteomyelitis treated with a 1-stage protocol and host optimization in Type B hosts resulted in 96% infection-free outcomes.7

Shoulder

–As in lower-extremity procedures, the risk of infection after shoulder arthroplasty and arthroscopy is higher when the surgeries are performed less than 3 months after a corticosteroid injection. This finding suggests elective shoulder procedures should be delayed for at least 90 days after such injections.8

References

  1. Singh G, Deutloff N, Maertens N, Meyer H, Awiszus F, Feuerstein B, Roessner A, Lohmann CH. Articulating polymethylmethacrylate (PMMA) spacers may have an immunomodulating effect on synovial tissue. Bone Joint J. 2016 ;98-B(8):1062–8.
  2. Williams RL, Ayre WN, Khan WS, Mehta A, Morgan-Jones R. Acetic acid as part of a debridement protocol during revision total knee arthroplasty. J Arthroplasty. 2017 ;32(3):953–7. Epub 2016 Sep 28.
  3. Medvedev G, Wang C, Cyriac M, Amdur R, O’Brien J. Complications, readmissions, and reoperations in posterior cervical fusion. Spine (Phila Pa 1976). 2016 ;41(19):1477–83.
  4. Hijas-Gómez AI, Egea-Gámez RM, Martínez-Martín J, González-Díaz RC, Losada-Viñas JI, Rodríguez-Caravaca G. Surgical wound infection rates and risk factors in spinal fusion in a university teaching hospital in Madrid, Spain. Spine. November 2016.
  5. Ohya J, Chikuda H, Takeshi O, Kato S, Matsui H, Horiguchi H, Tanaka S, Yasunaga H. Seasonal variations in the risk of reoperation for surgical site infection following elective spinal fusion surgery: a retrospective study using the Japanese diagnosis procedure combination database. Spine (Phila Pa 1976). 2016 . Epub 2016 Nov 22.
  6. Ahmed SI, Bastrom TP, Yaszay B, Newton PO; Harms Study Group. 5-year reoperation risk and causes for revision after idiopathic scoliosis surgery. Spine (Phila Pa 1976). 2016 . Epub 2016 Nov 9.
  7. McNally MA, Ferguson JY, Lau ACK, Diefenbeck M, Scarborough M, Ramsden AJ, Atkins BL. Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite: a prospective series of 100 cases. Bone Joint J. 2016 ;98-B(9):1289–96.
  8. Werner BC, Cancienne JM, Burrus MT, Griffin JW, Gwathmey FW, Brockmeier SF. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients. J Shoulder Elbow Surg. 2016 ;25(3):390–7. Epub 2015 Nov 30.

By Itself, Spine Surgery Not a Risk Factor for Prolonged Opioid Use

OpioidsThe use of prescription painkillers in the US increased four-fold between 1997 and 2010, and postoperative overdoses doubled over a similar time period. In the August 2, 2017 edition of The Journal of Bone & Joint Surgery, Schoenfeld et al. estimated the proportion of nearly 10,000 initially opioid-naïve TRICARE patients who used opioids up to 1 year after discharge for one of four common spinal surgical procedures (discectomy, decompression, lumbar posterolateral arthrodesis, or lumbar interbody arthrodesis).

Eighty-four percent of the patients filled at least 1 opioid prescription upon hospital discharge. At 30 days following discharge, 8% continued opioid use; at 3 months, 1% continued use; and at 6 months, 0.1%. Only 2 patients (0.02%) in this cohort continued prescription opioid use at 1 year following surgery.

In an adjusted analysis, the authors found that an age of 25 to 34 years, lower socioeconomic status, and a diagnosis of depression were significantly associated with an increased likelihood of continuing opioid use. Those patient-related factors notwithstanding, the authors claim that the outcomes in their study “directly contravene the narrative that patients who undergo spine surgery, once started on prescription opioids following surgery, are at high risk of sustained opioid use.”

However, in his commentary on this study, Robert J. Barth, PhD, cautions that the exclusion criteria restricted even this large sample to about 19% of representative spine surgery candidates, making the findings not widely generalizable. Having said that, the commentator adds that the study supports findings of prior research that persistent postoperative opioid use is more related to “addressable patient-level predictors” than postsurgical pain. He also notes that the findings are “supportive of guidelines that call for surgical-discharge prescriptions of opioids to be limited to ≤2 weeks.”

July 2017 Article Exchange with JOSPT

JOSPT_Article_Exchange_LogoIn 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of July 2017, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “An Integrated Model of Chronic Whiplash-Associated Disorder.”

This clinical commentary explains how psychological and neurobiological factors interact with, and are influenced by, existing personal and environmental factors to contribute to the development of chronic whiplash-associated disorder.

Surgical Approach for Cervical Myelopathy: Front or Back?

Propensity Match for OBuzz.jpegSpine 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.”

What’s New in Spine Surgery

Spine for O'Buzz.jpegEvery 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

  1. 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.
  2. 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
  3. 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.

Fracture Liaison Service Boosts Patient Engagement with Secondary Prevention

fragility fractures for O'Buzz.pngOrthoBuzz has published several posts about osteoporosis, fragility fractures, and secondary fracture prevention. In the May 17, 2017 edition of JBJS, Bogoch et al. add to evidence suggesting that a coordinator-based fracture liaison service (FLS) improves engagement with secondary-prevention practices among inpatients and outpatients with a fragility fracture.

The Division of Orthopaedic Surgery at the University of Toronto initiated a coordinator-based FLS in 2002 to educate patients with a fragility fracture and refer them for BMD testing and management, including pharmacotherapy if appropriate. Bogoch et al. analyzed key clinical outcomes from 2002 to 2013 among a cohort of 2,191 patients who were not undergoing pharmacotherapy when they initially presented with a fragility fracture.

  • Eighty-four percent of inpatients and 85% of outpatients completed BMD tests as recommended.
  • Eighty-five percent of inpatients and 79% of outpatients who were referred to follow-up bone health management were assessed by a specialist or primary care physician.
  • Among those who attended the referral appointment, 73% of inpatients and 52% of outpatients received a prescription for anti-osteoporosis medication.

The authors conclude that “a coordinator-based fracture liaison service, with an engaged group of orthopaedic surgeons and consultants…achieved a relatively high rate of patient investigation and pharmacotherapy for patients with a fragility fracture.”

May 2017 Article Exchange with JOSPT

JOSPT_Article_Exchange_LogoIn 2015, JBJS launched an“article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of May 2017, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Risk of Recurrence of Low Back Pain (LBP): A Systematic Review.”

In that systematic review, the authors found low quality and heterogeneity among studies of this topic. They concluded that “the available research does not provide robust estimates of the risk of LBP recurrence and provides little information about factors that predict recurrence in people recently recovered from an episode of LBP.”