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JBJS 100: Lumbar MRI and Bunions

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects
S D Boden, D O Davis, T S Dina, N J Patronas, S W Wiesel: JBJS, 1990 March; 72 (3): 403
Many important subsequent studies were inspired by the findings of this landmark JBJS study. Most of them emphasize that for lumbar-spine diagnoses, an MRI is only one (albeit important) piece of data; that interpretation of MRI is variable; and that all imaging information must be correlated to the patient’s clinical condition.

A Conservative Operation for Bunions
E D McBride: JBJS, 1928 October; 10 (4): 735
Many other bunion procedures have been described since 1928, but the principle of restoring congruency of the first metatarsophalangeal joint remains very important in bunion operations. The most substantial modification of McBride’s procedure is that the lateral sesamoid is no longer typically excised.

Topical Vancomycin in Spine Surgery: Pediatric Patients Benefit Too

Vancomycin for OBuzzWhen >10% of patients undergoing procedures to correct a spinal deformity develop one or more surgical-site infections, investigations into how to mitigate such infections seem warranted. This is especially true when a single such infection can cost nearly $1 million to treat—not to mention the physical and psychological burdens.

In the March 21, 2018 edition of JBJS, Thompson et al. report important findings from a retrospective study that sought to evaluate the efficacy of adding topical vancomycin powder to the wounds of patients undergoing growing-spine surgeries to address early-onset scoliosis. The mean patient age at the beginning of the study was 7.1 years.

Cases in which topical vancomycin powder was placed into the wounds at the time of fascial closure (n = 104 cases) had a significantly lower surgical-site infection rate (4.8%), compared with the rate in the 87 cases in which no vancomycin was used (13.8%). Furthermore, the “number needed to treat” found in this study was 11, meaning that for every 11 cases in which vancomycin powder was used, a surgical-site infection was prevented.  The authors found no complications related to the use of topical vancomycin and note that their study provides the first evidence supporting the efficacy of vancomycin powder in pediatric spine patients.

Because this study was retrospective and based out of one center, further multicenter, prospective studies are needed to verify these results and to address open questions such as appropriate vancomycin dosages. Still, considering the extremely high costs (economic, physical, social, and psychological) associated with surgical-site infections in these complex patients, it appears that a vial of vancomycin powder costing between $10 and $40 may deliver outstanding value in these scenarios.

Chad A. Krueger, MD
JBJS Deputy editor for Social Media

What’s New in Pediatric Orthopaedics 2018

Pediatrics Image from HUBEvery 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, Derek Kelly, MD, co-author of the February 21, 2018 Specialty Update on Pediatric Orthopaedics, selected the most clinically compelling findings from among the more than 50 studies summarized in the Specialty Update.

Trauma

—An analysis of pediatric femoral shaft fractures before and after the publication of clinical practice guidelines1 revealed a significant increase in the use of interlocked intramedullary nails in patients younger than 11 years of age, and an increase in surgical management for patients younger than 5 years of age. Considerable variability among level-I pediatric trauma centers highlights the need for further outcome studies to facilitate updating of existing guidelines.

Scoliosis

—A prospective cohort study of pain and opioid use among patients following posterior spinal fusion for adolescent idiopathic scoliosis found that increased age, male sex, greater BMI, and preoperative pain levels were associated with increased opioid use. Findings like these may help guide clinicians in opioid dispensing practices that minimize the problem of leftover medication.

Infection

—Two stratification/scoring systems may aid in the early prediction of musculoskeletal infection severity and promote efficient allocation of hospital resources. A 3-tiered stratification system described by Mignemi et al.2 correlated with markers of inflammatory  response and hospital outcomes. Athey et al.3 validated a severity-of-illness score and then modified it for patients with acute hematogenous osteomyelitis.

Hip

—A study of closed reduction for developmental dysplasia of the hip4 revealed that 91% of 87 hips achieved stable closed reduction. Of those, 91% remained stable at the 1-year follow-up. Osteonecrosis occurred in 25% of cases, but it was not associated with the presence of an ossific nucleus, a history of femoral-head reducibility, or age at closed reduction.

—Regardless of obesity status, serum leptin levels increase the odds of slipped capital femoral epiphysis (SCFE), according to a recent study. Researchers reached that conclusion after comparing serum leptin levels in 40 patients with SCFE with levels in 30 BMI-matched controls.

References

  1. Roaten JD, Kelly DM, Yellin JL, Flynn JM, Cyr M, Garg S, Broom A, Andras LM,Sawyer JR. Pediatric femoral shaft fractures: a multicenter review of the AAOS clinical practice guidelines before and after 2009. J Pediatr Orthop.2017 Apr 10. [Epub ahead of print].
  2. Mignemi ME, Benvenuti MA, An TJ, Martus JE, Mencio GA, Lovejoy SA, Copley LA, Williams DJ, Thomsen IP, Schoenecker JG. A novel classification system based on dissemination of musculoskeletal infection is predictive of hospital outcomes. J Pediatr Orthop.2016 Jun 13. [Epub ahead of print].
  3. Athey AG, Mignemi ME, Gheen WT, Lindsay EA, Jo CH, Copley LA. Validation and modification of a severity of illness score for children with acute hematogenous osteomyelitis. J Pediatr Orthop.2016 Oct 12. [Epub ahead of print].
  4. Sankar WN, Gornitzky AL, Clarke NM, Herrera-Soto JA, Kelley SP, Matheney T, Mulpuri K, Schaeffer EK, Upasani VV, Williams N, Price CT; International Hip Dysplasia InstituteClosed reduction for developmental dysplasia of the hip: early-term results from a prospective, multicenter cohort. J Pediatr Orthop.2016 Nov 11. [Epub ahead of print].

Webinar on March 29 – Spondylolysis in Adolescents: Diagnosis, Treatment, and Outcomes

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Low back pain is not typically thought to be a pediatric issue; however, this condition occurs in 33% of adolescents each year—a rate similar to that seen in adults. The most common identifiable cause of low back pain in the adolescent is spondylolysis, a defect in the pars interarticularis. How is this condition best diagnosed and treated? Do oblique radiographs help diagnose spondylolysis in adolescents? What kind of short- and long-term clinical outcomes can adolescents—and especially adolescent athletes—diagnosed with acute spondylolysis expect to have? What factors might predict long-term outcomes?

These important and clinically applicable questions will be addressed during a complimentary LIVE webinar, hosted jointly by the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) and The Journal of Bone & Joint Surgery (JBJS).

JBJS presenter, Peter Passias, MD, will discuss findings from a retrospective study of adolescents with and without L5 spondylolysis to address whether oblique radiographic views add value in the diagnosis of this cause of low back pain. This paper specifically addresses whether the diagnostic benefit of four-view studies outweighs the additional cost and radiation exposure, especially for young people.

JOSPT co-author Mitchell Selhorst, DPT, OCS, will share the results of a retrospective review of acute spondylolytic injuries in young athletes. This study reports long-term clinical outcomes for these patients and identifies significant predictors of these outcomes.

Moderated by JBJS Deputy Editor Andrew J. Schoenfeld, MD, who specializes in spondylolisthesis, spinal stenosis, and spinal surgery, the webinar will include additional insights from expert commentators, Chris Bono, MD,from Brigham and Women’s Hospital in Boston, and Michael Allen, PT, from Cincinnati Children’s Hospital Medical Center. The last 15 minutes will be devoted to a live Q&A session between the audience and panelists.

Space is limited, so Register Now.

Some Flags for Low Back Pain Screening Should be Yellow, Not Red

Low-Back-Pain for OBuzzAn estimated 85% of all adults will experience low back pain at some point in their lives. So-called “red flag” questions were developed to help primary care providers determine whether a patient’s back pain warranted an escalation of care, either through advanced imaging or referral to a spine specialist. However, in the March 7, 2018 issue of JBJS, Premkumar et al. found that, despite the widespread use of red flag questions, it appears that they have limited clinical usefulness when applied in isolation in a referral spine practice setting.

The authors analyzed the responses to commonly asked red flag questions from more than 9,000 patients presenting to a spine center with low back pain. They found that >90% of the patients had a positive response to at least one of the questions, but only 8% actually had a red flag diagnosis. Furthermore, the authors found that a negative response to one or two of the questions did not preclude a red flag diagnosis. No single red flag question had a sensitivity >75% or a clinically useful negative likelihood ratio—a measure of a screening tool’s ability to rule out a diagnosis.

Importantly, however, certain combinations of positive answers were predictive of specific disease processes. For example, a history of trauma in patients over the age of 50 years was predictive for a diagnosis of spinal compression fracture, and back pain in a patient with a history of a primary oncologic diagnosis should alert physicians to the possibility of metastatic disease. Conversely, the authors say that low back pain that awakens a patient from sleep was not found to be a useful parameter for making any diagnosis.

This is the first large-scale study to evaluate the clinical utility of these questions in the setting of low back pain, and the authors question their usefulness as screening tools. While the concept behind red flag questions remains valid, the rigid application of such questions in decision making regarding advanced imaging or additional testing is not appropriate. The utility of red flag screening questions for low back pain needs additional testing, especially in the primary care setting.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

JBJS 100: Shoulder Replacement and Odontoid Process Fractures

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Recent Experience in Total Shoulder Replacement
C S Neer, K C Watson, F J Stanton: JBJS, 1982 March; 64 (3): 319
“Recent” in this context refers to more than 30 years ago, but many aspects of this meticulous review of nearly 200 total shoulder replacements, followed for 24 to 99 months, remain instructive. To get a sense of the explosion in research on this topic, compare the 18 references accompanying this study, most citing work by Neer himself, to the 70 references in a 2015 JBJS Reviews article focused on one detail (glenoid bone deficiency) of shoulder replacement.

Fractures of the Odontoid Process of the Axis
L D Anderson and R T D’Alonzo: JBJS, 1974 December; 56 (8): 1663
The basic fracture classification posited in this article has stood the test of time. Since the 1980s, however, surgeons have developed treatments for type-II odontoid fractures that provide direct fixation without the need for fusion and subsequent loss of rotatory motion.

March 2018 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 March 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Pragmatically Applied Cervical and Thoracic Nonthrust Manipulation versus Thrust Manipulation for Patients with Mechanical Neck Pain: A Multicenter Randomized Clinical Trial.”

To thrust or not to thrust–that was the question investigated among 103 patients with mechanical neck pain in this randomized trial. Thrust and nonthrust manipulation produced equivalent outcomes.

Spinal Cord Compression/Joint Laxity & ACL

Spinal cord injury in the cervical spine is commonly accompanied by cord compression and urgent surgical decompression may improve neurological recovery. http://bit.ly/2FbYWpA #JBJSInfographics #JBJSJBJS.IG.16.00995.ig

Is there a difference in outcomes of ACL reconstruction between patients with generalized joint laxity and those without it? What are the effect of generalized joint laxity on outcomes of ACL reconstruction from 2 to 8 years postoperatively? http://bit.ly/2F6dlUY #JBJS #JBJSInfographics

Joint Laxity InfoGraphic for OBuzz

Cord Compression Reflects Neurological Outcomes after Thoracolumbar Injuries

cord compression for OBuzzThe association between spinal cord compression and functional deficits following cervical spine trauma has been well studied using both CT and MRI. However, until now, there was little data evaluating whether that same association is true for thoracic spine injuries. In the February 21, 2018 edition of The Journal, Skeers et al. identified the same correlations between canal compromise, cord compression, and functional outcome in the T1 to L1 region.

Using retrospective data, the authors showed that the severity of neurologic deficits was associated with the amount of maximal cord compression, as measured with advanced imaging. More specifically, their univariate analysis showed that cord compression >40% was associated with a tenfold greater likelihood of complete spinal cord injury compared to cord compression <40%. This study also found that MRI measures osseous canal compromise more accurately than CT, probably because it more clearly visualizes soft tissue changes related to the posterior longitudinal ligament, ligamentum flavum, and facet capsule.

A major issue with this study (and with almost all studies that evaluate spine trauma) is that these advanced imaging techniques are temporally static; even when they’re obtained relatively soon after injury, they cannot capture the position of vertebral body fragments and posterior structure deformities that existed upon impact. This shortcoming is probably more relevant for younger patients, who are more likely to experience higher-velocity trauma.

The population in the Skeers et al. study is skewed a bit toward older patients (mean age 34.8) with relatively severe spinal injuries (mean TLICS of 7.8 and mean cord compression of 40%). These factors may highlight the roles that lower bone density and decreased soft tissue elasticity play in the setting of high-energy spine trauma.

Although the data reflect some variability, this study should help spine surgeons counsel patients and their families following these tragic injuries. The more severe the initial cord compression in the thoracic spine, the more likely there is to be severe neurologic injury without improvement.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

February 2018 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 February 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “The Influence of Patient Choice of First Provider on Costs and Outcomes: Analysis From a Physical Therapy Patient Registry.”

The authors of this economic and decision analysis tackle a controversial topic: whether giving patients with neck and back pain direct access to physical therapy, without a medical referral, leads to lower costs of care. They also compare clinical outcomes in the medical-referral and direct-access groups.