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August 2018 Article Exchange with JOSPT

jospt_article_exchange_logo1In 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 August 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Impact of Risk Adjustment on Provider Ranking for Patients With Low Back Pain Receiving Physical Therapy.”

The authors’ findings confirmed their hypothesis that robust risk adjustment is essential for objective comparison of patient-reported outcomes and for accurately reflecting quality of care among patients treated for low back pain.

What’s New in Spine Surgery 2018, Part II

Spine_Graphic for OBuzz

Previously, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected what he deemed to be the most clinically compelling findings from among the more than 25 studies cited in the June 20, 2018 Specialty Update on Spine Surgery.  In this OrthoBuzz post, Theodore J. Choma, MD, author of the Specialty Update on Spine Surgery, selected his “top five.”

Spondylolisthesis
–A registry study of 765 patients with adult isthmic spondylolisthesis and at least 2 years of post-treatment outcome data found that at 1 year, global-assessment improvements were reported in 54% of patients who underwent uninstrumented posterolateral fusion, 68% of patients who underwent instrumented posterolateral fusion, and 70% of patients who underwent interbody fusion. Although similar patterns were seen in VAS back pain scores and in 2-year data, fusion with instrumentation was associated with a higher risk of reoperation.

Acute Low Back Pain
–In a cost analysis using data from a previously published Level-II study that randomized 220 patients with acute low back pain to early physical therapy or usual (delayed-referral) care, authors concluded that the incremental cost of early PT was $32,058 per quality-adjusted life year and that early PT is therefore cost-effective.1

Metabolic Bone Disease
–A randomized trial of 66 women ≥50 years of age who had osteoporosis and had undergone lumbar interbody arthrodesis found that those who received once-weekly teriparatide for 6 months following surgery demonstrated higher fusion rates than those in the control cohort (69% versus 35%). Once weekly teriparatide may be worth considering to improve fusion rates in this challenging patient population.

Adult Deformity Correction
–To test the hypothesis that performing 3-column osteotomies more caudally in the lumbar spine might improve sagittal malalignment correction, authors analyzed 468 patients from a spine deformity database who underwent 3-column osteotomies.2 The mean resection angle was 25.1° and did not vary by osteotomy level. No variations were found in the amount of sagittal vertical axis or pelvic tilt correction, but lower-level osteotomies were associated with more frequent pseudarthroses and postoperative motor deficits.

Spinal Cord Injury
–Authors directly measured the mean arterial pressure and cerebrospinal fluid pressure in 92 consecutive patients with traumatic spinal cord injury. Using that data to indirectly monitor the patients’ spinal cord perfusion pressure,3 the authors found that patients who experienced more episodes of spinal cord perfusion pressures <50 mm Hg were less likely to manifest objective improvements in spinal cord function.

References

  1. Fritz JM, Kim M, Magel JS, Asche CV. Cost-effectiveness of primary care management with or without early physical therapy for acute low back pain: economic evaluation of a randomized clinical trial. Spine (Phila Pa 1976).2017 Mar;42(5):285-90.
  2. Ferrero E, Liabaud B, Henry JK, Ames CP, Kebaish K, Mundis GM, Hostin R, Gupta MC, Boachie-Adjei O,Smith JS, Hart RA, Obeid I, Diebo BG, Schwab FJ, Lafage V. Sagittal alignment and complications following lumbar 3-column osteotomy: does the level of resection matter?J Neurosurg Spine. 2017 Nov;27(5):560-9. Epub 2017 Sep 8.
  3. Squair JW, Bélanger LM, Tsang A, Ritchie L, Mac-Thiong JM, Parent S, Christie S, Bailey C, Dhall S, Street J,Ailon T, Paquette S, Dea N, Fisher CG, Dvorak MF, West CR, Kwon BK. Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury. 2017 Oct 17;89(16):1660-7. Epub 2017 Sep 15.

JBJS 100: SCFE Outcomes, Scoliosis Treatment

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:

Long-term Follow-up of Slipped Capital Femoral Epiphysis
B T Carney, S L Weinstein, J Noble: JBJS, 1991 January; 73 (5): 667
In this retrospective study of 155 hips with SCFE followed for a mean of 41 years after onset of symptoms, Carney et al. found that pinning in situ provided the best long-term function and delay of degenerative arthritis—and that realignment techniques were associated with a risk of substantial complications.

Treatment of Scoliosis: Correction and Internal Fixation by Spine Instrumentation
P R Harrington: JBJS, 1962 June; 44 (4): 591
The need for this at-the-time revolutionary instrumented approach was the polio epidemic, which left Dr. Harrington caring for many patients with severe, collapsing curves that threatened their health. Just as current hip arthroplasty techniques represent incremental improvements to the contribution of Charnley, current techniques in scoliosis surgery are stepwise improvements to Harrington’s work.

What’s New in Spine Surgery 2018

Spine_Graphic for OBuzzEvery 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 Chad Krueger, MD, JBJS Deputy Editor for Social Media, to select the five most clinically compelling findings from among the more than 25 studies cited in the June 20, 2018 Specialty Update on Spine Surgery.

Cervical Spine
—A Level-III retrospective analysis found that patients who received a preoperative cervical epidural steroid injection prior to an anterior cervical discectomy and fusion or a posterior cervical fusion had a significantly greater risk of postoperative infection than those who did not receive a preoperative steroid injection.1 Prospective studies are needed to further clarify the perioperative infection risk associated with cervical epidural steroid injections.

Lumbar Spine
—A Level-II randomized pilot trial comparing titanium-coated PEEK interbody spacers with non-coated PEEK spacers among 40 patients who underwent transforaminal lumbar interbody fusion found that patients in both groups had 92% fusion at 3 months, with no significant between-group differences in pain and disability outcomes.2

—A Level-II randomized study of 108 patients who underwent lumbar discectomy compared outcomes among those who experienced 2 weeks versus 6 weeks of postoperative activity restriction. At the 1-year follow-up there was a nonsignificant difference in recurrent herniation (11% in the 2-week group versus 7% in the 6-week group) and no significant between-group differences in pain or disability scores.3

RF Ablation for Chronic Low Back Pain
—A Level-II meta-analysis involving 454 patients with chronic low back pain found that those who underwent radiofrequency (RF) lumbar-facet denervation had significantly reduced VAS back pain compared to a group that underwent a sham procedure or epidural block. Those in the denervation group who benefited most were those who had responded favorably to an initial diagnostic facet block.4

Adolescent Idiopathic Scoliosis
—A Level-II study assessing the ability of surface topography to evaluate spinal deformity in children with adolescent idiopathic scoliosis followed 45 patients for 1 year. This method plus radiography allowed researchers to determine mild curves with strong negative predictive value and sensitivity. The authors estimated that surface topographic analyses could reduce patient exposure to ionizing radiation by eliminating 31% of surveillance radiographs in these patients.5

References

  1. Cancienne JM, Werner BCPuvanesarajah VHassanzadeh HSingla AShen FHShimer ALDoes the timing of preoperative epidural steroid injection affect infection risk after ACDF or posterior cervical fusion?Spine (Phila Pa 1976). 2017 Jan 15;42(2):71-7.
  2. Rickert M, Fleege CTarhan TSchreiner SMakowski MRRauschmann MArabmotlagh MTransforaminal lumbar interbody fusion using polyetheretherketone oblique cages with and without a titanium coating: a randomised clinical pilot studyBone Joint J.2017 Oct;99-B(10):1366-72.
  3. Bono CM, Leonard DACha TDSchwab JHWood KBHarris MBSchoenfeld AJThe effect of short (2-weeks) versus long (6-weeks) post-operative restrictions following lumbar discectomy: a prospective randomized control trialEur Spine J.2017 Mar;26(3):905-12. Epub 2016 Nov 2.
  4. Lee CH, Chung CKKim CHThe efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints: a meta-analysis of randomized controlled trialsSpine J.2017 Nov;17(11):1770-80. Epub 2017 May 30.
  5. Hong A, Jaswal NWestover LParent ECMoreau MHedden DAdeeb SSurface topography classification trees for assessing severity and monitoring progression in adolescent idiopathic scoliosisSpine (Phila Pa 1976).2017 Jul 1;42(13):E781-7.

Quantitative Guidance for Treating Patients with Spinal Epidural Abscess

epidural abscess for OBuzzAny patient presenting with a spinal epidural abscess is in a high-risk situation, but decisions about operative versus nonoperative management in such cases are influenced largely by the presence, absence, or imminent risk of a motor deficit. This is why the identification by Shah et al. of 8 independent predictors of pre-treatment motor deficit and 7 independent predictors of 90-day mortality among patients with spinal epidural abscess is so important. The findings appear in the June 20, 2018 issue of JBJS.

The authors retrospectively analyzed data from 1,053 patients admitted with spinal epidural abscess at 2 tertiary medical centers and 3 regional community hospitals. Using multivariable logistic regression, they identified the following 8 significant risk factors for pre-treatment motor deficits in these patients:

  • Diabetes
  • Sensory changes
  • Urinary incontinence/retention
  • Fecal incontinence/retention
  • Abscess location proximal to conus medullaris
  • Abscess location dorsal to the thecal sac
  • Abscess in multiple locations
  • White blood cell (WBC) count >12 X 109 cells/L

Similarly, the authors identified the following 7 significant risk factors for 90-day mortality:

  • Diabetes
  • Age >65 years
  • Active malignancy
  • Renal disease requiring hemodialysis
  • Pre-treatment motor deficit
  • Endocarditis
  • WBC count >15 X 109 cells/L

By themselves, these predictors are not prognostic, but the authors provide an algorithm that clinicians can use to generate an individualized probability of pre-treatment motor deficit or 90-day mortality for a given patient. The authors express hope that the resulting quantitative information will help guide management decisions for patients with spinal epidural abscess.

JBJS 100: Juvenile Rheumatoid Arthritis, Tibial Fracture Healing

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:

Changes in the Cervical Spine in Juvenile Rheumatoid Arthritis
R N Hensinger, P D DeVito, C G Ragsdale: JBJS, 1986 January; 68 (2): 189
This study of 121 patients with juvenile rheumatoid arthritis (RA) found that severe neck pain was not common, although neck stiffness and radiographic changes were commonly seen in the subset of patients with polyarticular-onset disease. The authors concluded that patients with juvenile RA who present with evidence of disease in the cervical spine should be examined carefully for involvement of multiple joints.

A Functional Below-the-Knee Cast for Tibial Fractures
A Sarmiento: JBJS, 1967 July; 49 (5): 855
In this report of 100 consecutive tibial shaft fractures, Gus Sarmiento encouraged early weight bearing in a skin-tight plaster cast that was molded proximally to contain the muscles of the leg. All 100 fractures healed, and healing occurred with minimal deformity or shortening. While most tibial shaft fractures are now treated with intramedullary nails, the principles developed by Dr. Sarmiento still apply, as the nail acts much like the fracture brace to maintain alignment during the weight-bearing healing process.

Progression of Cervical Spine Degeneration Over 20 Years

Few studies have addressed in detail long-term degenerative changes in the cervical spine. https://jbjs.org/reader.php?source=The_Journal_of_Bone_and_Joint_Surgery/100/10/843/fulltext&id=30295&rsuite_id=1666209#info #JBJSInfographics #VisualAbstract

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Scoliosis Management Shows Success Long-Term

Scoliosis for OBuzzHealth-related quality of life (HRQOL) in adulthood is an important outcome measure for patients diagnosed with juvenile or adolescent idiopathic scoliosis. In the May 16, 2018 issue of The Journal of Bone & Joint Surgery, a cross-sectional study of 1,187 Swedish patients with scoliosis by Diarbakerli et al. reveals patient-reported HRQOL outcomes at an average follow-up of approximately 18 years. Using the Scoliosis Research Society-22r (SRS-22r) and the EuroQol 5-Dimensions (EQ-5D) instruments, the authors analyzed outcomes among those who had been untreated (n = 347), brace-treated (n = 459), or surgically treated (n = 381) in accordance with standards at the time of diagnosis.

The surgically treated group had significantly lower scores in the SRS-22r domains of function and self-image, compared with the scores in those domains among the other two groups. According to Daniel J. Sucato, MD, who commented on the study, those findings “most likely reflect the various effects of the surgical procedure, including the stiffness imparted by the arthrodesis of the spine,… stiffness of the soft tissues, and the presence and awareness of implants and a surgical incision.” Diarbakerli et al. also found that untreated patients did not report a decrease in HRQOL with age.

Interestingly, patients treated surgically had higher SRS-22r satisfaction-domain scores than brace-treated patients, even though overall SRS-22r and EQ-5D scores were lower among surgically treated patients than brace-treated patients. For spine surgeons, one key finding was that “a more caudal extent of fusion may be one of the most important characteristics that negatively affects quality of life” in patients undergoing scoliosis surgery.

With its large number of patients and long-term, patient-focused outcomes, this study generally corroborates findings from previous, smaller studies. But, as Dr. Sucato points out in his commentary, “the brace and surgical groups had treatments that were current at the time but not relevant today, especially as they involved the use of first-generation techniques and instrumentation.”

Fragility Fracture Workshop & Symposium—June 28 & 29, 2018

ownbone_logo-rOn Thursday evening, June 28 and all day Friday, June 29 in Boston, The American Orthopaedic Association (AOA) and the National Association of Orthopaedic Nurses (NAON) will present two educational/networking events concentrating on secondary fragility fracture prevention.

The Thursday evening Workshop, available only to those attending the Friday Symposium, will convene clinicians with expertise in counseling and treating fragility fracture patients. “This new two-hour workshop provides an additional opportunity to learn more about identifying, assessing, counseling, and treating fragility fracture patients,” said program co-chair Debra Sietsema, PhD, RN. “The Workshop also includes special breakout stations on calcium, FRAX, and the AOA’s ‘Own the Bone’ initiative.”

The all-day Symposium on Friday focuses on how to establish a multidisciplinary secondary fragility fracture program. In addition, the Symposium will include relevant case studies demonstrating how to translate the principles into hospital, private-practice, or clinic settings. “This Symposium is a great opportunity for orthopaedic surgeons and allied health professionals to get the full picture in one day,” said Dr. Sietsema. “Attendees will gain both basic and expanded knowledge to put their programs in place.”

Register by May 15 to receive early-bird pricing for these important events. NAON members and clinicians from enrolled Own the Bone institutions save an additional $50.

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.