Tag Archive | lumbar spine

Questionnaire Helps Identify Lumbar Patients Who Need Surgeon Consult

Only about 10% to 15% of patients with low back pain who are referred to a spine surgeon actually require a surgical procedure. And because low back pain is such a common presenting complaint, many such patients often wait a long time for a surgery consult. In the December 19, 2018 issue of JBJS, Coyle et al. demonstrate that a simple, 3-item patient-administered questionnaire can identify those better suited for nonoperative management—and thus increase the likelihood that surgical candidates are seen by spine surgeons in an acceptable time frame.

All 227 of the Canadian patients enrolled in this randomized controlled trial received the questionnaire, which elicited information to distinguish between patients with leg-dominant radicular pain and those with back-dominant pain. Evidence-based guidelines recommend nonoperative management for most back-dominant pain, while patients with leg-dominant pain are more likely to need surgery. Researchers randomized 116 patients into an intervention group; these patients were triaged by a spine surgeon and then had their triage status upgraded if responses to the questionnaire indicated leg-dominant symptoms. The 111 patients in the control group were triaged only by a spine surgeon.

After triage, 33 of the 227 patients (15%) were recommended for a surgical procedure—16 from the intervention group and 17 from the control group. Of the 16 surgical candidates identified from the intervention group, 9 (56%) were re-prioritized on the basis of questionnaire results.

The median wait time for a consultation among the 16 surgical candidates in the intervention group was 2.5 months, compared with 4.5 months for the 17 surgical candidates in the control group. A significantly greater percentage of patients in the intervention group than in the control group were seen for a consult with a spine surgeon within the “acceptable” time frame of 3 months. Another benefit of the questionnaire approach evaluated in this study is that it helps identify nonsurgical candidates early, so they can be directed toward more appropriate treatment (such as physical therapy) rather than delaying treatment while waiting for a consult with a spine surgeon.

Although this study was conducted in the setting of the “nationalized” Canadian health care system, wait times to see orthopaedic surgeons and neurosurgeons are also long for many patients in many regions of the US. This questionnaire enhancement to triage could therefore be viable throughout North America, and perhaps beyond.

JBJS 100: Approach to the Lumbar Spine, Knee Flexion Contracture

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 full-text 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:

The Paraspinal Sacrospinalis-Splitting Approach to the Lumbar Spine
LL Wiltse, JG Bateman, RH Hutchinson, WE Nelson: JBJS, 1968 July; 50 (5): 919
In this classic 1968 JBJS paper, Wiltse and co-authors described a novel and innovative access route to the lumbar spine. Advantages included reduced blood loss, less muscle ischemia, and the preservation of spinous processes and intra-/supraspinous ligaments. The Wiltse approach still represents one of the main access routes to the lumbar spine.

Treatment of Knee Flexion Contracture Due to Central Nervous System Disorders in Adults
JN Martin, R Vialle, P Denormandie, G Sorriaux, H Gad, I Harding, O Dizien, T Judet: JBJS, 2006 April; 88 (4): 840
To address what was at the time a lack of interest among orthopaedic surgeons in treating spasticity in adults, these authors expanded upon earlier work studying the treatment of knee flexion contractures in this population. Their procedure included distal hamstring lengthening, a posterior capsulotomy in some of the knees, and use of a unilateral external fixator in most of the knees. Mean flexion contracture improved from a mean of 69° preoperatively to a mean of 6.2° at 1 to 5 years after surgery.

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.

Lumbar Spine Surgery Helps Parkinson Patients

Despite a higher rate of complications than in the general population, overall outcomes of lumbar spine surgery in patients with mild to moderate Parkinson disease are favorable, with significant improvements in spine-related pain and function. So concludes a study by Schroeder et al. in the October 21, 2015 Journal of Bone & Joint Surgery. Improvements were seen in surgeries with and without instrumentation over an average follow-up of more than two years.

Among the 20 of 96 patients in the study who required revision surgery, risk factors for revision included a Parkinson disease severity of ≥3 on the modified Hoehn and Yahr scale, a history of diabetes mellitus, treatment for osteoporosis, and a combined anterior/posterior surgical approach (which was used in 22 of 63 patients who underwent instrumented fusions).

In light of these findings, Schroeder et al. recommend that, among patients who have Parkinson severity ≥3 and in those with non-insulin-dependent diabetes or severe osteoporosis, lumbar spine surgery should be done only in cases with concomitant myelopathy. They also remind surgeons that if the patient’s spine pathology is severe enough to mandate a combined anterior and posterior approach, “the risk of surgery is high.”