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.”
–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.
- 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.
- 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.
- 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.
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.
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).
- 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.
The May 3, 2017 issue of JBJS contains one more in a series of personal essays where orthopaedic clinicians tell a story about a high-impact lesson they learned that has altered their worldview, enhanced them personally, and positively affected the care they provide as orthopaedic physicians.
This “What’s Important” piece comes from Dr. Edward Farrar of Wenatchee Orthopaedics in Washington. In his powerful and inspiring essay titled “Lessons on Life, Death, and Disability,” Dr. Farrar explains how a serious bicycle accident in 2008 severed his spinal cord at the T4 level.
What happened after a long and arduous recovery that left him paraplegic, followed shortly thereafter by the death of his partner from a brain tumor? He returned to work and saw patients although he could no longer operate. In his words, “I became a better listener and realized how much this has helped my patients and me.”
One of the many things he has learned from his experiences so far: “We may not always find the meaning and purpose that we were searching for, yet meaning and purpose can find us.”
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.
This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) presents the case of a 55-year-old woman with neck pain and upper-extremity weakness after a motor vehicle accident that occurred 1 week prior, during which she sustained a whiplash injury. She notes severe bilateral arm weakness, “clumsy hands,” and mild lower-extremity weakness with walking. The bilateral upper-extremity muscle groups have a strength of 3 of 5, and the lower-extremity muscle groups have a strength of 5 of 5. Sensation remains intact throughout the upper and lower extremities.
Select from among four choices as the most likely diagnosis:
- Central cord syndrome
- Brown-Séquard syndrome
- Anterior cord syndrome
- Posterior cord syndrome
The November 25, 2015 “Case Connections” looks at four JBJS Case Connector cases involving injuries to the cervical spine in which the outcomes were about as good as anyone could have wished, considering the potential for disaster. Two of the cases required surgical intervention to achieve the positive outcomes, but the outcomes in the other two cases were remarkably positive without surgery.
While these four cases of cervical spine injury had relatively “happy endings,” orthopaedic surgeons and other health-care professionals treating patients with any suspected spine injury are trained to proceed with the utmost care and caution out of concern for devastating neurological sequelae. Watchful waiting under close medical scrutiny is sometimes warranted, but many cases of cervical fracture, dislocation, or instability call for operative stabilization to reduce the risk of life-changing or life-threatening consequences. The potential seriousness of surgical complications when operating on the spine must also be recognized.
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. Here is a summary of key findings from studies cited in the November 19, 2014 Specialty Update on orthopaedic rehabilitation:
- Among geriatric hip fracture patients, those who received comprehensive postsurgical care (including a multidisciplinary assessment of health, function, and social situation) had significantly more upright time and better Short Physical Performance Battery scores than counterparts who received hospital physiotherapy and conventional care.
- Seventy-two percent of 51 orthopaedic inpatients exceeded their target goal for prescribed partial weight bearing after being trained. The inability to comply with the training was not associated with poorer outcomes at three months, suggesting clinical support for less-restrictive weight-bearing protocols.
- A prospective study of 38 unilateral TKA patients revealed that results from squatting exercises more accurately predicted overall functional difficulties than did results from standing with increased weight.
- A prospective randomized trial among 36 patients who underwent primary ACL reconstruction with semitendinosus-gracilis autograft found no difference in knee laxity, peak isometric force, or subjective IKDC scores between those who had aggressive early rehabilitation versus those undergoing a nonaggressive protocol.
Pediatric Rehabilitation (focused on cerebral palsy patients)
- Among 100 young children with cerebral palsy, the development of mobility and self-care was faster in children with less severe levels as assessed with the Gross Motor Function Classification System (GMFCS). A separate assessment study supported the validity of the Patient Reported Outcomes Measurement Information System (PROMIS) Mobility Short Form.
- Results from two gait-analysis studies suggested that using gait analysis in planning interventions for children with cerebral palsy can lead to beneficial alterations in gait.
Amputation and Prosthetics
- A study comparing functional outcomes after two types of unilateral transtibial amputation (modified Ertl and modified Burgess procedures) found no significant between-group differences.
Spinal Cord Injury
- A study to assess the safety and efficacy of ReWalk (a lower-limb powered exoskeleton) among 12 patients with motor-complete thoracic spinal cord injury found that all subjects were able to walk independently and continuously for at least 50 to 100 meters. No falls were reported, but a few adverse events related to pressure and irritation occurred.
About 12,000 new cases of spinal cord injury occur each year. The average annual cost for patients living with spinal cord injury is more than $70,000.
Armin Curt, MD, principal investigator in the StemCells trial for spinal cord injury patients, gave an update on the Phase I/II trials at the recent annual meeting of the American Spine Injury Association. All patients in the study have chronic spinal cord injuries and were treated with human central nervous system stem cells and short-term immunosuppressive drugs.
Dr. Curt reported that post–transplant gains in sensory function that were first reported in two patients have now appeared in two additional patients. The initial group of spinal cord injury patients participating in the trial had no mobility or sensory perception below the point of injury. Those in the second group were paralyzed but retained sensory perception below the point of injury. Two of the three patients in this second group, treated four to 24 months post injury, had significant sensory gains.
Researchers also noted that no one in the trial has experienced any adverse medical anomalies, such as segment deterioration, unexpected or unknown pain conditions, or loss of overall functional capacity.