Every month, JBJS publishes 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, Jacob M. Buchowski, MD, MS, coauthor of the June 19, 2019 “What’s New in Spine Surgery,” selected the five most clinically compelling findings from among the 47 noteworthy studies summarized in the article.
Predictive Analytics for Deformity Conditions
–A validated model for predicting outcomes after lumbar spine surgery1 found that patients with lower preoperative disability scores, those covered by Medicaid or Workers’ Compensation, and current and previous smokers were less likely to improve with lumbar fusion surgery. Invasiveness of surgery and surgeon and hospital type had lower predictive value.
Early-Onset Scoliosis (EOS)
–A 5-year direct-cost estimate2 comparing magnetic growing rods and conventional growing rods for the treatment of EOS found the total cost for magnetic growing rods to be £34,741 compared with £52,293 for conventional growing rods.
Pediatric Neuromuscular Scoliosis
–A Level-II study investigated patient factors associated with postoperative pulmonary complications among patients with neuromuscular scoliosis who underwent posterior spinal fusion.3 Patients with a history of pneumonia or gastrotomy tube at the time of surgery had an elevated risk of postoperative respiratory infections.
–Findings from a retrospective study of >27,000 patients who underwent lumbar decompression with or without fusion revealed that the majority of patients using prescription opioids discontinued those medications postoperatively. However, among the patients with opioid use >90 days after surgery, the duration of preoperative opioid use was the most important predictor of postoperative opioid use.
Neurological Decline after Adult Spinal Deformity Surgery
–In a retrospective analysis of 265 patients who underwent corrective surgery for adult spinal deformity,4 23% of patients experienced a neurological injury; among those, 33% experienced a major neurological decline. Among the patients with major decline, full recovery was observed in 24% at 6 weeks and 65% at 6 months, but one-third of those patients experienced persistent neurological deficits at 24 months postoperatively. Among patients who experienced a minor neurological injury, 49% reported full recovery at 6 weeks and 70% reported full recovery at 6 months. About one-quarter of those patients showed no improvement at 24 months.
- Khor S, Lavallee D, Cizik AM, Bellabarba C, Chapman JR, Howe CR, Lu D, Mohit AA, Oskouian RJ, Roh JR, Shonnard N,Dagal A, Flum DR. Development and validation of a prediction model for pain and functional outcomes after lumbar spine surgery. JAMA Surg.2018 Jul 1;153(7):634-42.
- Harshavardhana NS, Noordeen MHH, Dormans JP. Cost analysis of magnet-driven growing rods for early-onset scoliosis at 5 years. Spine (Phila Pa 1976).2019 Jan 1;44(1):60-7.
- Luhmann SJ, Furdock R. Preoperative variables associated with respiratory complications after pediatric neuromuscular spine deformity surgery. Spine Deform.2019 Jan;7(1):107-11.
- Kato S, Fehlings MG, Lewis SJ, Lenke LG, Shaffrey CI, Cheung KMC, Carreon LY, Dekutoski MB, Schwab FJ, Boachie-Adjei O, Kebaish KM, Ames CP, Qiu Y, Matsuyama Y, Dahl BT, Mehdian H, Pellisé F, Berven SH. An analysis of the incidence and outcomes of major versus minor neurological decline after complex adult spinal deformity surgery: a subanalysis of Scoli-RISK-1 study. Spine (Phila Pa 1976).2018 Jul 1;43(13):905-12.
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.
Vernon Tolo, MD, JBJS Editor-in-Chief Emeritus, provided outstanding editorial stewardship for The Journal during the last four years. In this interview, he explains what the experience has meant to him.
JBJS: As you transition out of the role of Editor-in-Chief at JBJS, what will you miss the most?
Dr. Tolo: There are a few things I will miss. One is the opportunity to work with a great group of Deputy Editors, whose work is essential and so important to the Editor. I will miss the JBJS staff, who are all talented professionals and who provided great support to me during my time as Editor. And I will miss seeing the latest in research reports, often months before publication occurs. The time I spent as Editor were some of the most exciting and rewarding years of my orthopaedic career… a true privilege to be able to carry forward the tradition of JBJS. Nonetheless, I will not miss the relentless assignment of manuscripts which required nightly connection to my computer….but I still had a great time.
JBJS: When you first joined JBJS, what surprised you the most about The Journal or about journal publishing in general?
Dr. Tolo: I had known primarily about the editorial side of journal publishing from my years being a JBJS Deputy Editor. What surprised me the most when I became Editor was how little I knew about trends in medical publishing and the challenges facing journals such as JBJS in today’s publishing world. Being involved in meeting these challenges has stimulated me to think about problems and challenges that I otherwise would not have considered.
JBJS: As JBJS celebrates its 125th anniversary this year, how would you describe the impact of The Journal on orthopaedics?
Dr. Tolo: The Journal has had a tremendous impact on orthopaedics. For the first 100 years, JBJS was the primary written source of orthopaedic education for all orthopaedic surgeons in North America. Articles published in JBJS were the source of a large percentage of questions in the Board examinations for years. Even after the explosion of educational sources in the past 25 years, The Journal still holds a pre-eminent position for quality, trusted research reports that affect day-to-day patient care.
JBJS: How do you think JBJS can best support orthopaedics going forward?
Dr. Tolo: We need to continue to be the trusted source for new orthopaedic knowledge that improves patient care. The multiple journals that the JBJS family has developed over the past few years have really broadened the choices available to orthopaedists, as has the option for webinars throughout the year.
JBJS: What trends in orthopaedics are you most intrigued by?
Dr. Tolo: I am not sure “intrigued” is the right word, but I am concerned about the ongoing tendency for super-specialization within our profession. Despite having exposure to and training for the treatment of a wide variety of orthopaedic conditions during residency, orthopaedists are increasingly claiming they are inadequately trained to treat a wide variety of orthopaedic conditions, particularly once they have completed a fellowship in a subspecialty. For example, pediatric orthopaedists may feel uncomfortable treating hand or pelvic fractures. Sports medicine orthopaedists will often not get involved with treatments outside their fellowship training. And it goes on with many other examples. This situation only seems to be increasing. The ongoing challenge is how to adjust training programs to allow for appropriate broad-based training opportunities and still allow residents to focus on the subspecialty in which they will eventually practice.
The trend over the past several years of orthopaedics being a specialty selected by more medical students than there are residency openings will likely continue. We are still the most underrepresented surgical specialty for women in training programs and on faculties. While some progress has been made in this area, we need to increase the number of women in orthopaedics.
JBJS: Looking ahead to the next 20 years or so, what do you think might be three significant advances or changes in orthopaedics?
Dr. Tolo: The changes in orthopaedics have been so dramatic in the past 20 years that it is a challenge for me to predict how our profession will look in 2034. I think medical schools will finally include education in musculoskeletal disorders commensurate with the percentage of patients with these conditions who are seen by primary care physicians. Robotic surgery, currently so common in surgical specialties that deal with soft tissue disorders, may soon be ready for orthopaedic use, but that will be a decade or more from now. Biologics will be used more often, particularly in settings to decrease the onset of articular cartilage damage after ACL injury or intraarticular fractures, and this would be a major advance. It may be that a “bone glue” may supplant casts as a fracture treatment. Whatever advances occur, JBJS is where they should be published.
JBJS: What is your favorite thing about your profession?
Dr. Tolo: No question….it is helping patients get better. I am fortunate to have worked in pediatric orthopaedics my entire career. All children want to get better, and the ability to play a part in helping advance the health of children has been extremely rewarding for me. I still love going to work every day, and the grateful feedback that I receive almost daily from families is incredible. There are few other professions or vocations that provide this benefit.
JBJS: What are you looking forward to most as you make this transition?
Dr. Tolo: Once I have dealt with my withdrawal symptoms from my time at JBJS, I will increase my clinical outpatient and operative activity at the Children’s Hospital Los Angeles, mainly in spinal deformity, skeletal dysplasia, and cerebral palsy, though probably a bit less than 100% full time. I look forward to spending quality time with my wife Charlene, who has put up with a sometimes crazy schedule for 49 years of marriage, and to getting my golf handicap down to the low teens. It will be difficult for me to break away completely from orthopaedics, which has provided me with an incredibly satisfying career and multiple opportunities to contribute to our profession globally, through a number of societies/associations–and through JBJS.