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, Nitin Jain, MD, MSPH, a co-author of the November 15, 2017 Specialty Update on Orthopaedic Rehabilitation, summarized the most clinically compelling findings from among the nearly 50 noteworthy studies summarized in the article.
–Results from a retrospective review1 of patients with noncancer pain highlighted that the risks of long-acting opioids extend beyond overdose, and include increased risks of cardiovascular death and all-cause mortality.
–A randomized prospective trial2 comparing celecoxib, ibuprofen, and naproxen for treating arthritis pain found no significant difference in the hazard ratios for those medications as related to risk of cardiovascular events.
Cost & Quality
–An assessment of a value-improvement initiative3 that examined hip and knee arthroplasty and hip fracture outcomes in a large regional health-care system found reduced costs and improvements in quality of care from 2012 to 2016.
–A literature review4 of 7 studies determined that the long-term cognitive and neurogenerative effects of multiple concussions in patients ≤17 years of age remain inconclusive.
–A randomized trial5 found no difference between anesthetic-only and anesthetic-plus-steroid epidural injections in the treatment of lumbar spinal stenosis.
–A prospective cohort study6 by the MOON Shoulder Group found that the strongest predictor of failure of nonoperative treatment for symptomatic atraumatic rotator cuff tears was lower patient expectations that such treatment would be successful. Pain level, duration of symptoms, and tear anatomy did not predict treatment failure.
- Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016 Jun 14;315(22):2415-23.
- Nissen SE, Yeomans ND, Solomon DH, Lüscher TF, Libby P, Husni ME,Graham DY, Borer JS, Wisniewski LM, Wolski KE, Wang Q, Menon V,Ruschitzka F, Gaffney M, Beckerman B, Berger MF, Bao W, Lincoff AM; PRECISION Trial Investigators. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016 Dec 29;375(26):2519-29. Epub 2016 Nov 13.
- Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C, Johnson S,Gulbransen S, Pelt CE, Horton DJ, Graves KK, Greene TH, Anzai Y, Pendleton RC. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.
- Yumul JN, McKinlay A. Do multiple concussions lead to cumulative cognitive deficits? A literature review. PM&R. 2016 Nov;8(11):1097-103. Epub 2016 May 18.
- Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Sullivan SD,Bauer Z, Bresnahan BW, Avins AL, Nedeljkovic SS, Nerenz DR, Standaert C,Kessler L, Akuthota V, Annaswamy T, Chen A, Diehn F, Firtch W, Gerges FJ,Gilligan C, Goldberg H, Kennedy DJ, Mandel S, Tyburski M, Sanders W, Sibell D, Smuck M, Wasan A, Won L, Jarvik JG. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014 Jul 03;371(1):11-21.
- Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH,Carey JL, Harrell F, Holloway BG, Jones GL, Ma CB, Marx RG, McCarty EC,Poddar SK, Smith MV, Spencer EE, Vidal AF, Wolf BR, Wright RW; MOON Shoulder Group. 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2016 Aug;25(8):1303-11.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Brett A. Freedman, MD, in response to two recent NEJM studies on treating spondylolisthesis.
The April 14, 2016 edition of The New England Journal of Medicine published results from two randomized clinical trials (RCTs) evaluating the benefits of laminectomy alone versus laminectomy and fusion for the treatment of specific spinal conditions in patients 50 to 80 years old, with at least 2-year follow-up. The larger study was conducted in Sweden and included 247 patients, 135 of whom had degenerative spondylolisthesis of some magnitude. In this study, the surgical technique varied and was left to the treating provider’s preference. The ultimate conclusion of this study was that adding fusion to the procedure did not result in better patient outcomes by any index measured.
Conversely, an essentially concurrent but unrelated RCT evaluating similar outcomes in a US patient population (n=66) with degenerative spondylolisthesis that measured at least 3 mm, but in which there was no instability, concluded that spinal fusion, using a standardized technique (pedicle screws and rods with iliac crest bone graft), did provide a significant clinical benefit. Specifically, this study found significant improvement in SF-36 physical-component summary scores (the primary outcome measure) and lower reoperation rates (14% vs. 34%; p=0.05) compared to decompression alone.
When two Level 1 studies published on the same day in the same high-impact journal come to divergent conclusions about the same clinical question, we must pause and look to the past. Spine surgeons have investigated decompression alone for spondylolisthesis, first by necessity (prior to the era of reliable spinal fusion) and then later in comparison to in-situ and instrumented fusion1,2. Consensus is consistent with anatomic reasoning. Dysfunctional lumbar mobile segments, especially those with preserved or excessive motion (i.e. >2 to 4 mm change on flexion-extension films), produce a mechanical pathoanatomic sequence of events that leads to critical and clinically symptomatic spinal stenosis. Addressing this first cause is paramount.
The immediate effect of surgery type is largely neutralized by the fact that the decompression component, which is common to both approaches, is principally responsible for acute improvement. Because most prospective studies are not able to reliably track patients beyond 2 to 5 years, the longer-term benefits of a solid arthrodesis of a dysfunctional spinal-motion segment compared to a simple decompression in which some of the incompetent posterior elements are further surgically removed remain largely unknown. Anecdotally, spine surgeons recognize that failures of decompression alone in mobile spondylolisthesis occur quite frequently—and that revision fusion surgery in this situation is significantly more complicated than primary decompression and fusion. That was the case in the Swedish study, where the majority of revision surgeries in the decompression-only cohort were performed at the same level as the prior surgery, versus adjacent levels in the fusion group. And, again, reoperation rates were significantly higher (>2x) in the decompression-only group in the US study.
Given conflicting data3, there likely are cofactors that need to be identified and further studied to select cases of spondylolisthesis that can be treated well with decompression alone, versus those that require the stabilizing effect of a fusion. Until then, surgeons must weigh the data available and provide the surgical option they feel is best for each individual patient.
Brett A. Freedman, MD is an orthopaedic surgeon specializing in spine trauma and degenerative spinal diseases at the Mayo Clinic in Rochester, MN
- Fischgrund JS, Mackay M, Herkowitz HN, Brower R, Montgomery DM, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine (Phila Pa 1976). 1997 Dec 15;22(24):2807-12.
- Bridwell KH, Sedgewick TA, O’Brien MF, Lenke LG, Baldus C. The role of fusion and instrumentation in the treatment of degenerative spondylolisthesis with spinal stenosis. J Spinal Disord. 1993 Dec;6(6):461-72.
- Joaquim AF, Milano JB, Ghizoni E, Patel AA. Is There a Role for Decompression Alone for Treating Symptomatic Degenerative Lumbar Spondylolisthesis?: A Systematic Review. J Spinal Disord Tech. 2015 Dec 24. [Epub ahead of print]
Two interesting investigations into lumbar spinal stenosis (LSS) appeared in the general medical literature recently.
—A registry-based observational study of nearly 900 patients in the BMJ found that microdecompression techniques were as effective as open laminectomy in improving disability scores 12 months after surgery. The two techniques yielded similar quality-of-life scores at the one-year point, but the microdecompression patients had shorter hospital stays.
—In Annals of Internal Medicine, a multisite randomized study of 170 patients 50 or older with lumbar spinal stenosis found that those receiving surgical decompression and those receiving physical therapy (2 PT visits per week for six weeks focused on lumbar flexion and general conditioning) had essentially the same functional outcomes at time points ranging from 10 weeks to two years after enrollment. However, 57% of patients assigned to PT crossed over to surgery—some due to high copays for physical therapy, said study co-author Anthony Delitto, PT. In an editorial accompanying the study, JBJS Deputy Editor for Methodology and Biostatistics Jeffrey Katz, MD, concluded, “Because long-term outcomes are similar for both treatments yet short-term risks differ, patient preferences should weigh heavily in the decision of whether to have surgery for LSS.”
When physical therapy or anti-inflammatory medication fails, one popular treatment for leg pain caused by spinal stenosis is a steroid injection. However, according to a recently published , that treatment may be less effective than previously thought. The study found that patients with painful lumbar stenosis who received a combined lidocaine-glucocorticoid injection had about the same pain levels and degree of disability six weeks later than similar patients who were injected with lidocaine alone.
While these findings question the presumed efficacy of adding a glucocorticoid to lidocaine for epidural injection, they do not necessarily mean that all epidural injections for spinal stenosis are ineffective.
NEJM abstract: http://www.nejm.org/doi/full/10.1056/NEJMoa1313265