News Category: General Spine

Non-operative treatment is usually the first line of treatment for benign compression fractures of osteoporotic vertebrae without neurological injury. These fractures are relatively stable secondary to the nature of the injury occurring from a compressional load versus involving shearing or rotational components. Typically this non-operative treatment has included the use of bracing as well as pain management. In theory braces have been utilized to provide stabilization to the injured site which facilitates alignment, early mobility and protecting it from further collapse. Some noted disadvantages of bracing include muscular atrophy from disuse, skin irritation and deconditioning. A recent research article looked to compare improvements in disability and pain in patients with osteoporotic compression fractures who were treated with the use of rigid, soft or no brace.

In total sixty patients were included in the study and underwent randomization and baseline assessment being allocated to the rigid-brace group, soft-brace group or no-brace group. Patients whom were allotted to the rigid-brace group were ordered on strict bed-rest until an appropriate rigid brace could be fit and applied. The soft-braces were ready made and thus could be utilized immediately upon patient enrollment in the study. In the two brace wearing groups patients were instructed to wear the brace at all times except when lying down. They were instructed to wear the braces for eight weeks. Patients in the no-brace group were instructed to walk without any brace as long as they were comfortable. All participants took pain medication as necessary and were educated on restricting spine movement, heavy lifting and carrying without a specific weight limit during the initial eight weeks. After the eight weeks, a two-week weaning period occurred. The primary outcome measure utilized was a baseline adjusted Oswestry Disability Index (ODI) at twelve-week post compression fracture injury. Secondary measures included pain ratings on Visual Analog Scale (VAS), ODI score, progression of the compression ratio over follow-up visits, general health status, and treatment satisfaction. Baseline characteristics were similar among all participant regardless of grouping. Every participant had one vertebral fracture located from T7 to L3 vertebrae.

The baseline adjusted ODI score at twelve weeks in the non-brace wearing group was not inferior in comparison to the soft-brace or rigid brace group. This primary outcome score was 35.95 points in the no-brace group compared to 37.83 and 33.53 points respectively in the soft-brace and rigid-brace groups, demonstrating a predetermined margin of noninferiority (an ODI score of ten points). There was no statistical difference found in any of the secondary outcome categories. The ODI scores and VAS scores for back pain significantly improved with time in all three groups. Additionally the body compression ratios significantly decreased with time in all three groups. Patient satisfaction in treatment as well as general health status did not differ between the three groups. The authors concluded that treatment without a brace for benign osteoporotic compression fractures did not result in inferior outcomes in patient disability as compared to use of rigid or soft-brace treatments.

Surgical techniques for the cervical and lumbar spine can be separated into two categories based on amount of tissue disruption. Minimal access surgery (MAS) is reported to have better short term perioperative results as it utilizes small incisions and minimal muscle disruption. This technique involves use of a tube or sleeve to complete a muscle dilating or muscle splitting approach. Conventional surgery or open spine surgery involves lifting or stripping the musculature along the spine to gain access to the spine.

Patients undergoing minimal access cervical or lumbar surgery report less blood loss, lower chance of infection shorter hospital stays and less pain medication and often a faster return to activity. Long term outcomes of a minimal access surgery are not significantly different from a conventional approach that may involve less favorable short term benefits. On the surface, with results such as shorter hospital stays and a lower chance of infection, it would seem that minimal access surgery would be more cost effective. However, the instrumentation required for these techniques is often expensive and may outweigh the savings elsewhere.

A review of the current literature did not yield any results that compare the cost-effectiveness of minimal access spine surgery to conventional spine surgery for the cervical spine. There were six pertinent reports that met exclusionary criteria that were found comparing the two techniques for the lumbar spine. Surgical procedures in which the two techniques were compared include discectomy, hemilaminectomy, transforaminal fusion, and posterolateral fusion, all of the lumbar spine.

Results of the literature review using these six economic studies comparing MAS with conventional open spine surgery suggest that there is no economic difference between the two techniques. Complications post-surgery, particularly infection were reduced with MAS, and in at least one study they suggest that the minimal access surgery technique for fusion results in lower cumulative costs. Several other studies also suggested cost-saving with MMAS but were excluded from the review as they did not meet requirements of detailed methodology or long term follow up on clinical outcomes. There is a need for more detailed studies comparing cost-effectiveness of MAS to open conventional spine surgery in order to better understand these surgical approaches.

Neck and lower back pain are among the most prominent disorders that lead to time away from work as well as disability. Studies and models have already been developed focusing on the return-to-work (RTW) process. Multidisciplinary treatment for back pain has been a long standing tradition. In Norway, a recent randomized trial was performed that sought to look at utilizing workplace focused rehabilitation in specialized care versus traditional multidisciplinary treatments with the aim to see if there would be a reduction in the number of days needed before a sustainable RTW among sick-listed patients with chronic neck and low back pain. RTW was defined as the first five-week period after assignment that the patient did not receive sickness benefits, a work assessment allowance pension or a disability pension from the Norwegian Labour and Welfare administration.

The design was a multicenter trial in which sick-listed patients whom were referred to neck and back clinics in Norway were included and followed for one year. Each of the participants were allocated to either the work-focused or control interventions. All patients received a standard clinical examination with imaging evaluated and findings discussed with the patients. Emphasis was placed on removing fear-avoidance beliefs, restoring activity levels and enhancing self-care and coping. Rehabilitation for both groups included sessions of physiotherapy and overall interaction of a multidisciplinary healthcare team. Patients allocated to the work-focused intervention, additionally, had emphasis placed on RTW process. This process included individual appointments with a caseworker in which a RTW schedule was created. The caseworker also assisted members of the work-focused groups with setting up meetings with the employers and helped contact municipal social services if sick-leave compensation was an issue.

Results of the study demonstrated that there was no statistical significant differences found in RTW rate of work-focused group as compared to control intervention group. The median time before RTW was 161 days for the work-focused group and 158 days for the control group. The analyses did demonstrate that 70 per cent of participants in the work-focused group and 75 per cent of participants in the control group returned to work within the first year after inclusion.

Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets and growth factors. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

The use of PRP to aid spinal fusion is still under investigation using animal models. In this study, researchers from Italy report on the use of PRP in experimental spinal fusion. They used rabbits and performed the fusion using a posterolateral approach (injecting the PRP from the back and side of the spine).

The rabbits were divided into three groups. One group received just the PRP (on the right side of the vertebrae) while the second group were injected with PRP combined with uncultured bone marrow (on the left side). Group three (control group) had a sham operation on both sides to simulate the other two groups but without actually injecting anything into the area.

The goal was to create a bony bridge between the transverse processes of the vertebrae. Each vertebra also has two bony knobs that point out to the side, one on the left and one on the right. These bony projections are called transverse processes.

A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.

Each step of the experiment is described in the article (e.g., materials and methods used, statistical analysis) as well as the platelet concentrations used, surgical procedure, X-ray analysis of the fusion site. The results were measured based on how much bone growth and blood supply were stimulated.

Although they did find some new bone growth, none of the rabbits had formed a complete bridge of bone across the transverse processes. Signs of inflammation and some blood vessel formation were observed but no significant changes were seen in either of the PRP groups. The control group had significantly fewer changes seen in terms of bone growth or new blood supply.

Previous studies have used stem cells, bone morphogenetic protein (BMP), and bone graft in rabbit models to stimulate bone bridging and fusion. This is one of the first attempts to use platelet activation and release of growth factors (via platelet-rich plasma injection) in the bone healing process. But none of the studies so far have shown complete bony bridging needed for spinal fusion (including this study).

The authors made some suggestions that might explain why PRP did not work in promoting bone growth or blood supply in their rabbits. For example, no one really knows the ideal amount of platelets (and therefore growth factors) to use.

Growth factors don’t last long before they become inactive. Injecting them into the area is one challenge but they must also be released and activated. It is still unknown just what is the best way to deliver and activate them. Should they be “preactivated” or will they start up on their own once they reach the intended destination? Is there a way to create a “time-release” effect? These are just some of the questions that remain to be answered before platelet-rich plasma can be used routinely to enhance spinal fusion.

Researchers from Australia are trying to pinpoint the indirect costs associated with spinal disorders in the work place. In this study, they evaluated the cost (in dollars) of retirement among workers between the ages of 45 and 64 (Baby Boomers). Each worker reported leaving work permanently due to spinal disorders such as disc herniation, scoliosis, mechanical low back or neck pain, and spinal deformities.

The personal cost of lost wages as well as the burden on the government in the form of lost taxes and welfare or unemployment benefits was in the billions. Workers who seek early retirement due to spinal disorders earn one-fourth the wages of someone who has no back pain and who is employed full-time.

The authors focus their report on three areas: The Problem, The Impact, and The Plan. The problem as stated is the high personal and national cost of spinal disorders in middle-aged workers who retire early. Previous studies have reported on the cost of missed work (absenteeism), sick leave, inactivity (reduced productivity), and worker’s compensation but not retirement.

It is clear there is a significant relationship between early retirement and the effect on income. And the lost income is reflected in reduced taxes collected by the government as well as the increased costs associated with government support payments to retirees.

The impact goes even deeper than that, though. Declines in taxable income means less spending, fewer taxes collected, and less money to support government programs. There are also fewer younger individuals entering the workforce. When Baby Boomers retire early without younger workers entering the picture, the impact from reduction in labor is magnified.

So what can be done about this problem? What’s The Plan? The authors suggest a two-step approach. First, prevention of spinal disorders and second, getting injured workers or workers with painful spinal disorders back to work rather than into retirement. These are the keys to keeping the labor force in full work participation.

Research has shown that exercise is one way to prevent (or if necessary: to manage) spinal disorders. In fact, when comparing different forms of exercise (stretching, calisthenics, aerobics, coordination, strength training, relaxation) people generally improve across the board. There are fewer episodes of back pain, less absenteeism at work, and greater productivity.

A more specific approach may be needed for those workers who continue to experience a decreased ability to carry out daily activities due to back pain from spinal disorders. Rather than a global exercise approach, physical therapy to address individual problems may be helpful.

And when conservative (nonoperative) care fails to get the worker back into the labor force, surgery has been shown to benefit many people. Even with the added costs of these treatment measures, they are more cost-effective than not getting anyone back on the job.

The Plan proposed by these researchers also includes government investment in preventive health measures. Spending money to prevent chronic spine problems that would otherwise force early retirement of workers still capable of staying in the labor force will ultimately pay off. More workers on-the-job means more taxable income and government revenue to support government budgets.

The authors conclude that the cost of early retirement because of spinal disorders is very high. Maintaining the health of the work force and prevention of spinal disorders is important now and into the future. In fact, these goals are essential to the personal health of the labor force as well as the economic health of the country. A plan of action must be put into place soon before the work force dwindles further.

Anyone with a joint replacement knows to carry a special letter from the doctor when traveling through airport security. Even with the documentation, travelers with implants can expect delays while security measures are applied. But what about metal implants in the spine? Are they deep enough and/or surrounded by enough body mass to avoid detection?

In this study from England, the handheld metal detectors and arch way metal detectors were put to the test. Researchers used volunteers carrying metal implants commonly put in the spine as well as patients with metal plates, screws, rods, disc replacements, and/or cages already surgically implanted. Implants varied in size and weight, region (neck, thoracic spine, low back region), and location (anterior, posterior).

All electronic metal devices used were standard ones approved for use in European airports. The volunteers carrying implants walked through the arch way detectors with different combinations of implants (weight, size, location). Some implants were taped to the arms or legs. Others were carried in pockets.

Then 40 patients with spinal implants walked through. Of course, everyone removed all the usual items (cell phones, jewelry, watches, belts, shoes, and so on). Each person in the study (volunteers carrying metal implants and patients implanted with metal devices) was also tested using the handheld wand type of metal detector.

Would it surprise you to know that not one person set off the archway detector? The handheld detector was able to pick up most (but not all) spinal implants inside the body. The ones that were NOT detected were in the front (anterior) portion of the neck. Anything implanted posteriorly (from the back) did set off the alarm on the handheld detector.

The handheld wand was able to detect even a single screw when the wand was held five centimeters (1.25 inches) away from the body. Body fat did not affect the results. Density of the metal did not influence the alarm mechanism either. Volunteers carrying metal could carry up to seven and a half ounces (215 grams) in one location before detection.

The authors concluded that modern handheld metal detectors are sensitive enough to detect most (but not all) metal hardware in the spine. Even when set at maximum sensitivity, the handheld devices did not trigger an alarm for disc replacements or anterior plates and cages. It is possible the position of the implant makes a difference but this will have to be tested further to know for sure.

It is also likely that detection rates are low because the implants are made of titanium (and not iron like weapons and guns). It is also possible that the technology for archway detectors (developed in the late 1970s) needs to be updated for today’s modern devices. Different manufacturers and models of archway metal detectors may also make a difference that should be investigated.

More conclusive studies are needed before patients with spinal metal implants are given the green light to travel via airfare without carrying the necessary paperwork. This is one of only a handful of studies on this topic. Results have varied from study to study further demonstrating the need for closer investigation of airport detection of modern spinal implantation.

This study concerns the safety of bone morphogenetic protein (called BMP) in spinal fusions. BMP is a naturally occurring protein that scientists have discovered can be a replacement for bone grafts. But inappropriate use of this product has resulted in some adverse effects that have only been reported after the fact. Surgeons will want to review this information when thinking about using BMP with their spinal fusion patients.

What constitutes “inappropriate” use of BMP? That is an important point. The manufacturers of this product are clear in how it is to be used. Off-label use (in other words, using it for something other than it was meant for) is one inappropriate use. Another is changing the concentration of the BMP. It is usually applied on a collagen sponge. Squeezing the sponge too much or overfilling the sponge are two ways the implant may be used differently than recommended by the manufacturer.

That might not seem like such a terrible offense but the list of adverse effects suffered by patients as a result of using BMP inappropriately is long. Bone resorption, inflammation, leg pain from radiculitis, breathing problems, infection, swelling and fluid collections, too much bone growth or bone growth into the soft tissues, and blood clots are just a few of the complications reported.

Data is available on both neck and lumbar spinal fusions. Some adverse effects are specific to the location of the fusion. For example, dysphagia (difficulty swallowing) can occur with cervical spine fusions. And retrograde ejaculation has been reported with anterior lumbar spine fusions.

Half of all patients who develop adverse effects from the use of BMP in spinal fusion end up having another (revision) surgery to deal with the problem. Some of the problems encountered are potentially life-threatening, so there is a need to pay close attention to these reports of adverse effects.

But as the author of this study points out, reports of problems and complications after spinal fusion using BMP don’t necessarily mean the BMP was a direct cause of these effects. There are some serious adverse effects from BMP for sure but not all problems can be linked to this device.

More studies are needed to take a closer look at whether these reported events are, in fact, device-related adverse effects. Maybe the patients would have developed these problems as a result of the surgery and they have nothing to do with the use of the BMP. And it would be helpful if researchers could identify risk factors for adverse events associated with the use of BMP in spinal fusion.

Until more is known about the true risks and safety concerns about BMPs, surgeons are advised to be aware of potential problems and discuss them ahead of time with their patients. Using the products according to the manufacturer’s directions may help ensure safe and effective use of BMP. Inappropriate and off-label uses should be avoided until safety issues have been resolved.

Most Americans are aware that the war on terror continues on the battlefields in Afghanistan and Iraq. Blast munitions meant to rip through armored vehicles during Operations Enduring Freedom and Iraqi Freedom continue to cause serious injuries among our military warriors. Military physicians are studying the types and effects of these injuries in order to help prevent them.

In this study, surgeons from the United States Army review the medical records of soldiers who were treated for spine injuries. They were specifically trying to determine the number and type of complications that developed around or during surgery. Spine injuries included different types of fractures based on location in the vertebrae (e.g., pedicle, spinous process, facet, transverse process) as well as ligament injuries and dislocations.

Soldiers are evacuated in helicopters and planes referred to as flying intensive care units (ICUs). Surgeons and nurses treat the soldiers while in the air evacuating from the field of battle to military hospitals. But there are many challenges as you can imagine. They have limited equipment to make a complete diagnosis. The evacuation process is complex and can delay treatment. And there’s really only so much that can be done to treat serious injuries even in a flying ICU.

Focusing on ways to minimize complications that occur before, during, and after surgery is one alternate way to aid our wounded warriors. As this studied showed, major and minor complications are fairly common. And multiple complications in many soldiers were typical.

Major complications occurred in nine per cent of the military spine injuries. Minor complications were reported in six per cent of the total. But the most significant finding was the high number (more than 30 per cent) of complications among the dismounted soldiers who had surgery. And 80 per cent of all complications occurred among the dismounted service members. Military personnel in vehicles when injured made up only 20 per cent of those who had complications with treatment.

Understanding the mechanism of injuries is also important when planning wartime strategies. For example, the data from this study showed that soldiers in armored vehicles suffered fewer and less serious injuries compared with those individuals who were unprotected walking on the ground. The idea behind dismounted troops in today’s war theatre is to “win hearts and minds” of the nationals (people living in those countries) whom we are protecting. But this strategy does expose our soldiers to the risk of blasts from exploding bombs.

The specific types of complications experienced weren’t that different from what happens among civilian patients with similar injuries. Infections, blood clots, urinary tract infections, cerebrospinal leak after surgery, and pneumonia were typical minor complications. Likewise, more serious problems such as failure of the wound to heal, injury to blood vessels or nerves during surgery, spinal cord injury, injury to the gastrointestinal tract, and even death were the same as reported in civilian studies following surgery for spine injuries.

In summary, findings can be summarized by three points. 1) Risk of complications is greater when surgery is required — no matter what type of injury has occurred. 2) Dismounted soldiers are at greater risk of injury and 3) complications of treatment are greater among troops on foot compared to those who are in armored vehicles. This last point was true for all types of injuries regardless of treatment provided (surgical or nonsurgical).

How will the military use this information? Protection of our troops is an important goal — whether on the ground, in armored vehicles, during transport following injury, or during and after surgery. Examining the type and number of complications associated with military spine injuries will help with decision-making in the Theater of Battle. Given these findings, the placement of troops on the ground in an unprotected fashion will require some additional thought and consideration by military strategists.

This is the first report published comparing penetrating with blunt spine injuries in U.S. servicemembers in Afghanistan and Iraq. High-velocity gunshot or shrapnel injuries to the spine entered into the Joint Theater Trauma Registry (JTTR) were included. Records were reviewed to find out more information such as demographics on the soldiers, mechanism of injury, location of injury, type of surgery done, and long-term injuries sustained.

This information is important to gather and analyze strictly from an historical perspective tracing trends and changes in wartime over the years. But more importantly, this type of analysis may help improve treatment for our injured soldiers who experience high-energy, penetrating injuries to the spine. Many of these wounds are extensive and cause multiple injuries that cannot be treated on the field of battle.

Although some servicemembers had both a penetrating and a blunt injury from improvised explosive devices (IEDs), only those individuals with one or the other were included in this study. Excluding patients with both types of spinal injuries allowed for a more direct comparison of one mechanism (blunt) to the other (penetrating). Injuries from C1 (top of cervical spine) down to the sacrum were included. Injuries to the coccyx (tail bone) were not included.

As the names suggest, a blunt injury occurs when the soldier is exposed to a blast from a bomb explosion. For those soldiers inside an armored vehicle, the force of the blast throwing them against the inside of the vehicle can cause a concussive (blunt) spinal injury. Penetrating injuries are more likely from gunshot wounds to the spine injuring the spinal cord.

These are not typical injuries seen in the civilian sector but rather, specific to military war-time efforts in Iraq and Afghanistan. Men are affected more often than women because fewer women are in direct combat roles compared with men.

Surgery to decompress the spine is more common in penetrating injuries of the spinal cord. With penetrating injuries from gunshot, there is a greater chance for significant damage to the spinal cord as the bullet tumbles and spins, picking up speed and force before impact. Current recommendations are to perform surgical decompression only when the servicemember is medically stable and does not have a complete spinal cord injury.

Neurologic recovery is less likely with penetrating spinal cord injuries. Both blunt and penetrating injuries often cause additional injuries to the head, face, chest, and abdomen. Of course, severing the spinal cord results in long-term paralysis. Death is a possibility but this database did not have information on the number of spinal cord injured-related deaths have occurred among US servicemen and women in the War on Terror.

Complications (mostly from surgery) affect up to 10 per cent of all servicemembers with spinal cord injuries. These include pneumonia, skin and wound infections, blood clots, and urinary tract infections.

The authors summarize by saying this study helped surgeons identify the two main mechanisms that contribute to spinal cord injuries in US servicemembers involved in Operation Iraqi Freedom and Operation Enduring Freedom. Understanding the need for surgery required by spinal cord injuries will help military medical personnel better plan for on-site triage, treatment, and transportation at the time of the injuries. Efforts to prevent long-term neurologic problems are another important outcome of this study.

They also saw from reviewing the records that surgeons involved in immediate care for these surgeons understandably do not chart details about the mechanism of injury and severity of bodily harm at the time of injury. Likewise, spinal cord injuries in servicemembers who die on the battle field go unreported. This means there is a loss of information that would otherwise be helpful in a retrospective (looking back) type of study like this one.

Since 2002 surgeons have had a special tool in their box of techniques for spinal fusion. And that is a substitute for bone graft called bone morphogenetic protein or BMP. Although more expensive, this product has two major advantages over bone taken from the patient: 1) patients no longer suffer pain and discomfort at the pelvic crest where donor bone has been taken from and 2) patients with poor bone growth due to diabetes or tobacco use can have a spinal fusion when necessary.

But now some serious complications and post-operative problems have been reported. So it’s time to take a second look at the safety of this bone substitute product. BMPs were first discovered in 1965 with more than 20 types now being studied. Only one (BMP-2) has been approved for use by the Food and Drug Administration (FDA) in spinal fusion surgeries.

When used as it was approved and intended, BMP stimulates safe and effective bone growth to aid in the fusion process. And that primary use for which it was intended is only anterior lumbar (low back) interbody fusion. Troubles begin when this product is used off-label such as for cervical (neck) fusion, especially anterior (from the front of the spine) procedures and posterior (from the back) lumbar fusion.

Massive soft tissue swelling, extra bone formation, seromas (fluid-filled pockets), and even cancer have been reported as emerging concerns with BMP-use. To aid surgeons in evaluating the real concern about BMP in spinal fusion, three surgeons from the University of Pittsburgh provide some perspective and insight into the safety issues that have come to light.

First, they suggest surgeons-in-training should all learn how to harvest and use iliac crest bone grafts. In other words, this type of self-donation should not be abandoned in favor of only using BMP. Second, BMP should be used as indicated until further studies expand its use. In other words, it should not be used as an off-label product. Third, surgeons are responsible to select patients carefully for spinal fusion. In other words, not everyone is appropriate for the primary surgical procedure. Surgical success is more likely when used for the right patients.

And finally, until perfected through studies, BMP should NOT be used in anterior cervical spine patients and certainly not for anyone who has a past (or current) history of cancer of any kind. Using BMP for the ease and convenience of the surgeon is not acceptable when there are safety concerns and risks of serious harm to the patient.

In summary, BMP has a high rate of fusion when used as intended (for lumbar spine fusions). But there is no evidence or proof of any kind that BMP is better than patient donor bone from the iliac crest in terms of fusion rate or outcomes (decreased pain). More long-term studies are needed before expanding the use of this product, to identify those procedures in which its use is both safe and effective, and to document potential complications.

If you have ever had surgery of any kind or even known someone else getting ready for surgery, one thing is always discussed preoperatively. And that’s the possible complications. Though most post-op problems are uncommon or even rare, it is still the responsibility of the health care provider to review all possibilities with patients. Infection, blood clots, heart attacks, stroke and even death are all listed for major spine surgery.

In this study from Taiwan, the risk of stroke following spinal fusion surgery is investigated. Taiwan has a unique study situation in that the entire one million population is covered by a government-run health insurance. Everyone has free and unlimited access to health care even if they are traveling or out of their own country and receive treatment overseas.

This type of system makes follow-up easier and more predictable. Even if a patient in a study like this goes somewhere else within the system, the records are still available for follow-up. Therefore, incidence rates calculated tend to be more accurate and estimates of stroke risk more reliable.

Out of one million people, there were 2,249 who had spinal fusion. This group was matched with a very similar group of 2,203 adults who did not have spinal fusion. When we say the groups were “matched” closely, it means they were the same ages, gender (male versus female), education level, income level, and living location (rural versus urban). They were also very similar in terms of general health and the presence of other health problems such as diabetes, high blood pressure, heart or lung disease, and so on.

The rates of stroke during a three-year follow-up were compared. They found no differences between the two groups (those who had spinal fusion surgery and those who did not). In fact, the spinal fusion group had slightly (though not significantly) lower rates of stroke.

The authors suggest some possible reasons for these results. Stabilizing the spine reduces pain and improves function. Patients who were previously inactive or sedentary because of back pain can increase their activity and exercise after spinal fusion. This effect could reduce the risk of stroke. Patients with health problems like diabetes or heart arrhythmias are treated for these problems before surgery. Controlling conditions like these that can contribute to stroke may be another preventive factor.

People who smoke or use tobacco products are asked to stop prior to surgery. Some may not go back to this habit, thus improving their chances of better health afterwards. And surgeons do screen patients before surgery in order to select those who are more likely to have a positive result. Anyone with significant health problems may not be accepted for surgery. The healthier and more active someone is before surgery, the more likely they will have fewer complications and better results after surgery.

In summary, this was the first study to evaluate the risk of stroke after spinal fusion surgery. They did not find an increased risk of stroke. In fact, they report that stroke as a postoperative complication is rare following spinal fusion. It is possible to conclude that patients at increased risk for stroke should not be kept from having spinal fusion surgery if they need it. The positive results from the procedure (including increased activity and exercise) could improve their overall health and reduce risk for many other health conditions.

The authors point out several areas for future study related to this topic. First, there are many different ways to perform spinal fusion. There are different spinal levels and number of levels fused. These factors may affect how long someone is in surgery, how much blood is lost, and postoperative recovery. Any of these variables may influence the risk of stroke or other complications and should be investigated.

Likewise, as improved surgical techniques are developed, it has become safer for a larger number of older adults to have spinal fusion surgery. The increased age of patients having spinal fusion surgery may change the incidence of stroke following this procedure. Future studies are needed to keep an eye on this possibility as well.

Public health policies are influenced by the kinds of health problems Americans report. Evidence from research is a second driving factor in how common conditions like neck and back pain are treated. One way to reduce medical costs is to analyze where money is being spent and look for trends in care and utilization of medical services.

Treatment of back and neck (spine) problems accounts for billions (not just millions, but billions) of dollars every year. Low back pain alone accounts for 90 billion dollars in diagnosis and treatment. It is estimated that another 20 billion can be chalked up to lost wages and lost productivity. And those figures don’t include similar costs associated with neck pain and problems.

Given that up to 80 per cent of all adults will have back pain at least once (and often more than once) in a lifetime, this problem has grabbed the attention of health care policy makers. It’s their job it is to hold costs down without compromising care or outcomes (results).

When care exceeds recommendations made based on evidence, then health care policy makers get concerned. In this report, money spent on spine problems (including both the neck and back) is linked to specialty services that don’t necessarily improve results. Expensive MRIs and other imaging tests, referrals to orthopedic surgeons and neurologists, visits to the emergency department, and unnecessary lab testing make up some of the specialty costs that might be considered unnecessary.

In addition to expanded diagnostic tests thanks to improved technology, more aggressive marketing of medical supplies has driven some costs up. And the rising costs of care associated with these services don’t come with improved results.

On the other hand, dollars spent on spine care provided by general practitioners (GPs), chiropractors, and physical therapists have not gone up. This is contrasted with evidence that these services provide improved outcomes. Future research is needed to determine what is the most cost effective treatment (i.e., least cost and most benefits).

With the continued rise in health care costs, finding ways to improve results of treatment for spine problems (again, at a lower cost) is important to health care policy makers. It may be necessary to limit patient access to specialty care by restricting (rather than expanding) reimbursement. Policies that encourage better reimbursement can be put in place as more research is done to identify effective spine care.

It’s an unfortunate fact that patients can end up back in the hospital after spinal surgery. Sometimes there’s an infection that must be taken care of. In other cases, implants used to hold the spine together during the healing/fusion phase have to be revised. Medical complications such as blood clots, heart problems, breathing difficulties, or gastrointestinal problems can also bring patients back for early readmission after surgery.

In this study, surgeons from New York University Hospital for Joint Diseases went back through their patient records for a two year period of time to see how often these unplanned readmissions occurred and why. Patients included in the study had one of 12 common spine procedures (e.g., spinal fusion, kyphoplasty, laminectomy). There were a total of 3673 people operated on with 156 of these patients requiring return to the hospital. That works out to be a 3.8 per cent overall readmission rate.

Most of the readmissions (90 per cent) were unplanned. In the remaining 10 per cent, the patient was scheduled for a two-part (staged) procedure and came back for the second surgery. Lumbar stenosis (narrowing of the spinal canal) and disc herniation were the two most common problems patients were being treated surgically.

Taking a closer look at the data collected, the authors divided the readmissions into two groups: those who had surgical complications and those who had nonsurgical complications. Infection was definitely the biggest problem for both groups.

Surgical complications occurred most often in patients who had more spinal levels fused (average of six spinal segments). There were difficulties with implants (plates, screws) caused by infection or wound drainage in a smaller number of patients. Nonsurgical complications were most often related to GI problems and systemic illness with a few cases caused by heart, lung, or neurologic conditions.

The next step is to find ways to reduce early readmissions following spinal surgery. A closer analysis of all the factors present in patients who do go back to the hospital might reveal some helpful clues. For example, there may be certain aspects of the surgical procedure that is contributing to the high rate of infection. Or patient factors such as general health, pre-existing conditions (heart disease, cancer) and obesity may make a difference.

In addition to screening patients more carefully before surgery, closer postoperative monitoring may be a useful way to reduce readmissions. The data from this study do support the idea that medical complications after surgery are a big factor. And this may be one cause hospital staff can change with coordinated efforts and planning.

Many people in need of spinal surgery also suffer from other health problems such as high blood pressure, diabetes, cancer, obesity, neurologic problems and many others. These additional conditions are referred to as comorbidities. Patients often have more than one comorbidity. And then there are the complications that can occur after surgery. Comorbidities and complications take their toll on patients but can also add quite a bit to the hospital bill and cost of health care overall.

In this study from the University of Pennsylvania, the effect of comorbidities and complications (both minor and major) are examined. The researchers determined which problems are the most significant but also looked at the costs. You may not think someone else’s problems after surgery affect you, but as a taxpayer, many of these costs come from folks on Medicare. From a societal perspective, these costs are paid for by me and you. And that makes it everyone’s business.

Before looking at the specific results of this study, consider some of the points the authors make. First, the number of people seeking treatment for spine problems is increasing every year. So is the age of the patients looking for help. Along with an increased number of older adults in need of spinal surgery, there has been a steady rise in health care costs. The complexity of many procedures has also increased, which also pushes costs higher.

Efforts are being made to contain costs. Hospitals, private payers, and government are starting to take a closer look at what’s going on and how to cut costs. This study is an example of those efforts. The focus here is on patient characteristics that affect the cost of spinal care. Along with known risk factors such as obesity and smoking, other areas of health concerns were included.

Data on 226 patients undergoing spinal surgery for a variety of reasons was collected. Age, sex (male or female), body mass index (BMI, an indicator of obesity), number and type of comorbidities, type of procedure, and type and number of complications were reported and analyzed.

They found that although high blood pressure (hypertension) was the most common comorbidity, the problems that caused the most difficulty were pulmonary (blood clots, pneumonia), improper positioning of hardware used in spinal fusions, new neurologic problem (caused by the surgery), and wound infection.

Costs started escalating when a problem developed as a result of being in the hospital. This is referred to as a hospital-acquired condition or HAC. Those additional costs spiraled upwards as complications increased in number or severity. Longer hospital stays require more care and greater use of resources. The result is an increase in the cost to insurance companies (or payers like Medicare). Likewise, when the costs are greater than the reimbursement, then hospitals take a financial hit, too.

The question arises: should patients with multiple health problems be refused surgery? This study actually shows that the majority of problems were caused by the hospitalization and/or the surgery itself. And many of the problems required an additional surgery further raising costs associated with hospital acquired conditions.

What can be done to change all this? The authors do not offer any immediate solutions. They suggest the move to electronic medical records will make it possible to track costs and risk factors more closely. Likewise, any interventions applied to the problem can be analyzed to find the most efficient and effective course of action for each problem. Being able to identify patients at risk and predict the likelihood of a complication may help target those patients for prevention. As this study shows, much of the burden for change lies with improving internal measures (e.g., surgeon technique, hospital care) to reduce complications.

Surgeons don’t perform spinal surgery on just anyone without a strong chance that the procedure will help the patient. Possible complications are always considered ahead of time. And if a patient has too many risks, surgery may not be advised. In this study, surgeons from the University of Washington in Seattle explore various risks for medical complications after spine surgery.

Relying on surgeons and even patients to remember what happened for each person after surgery is not the most accurate way to identify common risk factors after spinal surgery. Even chart reviews are not always as complete as needed. That’s why this study used national databases of information (e.g., Medicare, Worker’s Compensation, National Inpatient Sample) collected on thousands of patients.

There are some disadvantages in using a national database to conduct research. Although the number of patients included tends to be large, not all the pertinent information is gathered. For example, details of the surgery are not collected (e.g., number of spinal levels affected, whether the procedure was a fusion or nonfusion, if hardware was used such as metal plates, pins, or screws).

Even so, the amount of data that is collected can be very helpful. Demographic factors such as age; gender; use of tobacco, alcohol, or other drugs; and diagnosis can be factored in. Body mass index (an indication of obesity), presence of other health problems (e.g., diabetes, high blood pressure, heart disease, history of cancer) can also be considered.

In this study, they also looked at area of the spine operated on (cervical, thoracic, lumbar, sacral) and the underlying pathology (degenerative, trauma, tumor, infection, fracture). The surgical approach (anterior, posterior, combined) was also recorded and compared with the number and type of complications after surgery. All patients were followed for at least two years after the first spinal surgery.

The most common problem after spinal surgery was pulmonary complications (e.g., acute respiratory distress syndrome, pneumonia). This was followed by hematologic complications (e.g., blood loss requiring transfusion, blood clots), urologic problems (e.g., urinary tract infections), and cardiac complications (heart attack, arrhythmias, heart failure).

Other problems involving the gastrointestinal (GI) system or neurologic complications though less common were also reported. GI bleeding, colitis, or ascites (fluid in the abdomen) were the most common adverse events. Neurologic problems stemmed most commonly from strokes, delirium, electrolyte imbalances, and seizures.

After gathering and analyzing all the data, they found the two strongest risk factors for complications after spinal surgery were age (older than 65) and extent of surgery (invasiveness). Surgical invasiveness refers to the number of spinal levels involved, the amount of hardware used, and the approach (anterior, posterior, both). A special scoring system was used to calculate level of invasiveness for each procedure.

Two other risk factors affecting almost all the body systems were hypertension (high blood pressure) and anemia. History of diabetes, heart disease, and thoracic surgery were major risk factors affecting four of the six major organ systems included in this study. Patients who had cardiac or pulmonary complications were four to 10 times more likely to die during the first two years after surgery.

Surgeons involved in spinal surgery may find the charts and tables provided in this article useful. Significant risk factors for medical complications are listed for each system (cardiac, pulmonary, GI, neurological, hematological, urological). Likewise, the risk of death based on individual patient risk factors is also provided. A complete breakdown of each system, type of complications, and incidence is presented in detailed tables.

What’s the take home message from this study? First, complications after spinal surgery are more serious than previously believed AND they happen more often than remembered or reported. Second, patient selection based on risks for complications should be an important part of the pre-operative work up. The decision to have surgery, the type of surgery, and the invasiveness of the procedure can be influenced in part by considering potential complications.

Six reliable factors have been identified as the most accurate predictors of the need for multiple “clean up” surgeries for surgical site infections following spine surgery. By “clean up” surgery, we mean the procedure called irrigation and debridement, a way to remove infection and cleanse the wound.

Surgical site infections after spinal surgery are not uncommon. Irrigation and debridement is the usual first-line of treatment for the problem. In one-fourth up to one-half of all patients with spinal surgical site infections, more than one clean-up procedure is required.

If the surgeon had some way to predict which patients might be at increased risk for this complication, then measures could be taken to reduce the risk. In this article, surgeons from the University of Massachusetts Medical Center present a model they developed to determine the need for a single irrigation and debridement versus multiple procedures.

This scoring system is called the Postoperative Infection Treatment Score for the Spine or PITSS. The surgeons developed the model and tested it on a large group of patients at one spine center. Once the scoring system was determined to be reliable, they validated it by repeating the study on a separate group of patients.

The predictive is based on the presence of one or more of six predictive factors: 1) location of infection in the spine, 2) patient’s health (presence of other diseases like diabetes, pneumonia, or heart disease), 3) type of infection, 4) presence of infection elsewhere in the body, 5) use of hardware in the spine such as metal plates and screws, and 6) the need for bone graft for the initial spinal surgery.

Over 30 factors were tested for significance and ability to predict the need for multiple debridement procedures. Patients with one or more of these six factors were the most likely to need more than a single debridement procedure. Once the test was applied to the patient and a high risk was determined, then additional care could be provided early on. This early intervention may reduce costs, duration of hospital stay, and need for further surgeries.

The authors stand by their new scoring system as being effective and reliable. But they do say that surgeons must use this as a tool along with their own judgment for each patient. The PITSS provides an aid in predicting which patients with a surgical site infection after spinal surgery may need multiple irrigation and debridement procedures. Setting up surgical dates in advance and preparing for the possibility of a second (or third) debridement procedure will benefit the patient in recovering more quickly from these infections with lower costs.

Back pain is no stranger in the adult world. Being overweight is a definite risk factor for back pain associated with spinal degeneration. Surgery in the form of spinal fusion may benefit obese patients but is also linked with higher complication rates. In this study from California, researchers look at the effect of morbid obesity on complications and complication rates.

Obesity is defined by a body mass index (BMI) of 30 or greater. Morbid obesity is determined by a BMI of 40 or more. The BMI is a measure of body fat based on height. It isn’t the only way to identify obesity but it is a quick and easy method to get a general idea of relative sizes.

California has a database with information on every patient who goes into the hospital anywhere in the state. Information is collected on a broad range of patient demographics such as age, gender, race, insurance coverage, and procedure performed. Patient body weight is another variable entered into the database. Using this database, the researchers were able to find 1,455 morbidly obese patients who had spinal fusion surgery.

The type of surgery was divided into four groups: cervical and lumbar fusions and anterior or posterior approach for those two locations. Total time in the hospital, total costs, and all complications were also recorded and available for comparison among the four groups. They found that morbid obesity was, in fact, the single most significant predictor of postoperative complications.

The rate of complications among the morbidly obese was 97 per cent higher than among patients of normal weight. That high rate was consistent for all types of postoperative problems (e.g., heart attacks, blood clots, pneumonia, infections). Fortunately, the death rate was not higher in those who were morbidly obese. Overall costs were increased by 28 per cent. Older age combined with morbid obesity resulted in even higher complication rates.

With an ever increasing number of overweight and morbidly obese people, surgeons can expect to see more problems with spinal degeneration requiring surgical treatment. Understanding the risks and costs to the health care system is an important way to reduce these features.

The authors are not suggesting that morbidly obese individuals should not have spinal fusion. On the contrary, these folks seem to benefit as much as adults who are not obese. The main idea from these findings is the need to reduce patient risks when pre-operative weight loss is not an option.

One other finding from this study that deserves further attention is the fact that wound complications (the number one postoperative problem) were equally present among all patients suggesting the need to address that issue first and foremost. Other future studies may need to compare risks and costs associated with open incision spinal fusions and arthroscopic mini-invasive approaches for this particular group of patients.

No one doubts that complex spinal surgeries come with a whole host of potential complications and post-operative problems. But the true measure of how often this happens and how serious the problems may be haven’t been really reported until now. Most of the data published comes from hospital-based administrative databases.

In this Canadian study from a large university hospital, we get an idea just what kinds of morbidity (problems) and amount of mortality (deaths) occur in adults undergoing spinal surgery. This particular university setting serves 4.5 million people. In a year’s time, there were 942 patients who had emergency or elective (planned) spinal surgeries.

The researchers conducting the study used a spine specific system called the Spine AdVerse Events Severity System (SAVES V2) to collect the data. This tool is designed to collect complete and accurate information about all complications from minor to major. Data was collected before, during, and after spinal surgery.

The SAVES V2 form includes a place to record the severity of each problem. The grade given each problem ranged from the number one (event does not require treatment and has no adverse effect) to six (adverse event resulting in death). Some examples of these intraoperative “adverse events” include allergic reactions, heart attack, blood loss, pressure sores, nerve root injury, or other organ injury. Intraoperative refers to complications and problems that developed during the operation.

Pre- or post-operative adverse events ranged from heart failure, blood clot, and wound infection to delirium, pneumonia, urinary tract infection, and cerebrospinal leak. In both categories (intraoperative and pre- or post-operative), surgeons could report and record “other” complications and provide a description of what that was.

Besides collecting data about specific adverse events, the authors also took this opportunity to analyze just how accurate, valid, and reliable the SAVES V2 is as a recording tool. And they compared their results using this tool against the more traditional (and previously used method) of reviewing patient charts some time after treatment to assess results.

They found that the old method significantly under-recorded postoperative events. The SAVES system was much more accurate and thorough. Deaths were more likely to occur in patients requiring emergency surgery for gunshot wounds, cancer, traumatic neck injuries, and spinal infections. Older adults with traumatic injuries were at the greatest risk of death during spinal surgery.

Four per cent of the total group had to have a second surgery. There was a variety of reasons for this including infection, nerve pain, problems with hardware, and the need for additional decompression of disc herniations. Infection was the number one reason why patients were readmitted to the hospital during the first year following the primary (first or initial) surgery.

Not surprisingly, the types of adverse events were different during surgery compared with after surgery. Blood loss, dural tears, and anesthetic-related problems were the most common intraoperative complications. After surgery, electrolyte imbalances, problems caused by medications, heart complications, urinary tract infections, and spinal deformities were among the most problems reported.

The authors took the time to tease out more specifically which complications occurred most often by patient group (emergency versus elective). Having this information will help surgeons plan, observe, and intervene in order to prevent or reduce the effects of such problems.

In summary, the SAVES tool has brought to light the significant underreporting of complications associated with complex spinal surgeries. With the new emphasis on patient quality-of-life as a measure of outcomes, this tool might help surgeons track results more accurately.

At the same time, the SAVES collection method will show surgeons their results from a performance-based measure. They will be able to compare their outcomes against national averages and make corrections accordingly (i.e., when their rates are higher than normal for any particular problem).

Knowing that morbidity and mortality surrounding spinal surgeries is much higher than previously reported will give surgeons an opportunity to address this problem. Having the specifics about type of adverse events, severity of complications, and subgroups of patients most likely to be affected will also help direct prevention and treatment efforts. Future studies can address the question of whether these adverse events affect overall outcomes including hospital length of stay and total costs.

Spinal steroid injections, nerve blocks, sacroiliac joint injections, and heat treatments to kill nerve endings have reached explosive numbers according to this report. In a 12-month period of time almost one million of these interventionalprocedures were done on 200,000 patients.

The patient database used for this study only included privately insured patients. Medicare, worker’s compensation, motor vehicle insurance, and Veterans Administration were not included. About 12 to 14 million people from all 50 states were represented in this study. And that only represents about five per cent of the total U.S. population surveyed. So it’s likely that many, many more of these interventional spinal procedures are really being done.

But is that so bad? Perhaps these numbers reflect the fact that physicians have found a treatment that works for back pain. And once they sharpen their skills by doing more of these procedures, their results improve. Word spreads and more people seek their services. That is one possible scenario.

But the authors of this study think it’s more likely that a small number of physicians have found an easy way to make a profit. They suggest that overutilization of these procedures is contributing to the high cost of health care without corresponding high-quality evidence to support this treatment.

Here’s a closer look at what they uncovered. Only a few providers are responsible for a disproportionately high number of interventional spinal procedures. Neurologists and pain specialists are at the top of the list for the number of these spinal procedures that are done. In fact almost 40 per cent of all spinal pain procedures mentioned here are done by this small group of physicians.

What is the significance of these findings? The bottom-line in the economics of health care is preventing overutilization and cost containment. What recommendations would be appropriate in the face of this information? Here’s what the authors suggest:

Studies have shown that Medicare and VA (Veterans Administration) patients receive a large number of spinal injection procedures. The report of this pattern of overutilization of spinal injections set this new study into motion. Researchers at the University of Colorado School of Medicine looked for similar patterns of overutilization among privately insured adults.

Spinal injections are used for people with back pain that has not improved with conservative care. Such injections include epidural steroid injections, nerve blocks, radiofrequency neurotomy (heat nerves to stop pain transmission), sacroiliac injections, and discography (injecting dye into the disc to look for disc protrusion or herniation).

There is a concern about this pattern of overuse because research does NOT support this treatment as an effective way to manage back pain. And in the case of spinal injection treatment, more is not better. In other words, if the first three injections didn’t help, further injection therapy isn’t likely to benefit the patient either.

In studies of Medicare and VA patients, the majority of spinal injection procedures were being done by a small number of medical specialists. Anesthesiologists, neurologists, and physicians at specialty pain clinics were the ones most likely to be giving these injections. And the top 10 per cent of providers were responsible for one-third of all spinal injections. Over half of all injections were being given by 20 per cent of all providers.

Similar patterns of overuse were found for privately insured adults between the ages of 18 and 99. Billing codes entered into a national central database were used to calculate how many of each type of spinal injection were given to each patient over a 12-month period of time.

Ten per cent of all injections were given by the same providers (neurologist and pain management specialists). This group of physicians did nine times as many procedures per patient than providers in the lowest 10 per cent group. And more than half of all spinal injection procedures were done by 20 per cent of the providers who did these kinds of injections.

This was not a small study. There were 200,000 patients, 20,000 physicians, and over 875,000 injections given. Besides the groups already mentioned (anesthesiologists, pain management specialists, neurologists), other types of providers giving spinal injections included orthopedic surgeons, radiologists, internal medicine physicians, neurosurgeons, physiatrists, and family practice physicians.

When Medicare saw there was an overutilization of spinal procedures, the response was to pay closer attention to claims submitted. They also cut reimbursement for these procedures. The authors of this study raise the same question for private insurance: what should be done to cut back overuse of spinal injections when research doesn’t show this treatment is effective?

First, it is important to remember that all high utilization doesn’t necessarily mean overuse. There may simply be some physicians who are so skilled at this treatment that patients do get better. They spread the word and before you know it, more patients are going to the same physicians. But there is a way to find out if this is really what is happening.

And this study sheds light on the subject. By showing who is doing how many procedures and then evaluating the results, it is possible to see that this isn’t the case. It looks more like a certain group of physicians are using spinal injections to treat more people than should be included (based on evidence of who is a good candidate for this procedure). It is also possible (though not proven yet) that these same providers are accepting less than optimal results. And profit can certainly be a strong motivator for some physicians.

That brings us back to the same question. What can be done about this pattern of overutilization of spinal injection procedures? Guidelines for the responsible use of injection spine procedures must be published based on high-quality evidence. Such guidelines would give physicians a standard by which to guide treatment decisions. Insurance companies could also use the guidelines to base reimbursement on.

That sounds simple enough but what may be excessive for one patient may be just right for another. Some insurance companies have set some limits and restrictions (e.g., only covering four injections in a six month period).

Until major guiding organizations such as the North American Spine Society can give more than suggestions for the use of spinal injections then perhaps treatment can be guided by practice consensus (best opinions of current experts based on current evidence).

If physicians do not follow the “best practice” guidelines, then insurance companies should look their claims over more carefully. If there are no special patient circumstances to justify the increased use of spinal injections, then coverage for the extra injection procedures would be denied. Likewise, denial of coverage for services is suggested if there are not significantly improved clinical results. And because one provider might be performing a broad range of spinal injection procedures under the same billing code, cases should be reviewed individually.

The authors conclude that policy makers must be very careful with the information provided in their study. It would not be in the best interest of patients to rush in and cut and slash services — especially if those services (i.e., spinal injections) are helping someone in pain. It may be too soon for aggressive regulations. But certainly when a small number of physicians are providing a large number of treatments that have not been shown effective, it’s time to target those cases and take a closer look.