Cement Leakage More Likely With Severe Vertebral Compression Fractures

Compression fractures are the most common type of fracture affecting the spine. A compression fracture of a spine bone (vertebra) causes the bone to collapse in height. A special surgical procedure called percutaneous vertebroplasty (PVP) has been used to treat painful vertebral compression fractures. But there have been some problems with that treatment from leakage of the cement used to repair the break.

In this study from the Netherlands, surgeons try to identify risk factors for cement leakage. If patients could be screened before surgery and identified as high risk for cement leakage, then perhaps the surgeon could do something different to change that. Or maybe patients at high risk just aren’t good candidates for this particular procedure. Let’s take a look and see what they found.

There were 177 cases of painful osteoporotic vertebral compression fractures in 89 patients. Everyone had MRIs taken before surgery to look at the type of fractures and areas affected. CT scans were done after surgery to look for cement leakage. The procedure itself involves placing a needle into the fractured vertebral body and then injecting a bone cement into the fractured area.

To perform vertebroplasty, the surgeon uses a fluoroscope to guide the needle. A fluoroscope is a special X-ray television that allows the surgeon to see the spine and the needle as it moves. Once the surgeon is sure the needle is in the right place, bone cement, called polymethylmethacrylate (PMMA), is injected through the needle into the fractured vertebra.

A reaction in the cement causes it to harden within 15 minutes. This fixes the bone so that it does not collapse any further as it heals. More than 80 percent of patients get immediate pain relief with this procedure. But this problem of cement leakage can cause problems of its own (e.g., paralysis, tears of the heart, and even death). Leakage must be prevented if percutaneous vertebroplasty is going to continue being a helpful treatment for this problem.

The researchers involved in this study gathered all kinds of information about each patient looking for potential risk factors. For example, they considered age, sex (male versus female), type and location of fracture(s), and severity of fracture.

They also used the pre-operative MRIs to look for any disruption of the disc called cortical disruption. Tears or disruption of the disc could make it possible for cement to seep into the disc. A hard disc would create even more problems since these are the spine’s shock-absorbers and must remain soft and pliable.

They found three major risk factors for cement leakage when using percutaneous vertebroplasty for osteoporotic vertebral compression fractures. First, leakage was more likely in the severe fractures. The presence of disc (cortical) disruption was another important risk factor. The surgeon doesn’t have control over either of those variables.

But the third risk factor is one surgeons can change and that is how viscous (thin or thick) the cement is. Low viscosity cements flow easily (they are less resistant to flow) so they fill in all the cracks in a bone fracture. This effect is good but the low viscosity also allows the fluid to seep into other areas. A higher viscosity cement clumps more and doesn’t spread as much so there is less leakage.

As the authors point out, the surgeon can see the consistency of the cement before injecting it so there is some control over how viscous it is. They recommend using cement that is “doughy” in consistency. A higher viscosity cement may be needed to avoid cement leakage when there is a more severe fracture or there is documented cortical disruption.

In summary, the findings of this study highlight what surgeons have observed clinically about percutaneous vertebroplasty. Cement leakage occurs most often with severe vertebral compression fractures and when the disc has been compromised. With the evidence available from this and other studies, it looks like the problem of cement leakage can be better managed. The surgeon can control the cement viscosity by selecting the cement with the best viscosity for the problem before injecting it into the bone.

Does Having Scoliosis Mean I Will Also Get Osteoporosis?

Researchers in Japan are investigating the link between scoliosis (curvature of the spine) and osteoporosis (brittle bones). They reviewed the medical records of 176 adults who had surgery for scoliosis. All patients were women between the ages of 26 and 82.

The authors were interested in finding out if women with scoliosis were more likely to develop osteoporosis as a result of having the scoliosis. Other studies have suggested a link between osteoporosis and scoliosis. Does it go both ways?

There is some question about the ability of standard osteoporosis scanning devices to accurately measure bone mineral density in a curved spine. It’s possible the readings may be falsely elevated (i.e., measurements record a higher bone mineral density than is actually present).

That’s why this study was designed to look at two separate bone density measurements: one in the lumbar spine and the other at the femoral neck (area of bone between the shaft of the thigh bone and the round bone at the top of the thigh bone). Dual energy radiograph absorptiometry or DXA scans were used to measure and compare bone mineral density at both sites.

A second feature of this study was to see if osteoporosis in adult women with scoliosis affects the final results of surgery. Success of the fusion, number and type of complications, and final scoliosis curve were used as measures of surgical outcomes.

They found that the older women in the study were more likely to have decreased bone mineral density. The amount of bone loss was similar between hip and spine. And the amount of bone loss in adult women with scoliosis was pretty much the same (no statistical difference) as women the same age who did not have scoliosis.

The study also showed that severity of the spinal curve was NOT linked with bone loss. In other words, a more severe curve did not mean a greater risk of developing osteoporosis. And vice versa: bone loss did not increase the size of the spinal curve.

As far as the results of the spinal fusion surgery, the fusion rate was excellent (93 per cent). The complication rate was 13.6 per cent. There was not a statistically significant relationship between the presence of osteoporosis and number of complications.

The authors think that the results of this study may help prove that adult scoliosis does not occur as a result of osteoporosis in postmenopausal women. And along the same lines, the spinal curvature won’t get worse if osteoporosis is present. It’s more likely that advancing age is the main reason why scoliosis curves develop and/or get worse in older women.

They suggest that having osteoporosis will not prevent bone fusion after spinal surgery. The bottom-line is that women (especially older women who have gone through menopause) can have spinal fusion for scoliosis. The procedure is safe and unaffected by the weaker bone structure so common in this age group. Further study on a larger number of patients including men is needed.

Complications with New Method of Spinal Fusion

Bone morphogenetic protein known as BMP-2 or BMP for short is a growth factor (protein) that helps bone heal and promotes bone fusion. BMP reportedly helps speed up the recovery rate after spinal fusion. BMP is designed to promote bone formation by setting up an inflammatory reaction. This type of enhancer was developed to avoid problems that occur with traditional bone grafting.

In this study, complications from the use of BMP with spinal fusion are explored. The neurosurgeons who conducted the study were interested to know how often and what type of problems occur. They compared complications of spinal fusions done with and without BMP.

This study is unique because of its size and when it was done. Almost 12,000 patients were included from a database of information collected by neurosurgeons around the country. The data was collected between 2004 and 2007, which makes the results very current. The group collecting the information was the Scoliosis Research Society.

Most of the studies reporting results of bone morphogenetic protein (BMP) with spinal fusions have been small. Only one other similar-size study has been published (Cahill, 2009). Results of this new study by the Scoliosis Research Society were compared with the results of the earlier Cahill study.

Neurosurgeons performing spinal fusions (with or without BMP) expect some complications. It goes with the territory, so-to-speak. The studies published up until now have reported problems such as infections, graft failure, and hematomas (pockets of blood). In rare cases, blood clots can cause death after surgery.

A less serious complication reported with the use of BMP in spinal fusions is the formation of too much bone growth. This is called ectopic bone. Ectopic bone can be a problem if the extra bone material presses on nearby nerves.

The Scoliosis Research Society’s database is set up to collect information on patent age, diagnosis, type of surgery, type of complications, and need for additional surgery later on. They also found by looking at all spinal fusions (with and without BMP) that about one-fifth (21 per cent) of the all spinal fusions in the database were done with this bone enhancer.

After analyzing information related to complications, they found that problems occurred most often when BMP was used for anterior cervical spinal fusions. Anterior cervical refers to the fact that the surgeon performed a fusion of the neck from a frontal approach (rather than from behind the neck, which would be a posterior approach). Wound infection and hematoma formation were the two most common problems associated with anterior cervical spinal fusion using BMP.

All other spinal fusions with and without BMP had an equal number of complications (around eight per cent for both groups). This is an important finding because if the risk of using BMP during spinal fusions is greater than the benefit, then the surgeon may not want to use BMP. Factors of this type must be taken into consideration when planning spinal fusion procedures.

The authors also took a closer look at the patients in both groups to see if a particular characteristic might be important to study in future research. Age, diagnosis, and location of fusion were three areas of special interest.

The effect of age was difficult to really gauge accurately. In general, patients in the BMP fusion group were older than patients in the group who had spinal fusion without using BMP. The reason for this may have to do with the underlying problem requiring fusion.

Surgeons were more likely to use BMP with older patients who have degenerative spine conditions. Younger (pediatric) patients who had spinal fusion for scoliosis (curvature of the spine) were more likely to be able to generate their own growth factors and form bone without the need for a bone enhancer.

There was no difference in mortality (death) as a complication of spinal fusion between the two groups (with BMP and without BMP). Each group had one death related to stroke, blood clot, or other heart or lung problems.

The only other major finding was that patients who had spinal fusion with BMP were twice as likely to need revision surgery as those who did not have BMP. But even among those patients who required a second surgery, the use of BMP did not increase the number of complications that occurred.

The authors concluded from this study that using BMP as a bone enhancer to foster bone fusion does not increase the patient’s risk of complications. This is true EXCEPT when the procedure is an anterior cervical spine (neck) fusion.

Most complications occur as a result of the surgery (with or without BMP) or in relation to other problems that come with age (e.g., heart disease, diabetes). Degenerative diseases of the spine associated with aging is another factor that affects the incidence of complications with spinal surgery.

The authors suggest more studies are needed to look at the amount of BMP used as a potential factor. Long-term results should also be measured and compared with and without BMP. The use of BMP with anterior neck fusions must be studied more closely, too.

Biologic Therapies for Aging Discs

The lines and wrinkles on our faces aren’t the only signs of the inevitable aging process. Progressive degenerative changes have also been documented in the spine. One of the areas of great interest is the intervertebral disc. New biologic therapies for aging discs are the subject of this review article on the topic.

There are 33 vertebrae or spinal bones. Between each vertebra is a disc made of tough cartilage with a fluid center. These discs provide the cushion that allows your backbone to bend and twist. Discs also act like shock absorbers as we walk, run, and jump. Each vertebral segment consists of bone next to bone with a cartilage cushion between. They are tied together with connective tissue, ligaments, and tendons.

Degenerative disc disease is an example of something that affects most people as they get older. Everyone is going to have a certain amount of damage to the spine. This occurs throughout a lifetime. The discs can flatten, and protrude from between the bones. In time, most people will have small tears in the outer layers of these discs.

Finding ways to repair damage to the discs is the focus of many research studies. One of the most recent directions in research has been the use of biologic therapies to restore the disc. Examples of these treatment approaches include disc cell reimplantation, stem cell implantation, disc denervation, injection of therapeutic proteins, and gene therapy.

What are these therapies and how do they work? Biologic therapies of this type are meant to help at the cellular level. Scientists have shown that inside the cells of the disc there is a limited amount of blood flow. As a result, there are waste products building up. The cell becomes very acidic and that is a harsh environment that doesn’t support cell health very well.

As we age, there are fewer new cells to replace the old. Fluid leaks out of the discs that never gets replaced. We start to lose the strength of the discs needed to cushion and support the spine. A loss of disc height can lead to disc space collapse.

That’s what’s happening on the inside at the cellular level. On the outside, the affected individual may not feel anything until the degenerative process has gone on quite a while. Eventually, back pain, loss of motion, and loss of function get our attention. By then, there may not be much that can be done to save the disc. Right now, surgery to remove the disc is often the only option.

That could change if any of these biologic therapies can be perfected. Right now they are still in the experimental stages. Most of the studies have been done on animals but a few human trials have been conducted.

For example, disc tissue reimplantation is a process in which a few healthy cells are removed from an intact disc. They are taken to a lab where they can be multiplied and then reinjected into the diseased disc. The hope is that the new, healthy cells will replace the damaged cells and restore the strength of the disc. The problem with this approach is that by removing healthy cells, the healthy disc is damaged and must repair itself.

Stem cells are the basic cells from which all other cells are formed. Attempts to inject stem cells into the disc so that they will form new disc cells have been limited. Remember, the internal cell environment of degenerated disc tissue is acidic and that doesn’t support new life very well. The stem cells are often quickly killed.

Disc denervation is a way to stop the pain but doesn’t really do anything to change the disc. Radiofrequency and electrotherapy are two ways used to heat up the nerve enough to kill it. But studies comparing these treatment techniques against sham (pretend) treatments have not shown any real advantage of the heat treatment over the sham treatment.

The injection of proteins such as growth factors into the discs has also been tried. It’s a fairly simple procedure, which makes it attractive. But again, puncturing the disc to inject the material sets up a painful inflammatory response that is counter productive. Trials in humans are just getting underway so there are no results to report yet using this treatment approach.

And finally, gene therapy has been investigated as a possible form of biologic therapy for degenerative disc disease. No injection is required. The gene is attached to a transportation unit called a vector (like a taxicab driver who takes you where you are going).

Most gene transfer methods use viruses as the vector. This works well to get the gene inside the cell but then the immune system starts to kill off the viral vector. The result may be illness from the virus as well as a die-off of the genes.

Rescuing degenerative discs has not been an easy task. The acidic cells and limited blood supply leave a fairly hostile environment for any of the biologic therapies to try and get a foothold. The chance to produce tissue repair with biologic therapies is promising but not ready yet for use by the general public. As the authors of this review pointed out, we are just starting to move from animal to human studies. Keep watch here and we will keep you informed of their progress!

Does a Disk Herniation Spell the End of a Pitching Career?

The results of this study show that major league baseball pitchers can recover from a neck or back disk herniation. It may take a while but they can even return-to-play after surgical treatment. How did they come to this conclusion? Public records were searched for information from 1984 to 2009. They found 40 major league baseball pitchers with a history of disk herniation and then followed the results of treatment.

Everyone included in the study had surgery for the problem. They either had a spinal fusion or a disk replacement. Although return-to-play status was the defining measure of success, there were other factors assessed. How long it took to go from the last game player before injury back to the playing field was one of those measures.

You can imagine how pitchers with similar injuries might want to know that information when faced with their own recovery. But the researchers also wanted to know how long the pitchers played before injuring their neck or low back. This is important information in terms of prevention of these kinds of injuries.

If you’ve ever watched the movements of a major league pitcher during the wind-up and pitch, you can appreciate the high forces placed on the arm. But that arm is connected to the neck and spine and those areas undergo torsional forces as well. And this study shows that these injuries don’t signal the end of a player’s career — even if they have surgery.

So if your favorite major league baseball pitcher is out with a disk herniation, you may wonder how long before he is back in action? According to the statistical analysis of the 40 pitchers in this study, it takes an average of about one year for players with neck herniations to recover fully.

And players with a low back disk herniation experience an average of seven months between injury and return-to-play. That’s a full season at least for both groups. But if the injury occurs mid-season, then a seven to 12-month period of time can extend into two seasons.

You may wonder: what about performance? Will my favorite pitcher return at the same preinjury level of elite performance? By performance we are talking about pitching statistics such as earned run average, innings pitched, and walks plus hits per innings. By comparing the pitcher’s pre-injury stats to his post-injury performance, it is possible to see if his pitching performance is better-same-or-worse from then until now.

A closer look at all the data showed that the biggest before and after surgery difference was in the number of innings pitched per season. In both groups (cervical and lumbar disk herniations), players pitched fewer innings after surgery.

When those statistics were compared to players with similar injuries treated conservatively (nonoperative care), the players in the nonoperative group had better post-treatment stats. The major difference was in the number of players who were able to return-to-play in the conservative care group (far less than in the surgical group).

In conclusion, major league baseball pitchers with disk herniations can indeed recover and return to sports action as good as ever. The disk injury does not necessarily mean the end of a career or even reduced performance. Hopefully this report will help dispel some of the suggestions to the contrary made by sports prognosticators and sports writers and reporters.

The authors suggest further study would be helpful. This was a fairly small study with only 40 players evaluated. Additional research is needed to look at differences in pitcher stability and performance based on age and experience. It might be a good idea to also compare severity of injury or herniation against the results of treatment. Finding factors that affect outcomes could help direct the timing and method of treatment.

Questions Raised About Bone Substitute for Lumbar Spine Fusion

Would you think zero complications in 13 studies of 780 patients receiving a new bone substitute product called rh-BMP-2 (BMP) is too good to be true? Those were the findings reported in early industry-sponsored trials. It was first used in 2002, so now we have almost 10 years of data to consider.

BMP stands for bone morphogenetic protein. Rh-BMP-2 is a protein that helps bone heal. BMP reportedly helps speed up the recovery rate after spinal fusion. BMP is designed to promote bone formation by setting up an inflammatory reaction. This type of enhancer was developed to avoid problems that occur with traditional bone grafting. But no adverse reactions or events raised a few eyebrows at the time of the first published reports.

And here again in this systematic review, surgeons from several different spine centers are pointing out some problems with the original research. By going back over all the published reports (industry-sponsored, FDA-data, and privately-sponsored publications), they were able to see there is a much higher risk of complications directly related to the rhBMP-2 product than was originally reported.

What types of problems did patients experience? And why didn’t these BMP-related adverse events show up in any of the original studies? rh-BMP-2 has been used now in lumbar spine fusions as well as cervical spine (neck) fusions.

This review focuses on both cervical (neck) and lumbar (low back) spine procedures. There are four separate methods for which rh-BMP-2 was used: 1) anterior interbody lumbar fusion, 2) posterior lumbar interbody fusion, 3) posterolateral fusion, and 4) anterior cervical discectomy and interbody fusion (ACDF).

As you can see by the names, the differences relate to the location, direction, and placement of the fusion. The first three are methods for lumbar spine (low back) fusion. The fourth one is a cervical spine (neck) fusion. Anterior means the fusion is done from the front of the spine. A posterior fusion is performed from the back of the spine. And a posterolateral fusion comes in at an angle with fusion along the side and back of the vertebrae.

Each of these procedures has its own benefits and risks. This systematic review focused just on risks associated with the fusion material (the rh-BMP-2 bone substitute). By taking a look back at the data collected, the authors of this review found that there was really a complication rate anywhere from 10 to 50 per cent reported.

For the one cervical spine procedure (anterior cervical discectomy and interbody fusion), the risk of complications with rh-BMP-2 as the fusion material was 40 per cent higher than for patients who did not get BMP.

What are these complications? Shifting of the implant, sinking down called subsidence, infection, extra bone formation, osteolysis (breakdown of bone) and increased back and leg pain top the list. Other problems such as the growth of cancerous tumors, bladder retention of urine, and retrograde ejaculation have also been reported.

Men are at risk for damage to the nerves controlling penis erection and ejaculation. With retrograde ejaculation, semen goes backwards and into the bladder instead of forward and out the penis. Not everyone recovers from this problem. In fact, only about one-third regain complete sexual function.

Retrograde ejaculation may not be life-threatening, but it is a very serious problem for those who develop this complication. Loss of sexual function and sterility (inability to have children) can adversely affect mental and emotional health as well as quality of life.

With the neck fusion, there were some life-threatening complications. Swelling of the neck and throat put pressure on the patient’s airway making it difficult to swallow, talk, and even breathe.

And the development of cancer is potentially life-threatening. As a product designed to stimulate bone growth, BMP may actually trigger cell growth resulting in cancer. The complication is for sure — the biologic mechanism by which it happens remains uncertain.

In general, overall function and outcome measures were consistently lower for patients who received rh-BMP-2 compared with patients in control groups (those who did not have BMP as part of the fusion procedure). How do we explain the discrepancy between zero industry-reported complications and a 50 per cent complication rate published in other studies?

Study design, funding of studies by the company making the product, bias by researchers employed by the companies making the bone substitute, and conflict of interest are named as potential sources of this reporting style.

Anyone being rewarded financially by the success of their own product may have a tendency to be overly enthusiastic by results and overlook potential problems. In some industry funded studies, there was simply no mention or discussion at all of problems.

In summary, this systematic review represents almost 10-years worth of research. The authors once again raise questions about the safety of this fairly new biologic bone substitute product called rh-BMP-2.

Data from private researchers, reports submitted to the FDA, and studies sponsored by groups like the Scoliosis Research Society are now available. Their results clearly demonstrate a much higher complication rate linked with the use of rh-BMP-2 than was originally reported by early studies funded by companies developing this product.

Further studies are needed to address these (and other) concerns. For example, the link to cancer is a significant concern. Perhaps the problem can be solved by simply regulating the dose of the BMP product.

Finding the lowest amount that can be used to get the maximum benefit may be an important research goal. Long-term studies to see the effects using BMP compared with traditional bone grafting techniques is another area where study is needed.

And finally, all future studies must be reviewed carefully. Funding sources, study design, and methods of analyzing and reporting the data should be examined in order to determine the true benefits, adverse effects, and safety of rh-BMP-2 in spinal fusion.

Neurologic Safety of Spinal Deformity Surgery

Any time surgery is done on the spine, there is a risk of neurologic problems. Best case scenario is a mild loss of motor or sensory function that only lasts a short time. The patient has a full recovery back to normal. In a worst case scenario, the patient is paralyzed and stays that way. Understandably, surgeons do everything they can to avoid neurologic complications, especially serious ones that lead to loss of function and disability.

When presented with the possibilities of complications associated with the spinal surgery, patients want to know a few things. Like how often do such problems develop? And what’s the usual prognosis? What are my chances of such a problem developing? Am I at risk and if so, why? What can I do to decrease my risk for neurologic complications? This study attempts to answer some of those questions.

A committee of fellowship-trained spine surgeons from many practice settings provided data on over 100,000 cases of spine surgery. The group is referred to as the Scoliosis Research Society Morbidity and Mortality Committee. The information gathered was analyzed in several different ways to get different perspectives on the problem of neurologic complications associated with spinal surgery. Types of information collected included patient age, main diagnosis, type of surgery, type of complication, and amount of recovery.

Both adults and children were included. Children were defined as anyone under the age of 21 years. Most of the adults were treated for degenerative spine conditions or idiopathic problems affecting the spine. Idiopathic means the surgeon does not know why the problem developed in the first place. Degenerative spine conditions ranged from disc herniation, spinal stenosis, and disc degeneration in the cervical (neck) area and the lumbar (low back) area. A smaller number of patients had similar problems in the thoracic (mid-spine) region.

Among the children, neuromuscular causes of scoliosis was the most common problem leading to surgical correction. Congenital and idiopathic causes were also reported many times in this age group. A much smaller number of cases were the result of trauma. Children were 59 per cent more likely to experience new neurologic problems associated with spine surgery compared with adults. The reason for this may have to do with the use of instrumentation (metal plates, screws, rods, and pins to hold the spine steady until fusion takes place).

One other risk factor for neurologic problems developing after spinal surgery was the need for revision (a second) surgery. Results showed a 41 per cent increase in risk of new neurologic problems developing when the case was a revision procedure. Overall, the study showed only a one per cent chance of new neurologic problems among the 100,000 plus patients. That low figure is considered pretty darn good.

One area of controversy in spinal surgery is the use of neuromonitoring. This is a way of detecting whether or not the patient is in immediate risk of damage being done to the spinal cord or spinal nerve roots. The surgeon can either wake the patient up and test him or her for normal sensation and movement or use a special device that monitors the patient’s neurologic status. The wake-up test isn’t very practical because it doesn’t measure what’s going on from moment-to-moment.

On the other hand, the use of tests such as electromyography, somatosensory evoked potentials (SSEP), and motor-evoked potentials (MEPs) can produce false negatives (test is negative indicating no problem when the patient is really compromised and in danger of paralysis). False negatives can be very serious.

In summary, this study is the largest reported on the number and causes of new neurologic problems occurring after spine surgery in adults and children. The information gathered can be used to warn patients planning to have spinal surgery what to expect in terms of a worst case scenario.

Analysis of the data also provided some idea of prognosis (likelihood of no recovery, partial recovery, full recovery) for patients who experienced paralysis. An equal number of patients had partial or complete recovery (around 46 to 47 per cent). Only a small number (4.7 per cent) had no recovery at all.

Tools to Predict Return-To-Work After Disabling Injuries

Getting back to work after a disabling injury can be a long and difficult challenge for some workers. Health care professionals including counselors, social workers, physicians, physical therapists, and case managers are interested in finding a way to identify treatment programs that make a difference in work retention.

One way to measure the results of treatment is to conduct before and after tests. These are usually surveys filled out by the patients answering questions about pain, self-care, physical function, attitude, and disability. Two of the main tools in current use include the Oswestry Disability Index (ODI) and the Short Form-36 (SF-36).

When using these assessment tools, the minimum clinical important difference (MCID) is evaluated. The MCID is defined as “the smallest change or difference in results that is beneficial and leads to a change in how the patient is treated.”

What that means is that we need assessment tools that actually measure an important change (or amount of change) as a result of treatment. If these commonly used tests don’t give us that information, then the time it takes to administer the test and calculate the results just isn’t worth it.

So, when it comes to a specific goal of getting back to work (called work retention), how well do these two tools work? What’s the minimum clinical important difference (MCID) that points to return-to-work? And does that value differ based on work status (full time, part time, or modified work schedule)?

Let’s take a look at the people who were evaluated in this study. There were just over 2,000 disabled workers who had a work-related injury resulting in disability. Treatment (operative or nonoperative) was unsuccessful in helping them achieve functional improvement and return-to-work.

Comparing test score to work status showed that neither the Oswestry Disability Index nor the Short Form-36 measured the amount of change that would predict employment a year after treatment.

Simply stated, these two tools are not responsive measures when used with workers compensation patients with chronic musculoskeletal problems. They just aren’t sensitive enough tools to measure statistically meaningful changes and should not be used to assess treatment outcomes in this group of patients.

As it turned out more than three-fourths of the group (77 per cent) did get back to work. There were enough success stories that if the measuring tools were going to be predictive, they would have shown some type of minimum clinical important difference (MCID). But they didn’t because what they were measuring wasn’t linked with the final outcome of getting back to work.

Going back and looking at the results, the authors found that this study supports what other studies have reported about factors that do predict work retention. That is, older age, female gender, and longer time out on disability are factors linked with failure to get back to work.

For now, as far as finding the best way to measure clinically important changes linked with work retention in this population, the Oswestry Disability Index and the Short Form-36 (mental and physical components) are not the tools to use. More study is needed to find a way to predict individual patient improvement that will lead to a return-to-work status as the final outcome.

Back Pain As a Risk Factor For Suicide

Back pain can be a very disabling problem that alters a person’s life in so many ways. Quality of life suffers. Depression is common. Suicide may be tempting. But how often do people with back pain really end their lives because of it? And how does that compare to the number of people who commit suicide who don’t have back pain?

Researchers from Finland used hospital discharge records to investigate suicide among people with back pain. They collected information from hospital charts for patients with and without musculoskeletal diseases and compared suicide rates. They also looked at differences in age, gender, history of mental illness, method of suicide, and alcohol and other drug abuse at the time of the suicide.

There were over 2300 suicides in Northern Finland between 1988 and 2007. There were actually probably more than that but this is how many patients treated at a hospital for musculoskeletal problems committed suicide. The data was taken from the required hospital discharge records.

Analysis of the data collected showed that men were four times more likely to complete a suicide than women. Autopsy reports were used to assess the use of alcohol or other drugs at the time of the death.

Method of suicide was divided into two groups: violent (e.g., hanging, drowning, shooting, jumping from a height, wrist cutting) or nonviolent (e.g., poisoning, gas). Poisoning referred to overdose of alcohol, other nonprescription drugs, and/or medications. Common medications used to commit suicide included antipsychotics, antidepressants, sedatives, and analgesics (pain relievers).

Most of the suicides (78.8 per cent) were among people without any hospital-treated back (or other musculoskeletal) pain disorders. Those who did have a musculoskeletal disorder and killed themselves were much older than the people who killed themselves who did not have back (or other musculoskeletal) pain. The most common types of other musculoskeletal disorders included rheumatoid arthritis and knee pain.

The group with back pain (and other musculoskeletal pain disorders) who committed suicide did so most often in a nonviolent way. Women were especially more likely to use a drug overdose compared with hanging or self-inflicted shooting among men. And women with back pain were more likely to be drinking when they died.

What else did they find? Well, men of all ages with back pain or musculoskeletal disorders were hospitalized more often than any others for depression and substance abuse. Whether the back pain came first and led to depression and drug abuse or the other way around was not known.

Turning the data around, they took a closer look at the 21.2 per cent of suicides that were linked with back or musculoskeletal pain. It turns out that these folks were 14 times more likely to commit suicide than patients in the general population.

When drug overdose was the chosen method of suicide, dextropropoxyphene was used in half the cases. This medication is prescribed as a pain reliever but it is in the drug category of opioids (narcotics). Sold under different brand names, dextropropoxyphene has been taken off the market in Europe and the United States. It is still available and widely used in Finland for chronic pain.

In summary, research has shown that suicide is common among people who suffer chronic pain. But there is wide variation in numbers of suicide from different causes of chronic pain. By taking a look back (a retrospective study), this report highlighted the role of age and overdose with narcotics and subsequent suicide in patients with back pain (and other musculoskeletal disorders).

The authors suggest that physicians treating adults (especially older adults) remember that drug overdose is the most common way patients with musculoskeletal disorders kill themselves. Therefore, dispensing prescription drugs for pain should be done carefully and monitored closely.

Update on Minimally Invasive Spine Surgery

Anyone thinking about having a minimally invasive (MI) spinal surgery will find the information in this review article of interest. In fact, surgeons performing this type of surgery will benefit from the detailed presentation of MI surgical techniques as well. Procedures discussed include tubular microdiscectomy, hemilaminectomy, and interbody fusion.

The authors also present information on the placement of screws used in fusion to hold the spine in place, a process called fixation or instrumentation. A brief history of minimally invasive development as well as a summary of the advantages and disadvantages of this approach are also provided.

For those who don’t know what minimally invasive spine surgery means, it is a way to reach the spine through the skin and soft tissues without cutting through all the muscles and many tendons. Instead of a large, open incision the surgeon makes small slits in the skin and slips a tube down to the target site (usually vertebral bone or disc).

Surgical tools needed to perform any of the procedures mentioned reach the target tissue through the tube. A tiny TV camera on the end transmits real-time pictures to a screen to guide the surgeon. That sounds very simple and in a way, it is (compared to open incision and dissection or cutting through all the soft tissues).

The replacement of self-retaining retractors (used during an open procedure) by the tubular retractor (used during a minimally invasive spinal surgery) was a major turning point in spinal surgery. The self-retaining retractors pulled the soft tissue apart after incisions were made. This allowed the surgeon to gain access to the spine.

But the force of the self-retaining type of retraction caused crush injuries to the muscles, blood vessels, and nerves. Replacement with the tubular retractor changed all that. Loss of blood supply to the muscles and damage to the nerves often meant the patient never regained the muscle strength needed to support the spine. The result was often chronic back pain and weakness, a condition referred to as failed back surgery syndrome.

But there are many preparatory steps that must be taken by the surgeon before making even the tiniest incision. X-rays and MRIs are studied to give the surgeon detailed information about the patient’s anatomy. The exact entry point for the tubular retractor and its pathway to the spine is carefully mapped out.

Patients are placed in different positions depending on the planned procedure. For example, a prone position (face down) may be used when performing surgery with a posterior approach (from the back of the spine).

In other cases, the surgeon may reach the intended disc from the side or lateral approach. Patients are placed on their side for that type of procedure. The surgical table can move dropping the patient’s legs down in order to open up the space between the pelvic bone and the spine.

Again, the surgeon uses imaging studies to plot out the best place to enter the spine. Proper positioning is the key to a direct approach and accurate placement of surgical tools. And all of this helps avoid muscle injuries, especially preserving ligaments and protecting the deep muscles that help stabilize the spine.

Studies show that even at the cellular level, the goals of minimally invasive spinal surgery (to reduce soft tissue injury and speed recovery) are met. Blood studies show that all levels of biomarkers for tissue injury return to normal much faster after minimally invasive surgery.

As more surgeons receive the necessary training and practice in minimally invasive spinal surgeries, results improve. Likewise, the application of minimally invasive approaches expands. In other words, this technique can be applied to many more patients with a wide range of problems from stenosis (narrowing of the spinal canal) to scoliosis, disc degeneration, and spinal fusion.

Spinal fusion can be done from the side now (lateral approach) with far less disruption of the soft tissues and without cutting through the bone. Single-level or multiple-level fusion can be done using minimally invasive surgery.

There are some drawbacks to minimally invasive surgery (MIS) and some potential complications. Surgeons who are not doing MIS say it is because the opportunity to learn this technique is limited. Intra-operative and post-operative problems are much higher when the surgeon is gaining experience. The technical difficulties can be overcome with training and practice but it takes time.

In summary, minimally invasive spinal surgery is replacing the traditional open incision approach. There is more and more evidence to support minimally invasive procedures. Studies show that patients recover faster with less time in the hospital and fewer costs. They return to daily activities and work sooner, too. In the hands of a skilled surgeon, the procedure is safe and effective with less tissue damage, less blood loss, and less post-operative pain.

Care of Soldiers on the Battlefield with Possible Spinal Cord Injuries

Soldiers in Iraq are not just coming home with missing fingers, toes, or limbs. Many active-duty service members involved in Operation Iraqi Freedom end up paralyzed for life because of spinal cord injuries. Emergency care given on the battlefield through transport back to the United States is the topic of this article.

Because high-energy blast trauma injures more than just the spinal cord, these patients can’t be treated the same way civilian spinal cord injuries are handled. Military emergency personnel learn how to manage the soldier who has what is referred to as polytrauma — a spinal cord injury plus traumatic brain, chest, back, bone, organ, and/or other injuries.

Getting the injured soldier on the first aeromedical transport isn’t the only goal. Assessment and protection to survive the flight home with no further harm is the central focus of battlefield emergency medical personnel. In these wartime situations, the phrase Do no harm becomes Do no further harm.

How do they accomplish this? When a soldier is down on the battlefield, the nearest service member or combat medic attempts to get him or her as far from the front line action as possible. If under enemy attack or fire, it may not be possible to protect the spinal cord from further injury. The hard cold fact is that the risk of death outweighs the risk of spinal cord injury. And keep in mind, not only are these folks often still under attack, there is often more than one comrade down and in need of care.

Emergency personnel are advised what to do as well as what not to do. Sandbags to hold the head in the middle are not a good idea. Experience has shown they can become more of a liability than an advantage — especially if they slip and push the patient’s head to one side. Rolling the patient like a log has been replaced by a different technique called the HAINES maneuver. HAINES stands for “high arm in endangered spine.”

Resources are limited on the battlefield. There may not be enough backboards and protective neck guards to go around. Medics learn how to evaluate each injured soldier for risk of spinal cord injury. Red flags suggesting a need for immobilization include altered consciousness (e.g., amnesia), unconscious state, or paralysis (even if only temporary). Type of injury can also raise a warning flag. Soldiers involved in explosion or blast, fall from height, ejection from vehicle, or vehicle rollover must be assessed carefully.

The current protocol for managing potential spinal cord injuries is to immobilize immediately to protect the spinal cord. But the authors point out that there isn’t enough evidence to really support this approach. In fact, there’s even some proof that patients have worse outcomes when they are placed in restrictive splints, neck braces, or strapped to a rigid backboard.

Not only that, but there are cases where spinal immobilization actually increases the risk of other problems like pain, decreased ability to breathe, failure to recognize other injuries, edema (swelling), and skin ulceration from pressure.

There are some changes in the way seriously injured soldiers are treated in today’s war time. Surgical teams are posted much closer to the front lines than ever before. That means patients get help much faster — sometimes going from battlefield to field hospital in under an hour. Once they are stabilized, they can be transported to Germany within 12 hours and stateside by day 5. That sure beats the 15 hour delay soldiers experienced just getting off the battlefield in World War II.

Once the injured solder has been removed to an area where helicopter transport can pick him or her up, then if needed, the patient is immobilized and secured in an effort to avoid any further damage or injury. Placing a firm collar around the neck is first, and then strapping the patient to a hard backboard is next. Any body part that can get bumped or dislodged when the helicopter takes off is taped down.

One final hurdle remains once the soldier is on board a helicopter. Vibration, decreased oxygen, g-forces, and low air humidity can add stress during air transport to the already impaired individual. Transport personnel are asked to do everything possible within their means to make patients comfortable and minimize adverse effects of air travel.

In conclusion, not all soldiers injured on the battlefield need to be immobilized to prevent further spinal injury. Evidence is lacking that these measures are needed and they can actually cause additional injuries. Anyone involved in the emergency care and transport of our wounded soldiers will find this article helpful in guiding assessment and management decisions. “Do no harm” and beyond that “Do no further harm” is the order of the day.

Chronic Arthritis in Children

Would it surprise you to know arthritis in children can affect only one joint with swelling and yet still be pain free? That’s one of the reasons it is so difficult to make the diagnosis. Those symptoms can also describe other conditions such as Lyme disease, tuberculosis, tumor, lupus, and even inflammatory bowel disease.

Dr. Marilynn Punaro from the Texas Scottish Rite Hospital for Children and University of Texas Southwestern Medical Center in Dallas, Texas provides this in-depth look at arthritis in children. Dr. Punaro reviews the diagnostic criteria for all of these conditions to help the pediatrician make an accurate diagnosis.

The arthritic condition used to be called juvenile rheumatoid arthritis or JRA but it has been renamed juvenile idiopathic arthritis (JIA). The word “idiopathic” means “of unknown cause.”

Rheumatologic diseases can be difficult to recognize at first. There isn’t one blood test that tells all. Tests used more reliably in adults to look for rheumatoid arthritis (e.g., rheumatoid factor, antinuclear antibody or ANA) are usually negative in children or are a false-positive (positive when there is no rheumatologic disease present at all). X-rays and other imaging studies have equally limited value. The diagnosis really depends on the child’s history and clinical presentation.

The well-trained physician will recognize a telltale pattern of history, signs, and symptoms that will point to juvenile idiopathic arthritis (JIA). In the process, these other possibilities (infection, tumor, other inflammatory diseases) will have to be excluded or ruled out.

When there is pain, finding out what makes the pain better or worse can be helpful. For example, pain that is worse after activity is more likely to be mechanical — meaning a tendon or muscle problem like patellofemoral syndrome. Pain that is worse at night after going to sleep for several hours is a red flag for tumor or growing pains.

Pain with weight-bearing is not a typical pattern with juvenile idiopathic arthritis (JIA). Pain that moves around from joint to joint is another tip-off that the problem isn’t JIA. A hot, tender, swollen joint is more common with infection or trauma. And the presence of extra-articular symptoms points to other conditions.

Extra-articular means “outside the joint” and includes such things as fever, nausea, vomiting, weight loss, elevated blood pressure, skin rash, sores in the mouth, redness of the eye(s), or sudden muscle weakness. When these kinds of signs and symptoms are present, blood tests and urinalysis may be more valuable in identifying the underlying cause.

All of this tells us what is NOT juvenile idiopathic arthritis (JIA). So what does the physician look for that tells him or her that the problem is really JIA? It goes back to something called pattern recognition.

The pattern looks like this: persistent swelling and loss of motion in at least one and up to four joints for six weeks or more. Morning stiffness and limping are more common than actual pain. The child feels well and does not complain of fatigue.

There are several subtypes of juvenile idiopathic arthritis (JIA) but the majority of children with this condition are girls. For every one male with JIA, there are five girls affected. The first symptoms start to show up early (ages one to three). The knee and ankle are involved most often.

Dr. Punaro concludes that diagnosing juvenile idiopathic arthritis (JIA) in children is a challenging task. The physician spends more time making sure it isn’t something else before being certain it is JIA.

After reviewing the history, examining the child, and taking all the tests, the diagnosis is tested out by treating the problem and waiting to see what happens. Symptoms that do not respond to nonsteroidal antiinflammatory drugs (NSAIDs) signal a need to re-evaluate and test further. As shown in this article, knowing what to look for with JIA as well as all the other conditions that look like JIA is essential.

Monitoring Spinal Function During Spine Surgery

Any spine surgery is a very delicate operation. Care must be taken to prevent damage to the spinal cord, spinal nerves, and blood vessels supplying these neural components. Damage to the blood vessels and loss of blood supply to the spinal cord can have serious consequences.

Surgeons have an important tool available during spinal surgery to monitor patients called intraoperative neuromonitoring or IOM. IOM methods include the wake-up test, somatosensory-evoked potentials (SSEP), transcranial motor-evoked potentials (tcMEP), spinal cord MEPs, spontaneous electromyography (sEMG), and triggered electromyography (tEMG).

Each one of these tests has its own purposes and functions. But the basic idea behind this type of monitoring is to make sure moment-by-moment during the procedure that no injury has occurred. This is called real-time monitoring. Warning is given so that any damage can be prevented or reversed.

The tests must be accurate enough to avoid any false positives or false negatives. A false positive means the test says there’s a problem when there really isn’t one. A false negative is a test that doesn’t indicate a problem when there is one.

In this study, neurosurgeons from the University of Pennsylvania and University of Virginia reviewed studies published on intraoperative neuromonitoring (IOM). They wanted to know how sensitive are each of the tests. Surgeons need to know what test values require immediate action.

Having these tests makes it possible to perform more complex spinal surgeries. That’s important for patients with severe scoliosis undergoing spinal correction to get the best possible result. The same is true for cancer patients with spinal tumors that have to be removed. It allows the surgeon to be more aggressive when it’s needed and with less risk of complications.

For each of the IOM tests, the authors provide a description of the test, when it would be used, and what the research reports about reliability, validity, and effectiveness of each test. Surgeons are given ways to avoid problems and obstacles with each test. A summary of all the technical information is provided with key points from the article offered in the conclusion.

Here’s a sample of the type of information surgeons can obtain from this review. The wake-up test (gradually reducing the amount of anesthesia until the patient wakes up enough to move their arms and legs) has many more drawbacks than benefits compared to the other tests. It’s easy to do but only offers a one-time look at what’s going on when really ongoing monitoring is much better. It should only be used along with a more consistent test.

Somatosensory-evoked potentials (SSEPs) became popular in the late 1980s and early 1990s. They were thought to be reliable but it turned out there was a high rate of false negatives. SSEPs don’t monitor all aspects of spinal cord, spinal nerve, and vascular (blood supply) function. They are not reliable to test motor (muscle) function and should not be used with patients who already have a neurologic problem. Again, it’s best to use this test along with others and to gear it toward specific cases depending on what type of surgery is being done.

Motor-evoked potentials (MEPs) apply electrical or magnetic impulses to the part of the brain that controls motor function (movement). Electrodes are applies to the scalp. Specific muscles are monitored this way. The problem with this test is that when the muscles contract, the patient moves, and the surgeon has to stop operating until the test is completed. That lengthens the time the patient is under anesthesia and total time in the operating room. It’s a safe test but can’t be used with patients who have skull defects, pacemakers or other implanted devices, or epilepsy.

It’s clear that there’s not one-individual test that works for all patients or that monitors all functions of the spinal cord. If the surgeon wants to monitor both sensory and motor function, then more than one test will certainly be needed. That’s referred to as multimodality intraoperative monitoring or MIOM. MIOM is a great help when the surgeon is trying to remove a spinal tumor completely but without damaging the neural tissues or creating paralysis or other disability.

If one test (such as the SSEP) is too slow to provide the kind of information needed, then MEP can be used. Studies show that when MIOM is used, there are far fewer cases of false-negatives. When problem do develop, they are only temporary and the patients recover within hours to days. The problem is that most surgeons don’t have access to all the different testing procedures and often have to rely on the one or two that are available.

For now, the use of intraoperative monitoring (IOM) is still optional, not required in all spinal surgeries. Because there’s not enough evidence to support specific protocols, there isn’t a legal requirement yet for use of these tests. Whenever IOM or multimodal intraoperative monitoring (MIOM) is used, the surgeon is advised to keep very careful records of everything that is done, how it is done, the exact time each step is performed, and the results.

Patients must understand that even with the best of testing available, problems can develop — even permanent paralysis is still a possibility. Intraoperative monitoring (IOM) isn’t really needed for the more simple spinal procedures, so patients shouldn’t expect this to be a standard part of every spinal operation.

The surgeon who understands IOM will know when and how to use it best. The details in this article will help aid in providing technical information needed about these tests. None of this information and none of the tests can replace a clear understanding of neurologic and vascular anatomy. Likewise, final outcomes of complex spinal surgery still require a high level of technical skill on the part of the surgeon.

Improving Treatment with Neuromonitoring During Spinal Surgery

For complex spinal surgeries that could potentially damage the spinal cord, spinal nerve roots, or blood vessels to these areas, surgeons use intraoperative monitoring (IOM) devices. These tools make it possible to check the patient and make sure everything is alright and no neurologic damage has occurred.

Monitoring neurologic function (motor control and sensory input) isn’t required with all spinal surgeries. The most common uses are for correction of spinal deformities (e.g., scoliosis) and removal of spinal cord tumors.

As with any new technology, as intraoperative monitoring (IOM) has developed, there has been a call for protocols and a standard of care. Research to show what works best should help guide the use of IOM. The goals are to improve patient care and reduce the number of complications and problems.

As such, it’s helpful for surgeons to have evidence-based guidelines. This review of the literature (studies already published on the topic) helps pull together what we know so far in an attempt to define a standard of care (SOC) for intraoperative neuromonitoring.

One of the problems with defining a standard of care is that each patient is unique and each procedure has its own twists and turns. Added to that are the differences in training among surgical personnel and ways to monitor these devices. There are no standard to dictate what is “proper” training and monitoring. There also isn’t a standard for who is qualified to read and interpret the tests.

A court of law wants a standard that it can judge each case by (despite any differences from patient to patient and in various surgical situations). Toward this end, the Scoliosis Research Society approved intraoperative monitoring in 2009.

They stated IOM is not just an investigational tool but a valuable way to detect problems early. Preventing loss of blood supply to the spinal cord or paralysis is both a medical and a legal problem. From a medico-legal perspective, having a standard of care for intraoperative monitoring is essential.

From the studies that have been done so far, we see that physicians aren’t the only ones who can monitor neurologic intraoperative devices with accuracy. Many nonphysician technicians and professionals have already proven their skill, ability, and experience with neuromonitoring.

In fact, the whole field of neuromonitoring was pioneered by nonphysician clinical professionals. But they must have proof of training or certification as required by the American Board of Neurophysiologic Monitoring. And recertification is required every 10 years.

Another area of concern has been the reading and interpretation of test results via internet connections. The technician isn’t in the operating room with the surgeon providing real-time (instant) feedback. He or she can’t see the patient and is often monitoring more than one person at a time. Is that safe? What if the internet connection fails or there is some computer glitch?

There are also automated monitoring systems that are not managed by a live person. Although these have been approved by the FDA, some experts question whether it is safe to apply electrical stimulation to the brain and trust a machine’s interpretation of it?

Can we afford to take chances with someone’s life or put them at risk of permanent paralysis and disability? These are the kinds of questions that must be considered when establishing a standard of care for everyone who is undergoing complex spinal surgery with neuromonitoring. And that’s why the American Society of Neurophysiological Monitoring recommends all monitoring be done by a trained and certified technical professional.

The author concludes by saying that all parties concerned (physicians, lawyers, neurophysiologic monitoring professionals, hospital administrators) must come together to formulate a standard of care that is in the best interest of the patient. Certification requirements for the staff carrying out the tests should result in specialty licensing as the bottom-line. It is not the medical degree that should be relied upon when it comes to neuromonitoring.

Surgery for Spinal Cord Injuries: What’s the Best Timing?

In this supplemental issue of the publication Spine, the editors tackle a big subject: spinal trauma. Three new studies addressing the optimal time for surgery are included. Timing for surgery after spinal trauma is a very important topic as every hour can make a difference in the final outcomes.

Every year, trauma takes the lives of 1000s of North Americans between the ages of five and 44. For those who are not killed but survive, spinal cord injury is a major problem. If the victim is lucky, there will be a trauma center nearby to address any spinal cord trauma and other injuries that occur at the same time. Even better is the presence of a spine trauma unit.

But even at specialized centers like the Neurosurgery and Spine Program at the University of Toronto in Canada where these studies originated, there is much debate about the best treatment strategy for these types of injuries. In fact, as one of the studies in this journal shows, interviews with 77 neurosurgeons showed a wide range of opinions about the optimal early management of spinal cord injuries.

There isn’t just one factor to consider when determining whether surgery should be done immediately (within 24 hours) or later after stabilizing the patient. There are safety issues for the patient, staffing issues (is a properly trained neurosurgeon available?), cost analysis, possible complications to consider, and considerations centered on patient quality of life. Children may be handled differently than adults. Older adults may require a different approach than younger individuals. And the level of the injury can make a difference, too.

There is some evidence that the longer the spinal cord is compressed (crushed, pinched, pressed by the damaged vertebrae), the worse the results. It makes sense to get the pressure off the cord as soon as possible.

But there can be other life-threatening issues that must be taken care of first. And there’s some question about what to do when surgery could make matters worse or even prevent the patient from recovering naturally. In cases where the cord is severed all the way across, the value of immediate surgery is less well-known.

From studies done so far, the current recommendations are for early surgery for patients with severe neurologic injury. For those who have mild neurologic symptoms, a wait-and-see approach is advised to give patients time to heal and recover on their own.

Early stabilization of the spine and decompression of the spinal cord has been shown to reduce hospital costs by decreasing length of hospital stay and fewer days on mechanical ventilation (machines keeping the patient alive by breathing for them).

The editors of this journal suggest that if ever there was doubt about the best timing for spinal cord surgery following traumatic injury, the evidence is piling up now to show support for early rather than late stabilization and decompression. Some surgeons advocate surgical intervention even earlier — within 12 hours rather than the 24 hours previously debated.

A special study conducted at multiple spinal cord trauma centers is currently underway. Many specialists are hoping the results of that study called Surgical Treatment of Acute Spinal Cord Injury Study or STASCIS will bring additional information. Results from STASCIS may help shape future recommended guidelines for the optimal timing of surgery in cases of acute spinal trauma.

Results of New Surgery for Adults with Scoliosis

Any good writer knows the reader wants to know who, what, when, where, and why to help make sense of any story or news item. The authors of this article use these guide posts and present a very clear picture right from the start. This is a study of older adults (40 years old and older) with scoliosis (curvature of the spine). That takes care of the who and what.

The ‘where’ is easy: Johns Hopkins University Hospital, a well-known medical facility. The ‘why’ is the most important feature. There are lots of studies done on children and adolescents treated surgically for scoliosis. Reported results among adults are harder to come by. And this is a prospective study (the ‘when’) meaning they gathered information and observed results as they treated and followed these patients.

To give you a little bit more information about the ‘who’ on both the patients and the surgeon — one orthopedic spine surgeon performed all the procedures on patients who had never had spinal surgery done before. The patients ranged in age from 40 to 66 years old. Most were in good health but everyone had at least one other health problem such as high blood pressure, heart burn, osteoporosis, depression, anxiety, asthma, and so on.

The surgery consisted of fusing the spine at multiple levels (at least 10 levels up to as many as 20 segments). Some fusions went to the bottom of the lumbar spine (just above the sacrum) while others fused the last lumbar vertebrae to the sacrum. Everyone in the study agreed to stay in the study for at least two years.

Information gathered from the patients during that time included questions about general health and the presence of comorbidities (other problems). They also measured outcomes using patient level of satisfaction, function, need for additional (revision) surgery, and development of complications. Complications were divided into two groups: major (e.g., death, blood clots, fractures, deep wound infection) and minor (urinary tract infection, nerve palsy, lung or spleen puncture).

The fusion procedures were done with today’s new technology and improved techniques and fixation devices. Devices used to fix (fuse) the bones in place included transsacral bars, alar screws, and iliac screws. This is the third-generation of instrumentation techniques — meaning the third round of improvements in these devices.

Analysis of the results showed successful fusion rates but with a high rate of complications. Almost half (49 per cent) of the patients had at least one problem following surgery. Most of the complications were minor and occurred later after the patient went home. The more major complications presented early and required additional hospitalization. There were no deaths and no cases of permanent paralysis.

But most of the patients were very satisfied with their improved results and said they would have the surgery again if they had to do it over. In fact, patient satisfaction was equal among all patients regardless of whether or not they had complications. Both mental and physical health improved. Many of the patients were able to return to work after recovering.

There was one important factor to note: fusion to the sacrum comes with some additional limitations and restrictions. Patients should be prepared for that before surgery. The sacrum is included in the fusion process when the lumbar spine is just too unstable or too fragile to allow for movement at the last lumbar/first sacral (L5-S1) level.

The authors make suggestions for reducing complications. They advise staging the surgery in two-separate procedures. The first part of the fusion is done posteriorly (from the back of the spine). The second stage is done about a month later from the front (anteriorly). The double fusion isn’t always needed — just when there is a need for structural support at the L5-S1 (lumbosacral) junction.

In summary, today’s third-generation fixation devices and improved surgical techniques make spinal fusion for scoliosis in older adults not only possible but very beneficial. The improvements in symptoms despite the loss of motion and possibility for post-operative complications is enough to satisfy the majority of patients.

Spinal Surgeons Offer Guidelines for Prevention and Management of Dural Tears

There’s nothing simple about any part of the human body. Even what appears to be a single layer of covering around the spinal cord and brain (the dura) has three layers. Thanks to the invention of the electron microscope, it is possible to magnify tissues enough to see the finest detail.

Spinal surgeons and patients having spinal surgery are affected most by this discovery. Any time surgery is done on the spine, there is a risk that the dura will get torn or damaged. And if all three layers are torn, then the cerebrospinal fluid (CSF), a plasma fluid that cushions the brain and spinal cord can leak out. If that happens, watch out! Major headache, nausea, and light sensitivity can develop after surgery.

Because dural tears are common during spinal surgery, the surgeon usually makes sure the patient understands the risk and the side effects of this complication. Patients are fully informed up front (before surgery) about the risk of a dural tear and the fact that if a dural tear occurs, a second surgery to repair the tear may be needed.

In this article, spinal surgeons review the complex anatomy of the dura mater and cerebrospinal fluid, point out risk factors (who is most likely to have a tear of this type), and guide surgeons through the intricate process of performing a dural repair.

Three intricate drawings are provided to show the various layers of tissue and fluid that surround the brain and the spinal cord. Besides the three-layer dura and cerebrospinal fluid, there are structures and layers such as the transverse sinus, tentorium cerebelli, cistern, and subarachnoid space.

That’s just around the brain. The protective coverings around the spinal cord are equally complex. Between the vertebra (spinal bone) and dura is the epidural space. Outside the dura are the arachnoid, denticulate ligament, subarachnoid space, and pia mater.

The average patient doesn’t really need to know the ins and outs of spinal anatomy. But the surgeon does in order to make a successful repair. The surgeon must also know what puts patients at an increased risk of dural tears. The plan of care must include prevention of dural tears. If such an event occurs, then the plan of care shifts toward management of the problem.

So, who’s at greatest risk for this complication? Naturally, anyone who is having spine surgery. Older adults who have developed stiffening of the spinal ligaments are at increased risk for intraoperative dural tears. In particular, a condition known as ossification of the ligaments is a big risk factor.

Ossification refers to tiny bits of bone infiltrating the soft tissue. Trying to cut through this tough ligament to get to the spine can results in a tear of the underlying dura. In the cervical spine (neck), ossification of the posterior longitudinal ligament (OPLL) increases the risk of dural tears. In the lumbar spine (low back), it’s more likely to be ossification of the ligamentum flavum (another supportive spinal ligament).

Another risk factor is previous spinal surgery. Scar tissue (adhesions and fibrosis) make it more difficult for the surgeon to see anatomic landmarks used to guide the procedure. When the surgeon must cut through the previous scar (now altered by adhesions), the risk of dural tears increases as well.

Other degenerative effects of aging can compromise the dura. For example, bone spurs, cysts, and narrowing of the spinal canal are typical effects seen in the older adult’s spine. And the ossification mentioned can be sharp enough to erode through the dura over time.

During the dural repair procedure, the surgeon will do everything possible to avoid puncturing this delicate structure. Smaller needles are being used now. Once a tear occurs, the surgeon makes every effort to repair it as quickly as possible. The smaller the tear, the better the expected results.

The authors offer several guiding principles for dural tear repairs. The surgeon is advised to keep the area well-lit (e.g., use a head lamp and an operating microscope) and dry (e.g., stop any bleeding or leakage of cerebrospinal fluid).

Stitch the tear carefully through all three layers. Test the strength of the repair. Add a graft if necessary or use a fat plug to make a water tight seal around the hole and/or around the sutures.

As you might expect, smaller tears (pinhole size) are easier to manage. Larger tears with more damage to the dural layers may actually require reconstruction of the dura. It’s easy to be fooled into thinking the tear is smaller than it is or that there is only one tear. If cerebrospinal fluid continues to leak, the surgeon knows the job is not finished yet.

Patients are warned that even with a dural repair, the problem can come back. In fact, studies show that five to 10 per cent of all patients who have a dural repair procedure will spring a leak again. The main reason for this is that cerebrospinal fluid can leak out of the suture holes made to thread the stitches through the tissue. Efforts are being made to come up with alternate ways to repair the tear without using sutures.

Sometimes it’s not possible to repair the tear. Reconstruction with a graft material may be needed. But finding the right dural substitute has been a challenge. The surgeon can use a xenograft (material taken from another species such as a pig) but there’s a risk of disease transmission. Collagen sponges are another option but these aren’t always water tight.

A popular technique right now is the use of graft material taken from the patient’s own tensor fascia lata. The connective tissue around this muscle along the outside of the upper thigh is a good substitute for the dura that can’t be repaired.

Once the repair or reconstruction has been done the patient must rest. The goal is to reduce pressure against the repair site until healing has gotten a good foothold. For tears in the cervical spine, sitting upright reduces fluid pressure. For the lumbar spine, lying flat is best.

How long does the patient have to stay in the prescribed position? Well, that’s a matter of debate. The old standard was 10 days — until healing took place. Gradually, that has been reduced with the use of medications to one to three days.

But more recent studies have even looked at no bed rest as a possible option with some good results. The surgeon will decide the optimal time for bed rest based on the size and location of the tear as well as the type of surgery done.

In the end, the goal of dural repair is to have a symptom-free result: no headache, no nausea, and no sensitivity to light. If tears can be prevented in the first place, then dural tear surgery can be avoided completely. Understanding spinal anatomy and assessing patients for risk factors are keys to prevention.

A Major Summary of Findings About Spinal Surgery Recommendations

With more and more studies being published on the topic of spine surgery — when should surgery be done, what works, what doesn’t, when should X-rays be taken, and so on — a group of surgeons from six well-known surgery centers got together and reviewed the evidence. The result was this summary of six studies on spine surgery along with whatever recommendations were made by the authors of the studies.

The basic idea behind each study was provided first. Then a quick review of how the study was done as well as how the results were interpreted was reported. Finally, recommendations for clinical practice were offered. The evidence for each recommendation was rated from weak to strong to give surgeons an idea of how much to rely on the guidance from the study.

The six studies included: 1) imaging strategies for acute low-back pain, 2) surgery versus nonoperative care for lumbar degenerative spondylolisthesis, 3) treatment of spinal burst fractures with and without fusion, 4) vertebroplasty versus conservative care for osteoporotic spinal fractures, 5) bone graft substitute versus using patients’ own bone for lumbar spine fusion, and 6) effect of needle placement during cervical spine fusion on the disc.

Each of the six studies was either a very large, high-quality study or a systematic review of many other research reports on a single topic. These six studies cover a wide range of problems surgeons treat everyday. Cost weighed against the benefits in terms of final patient outcomes is an important part of each study. The studies were analyzed with this idea of cost-effectiveness in mind. The recommendations made represent the best evidence available at the present time.

Here’s a summary of the ways surgeons practice that might be influenced by the results of these studies:

  • X-rays and other imaging studies should NOT be done for patients with acute onset of back pain when there are no other red flags. Red flags are the warning signs, symptoms, and patient histories that suggest something more serious than a simple or temporary back problem.
  • Patients with degenerative spondylolisthesis have better results (less pain, more function) when treated surgically to stabilize the spine. There is strong evidence that the positive results and benefits seem to last (at least for up to four years) in the studies reviewed.
  • Burst fractures of the thoracolumbar spine can often be treated without surgery. But when there are signs of spinal cord compression, then surgery becomes an urgent matter. There is weak evidence to suggest that fusion from the back and side of the spine (posterolateral approach) isn’t the best way to treat this problem. When surgery is needed, the surgeon should approach the spine from the front and perform an anterior decompression (remove bone pressing on the spinal cord).
  • For patients with painful vertebral compression fractures caused by osteoporosis, there is no long-term advantage of having a vertebroplasty procedure over conservative (nonoperative) care. The vertebroplasty involves placing a needle into the fractured vertebra and injecting cement into it to stabilize the bone and keep it from further damage. However, the vertebroplasty procedure does offer faster pain relief in the early days of the fracture. That could be an important deciding factor for some patients.
  • Right now, using bone substitute materials for spinal fusions is fairly costly and not recommended for routine use. Patients can still donate their own bone though it does mean a greater risk of complications and problems at the donor site. The authors point out that more studies are needed in this area.

    There was one final recommendation that will take a little bit of explanation. It has to do with using a needle inserted into the disc to make sure the surgeon is at the correct spinal level to perform an anterior cervical discectomy (remove the disc) and cervical spine fusion.

    This method of checking works fine so long as the needle goes in the correct disc (the one that’s going to be removed anyway). But when the needle punctures a healthy disc at the next level (above or below the diseased disc), then that healthy disc is at risk for degenerative changes.

    According to studies done, the practice of missing the correct disc space is more common than realized. Seventeen per cent (17%) of cases investigated had incorrect needle placement. And the risk of degeneration was three times higher for those previously intact discs. For now, it looks like there is a weak recommendation to avoid using the needle placement checking technique to confirm the disc space for discectomy.

    Surgeons take information like this and present it to their patients when making recommendations and suggesting a plan of care for the problem at hand. Patients are free to choose to take the surgeon’s advice based on their own personal preferences or circumstances. Any decision that involves spine surgery isn’t taken lightly — any and all information that can be offered based on evidence is helpful.

  • Surgeons Solve the Dilemma of Classifying Thoracolumbar Spinal Fractures

    Surgeons faced with decisions about treatment for thoracolumbar spinal fractures are really challenged by the lack of one simple, adaptable, easy-to-remember classification system. Currently there are at least eight different systems described and in use. In this article, a new valid and reliable system is introduced that can be used in the clinic.

    Let’s step back a minute and define and describe what we are talking about — first, what’s a thoracolumbar fracture and second what’s a classification system? Thoracolumbar refers to the spot in the spine where the thoracic vertebrae end (T12) and the lumbar vertebrae begin (L1). That point (T12-L1) is called the thoracolumbar junction. Fractures affecting one level above (T11) and one level below (L2) are also included in this category.

    Classification systems help surgeons identify the location and severity of the fracture. Some classification systems also include the mechanism of injury (how it happened). That information is what they use to determine the most appropriate treatment for each patient.

    A good system should be prognostic — in other words, give some idea of the outcomes (how bad is it, can the patient recover). And it should be all the things we’ve said so far: easy to remember, easy to use, easy to reproduce (any surgeon can use it and get the same results), and provide prognostic value. Not only that, but the system should not include unnecessary information because that just creates confusion in the decision-making process.

    To add another twist to the challenge, these kinds of fractures can be described based on the injury pattern. And there can be subtypes for each injury. How and what is done in surgery to treat these injuries depends on understanding what needs to be done to stabilize each specific injury type.

    To give you an idea of the wide range of classification descriptions already out there, here’s a partial list of fracture categories: wedge, dislocation, rotational fracture-dislocation, extension, burst, shear, vertical compression, compression flexion, distraction flexion, torsional, translation, and so on — you get the idea.

    The complexity of a system that can place the fracture in a category and assign a subtype is just too cumbersome for clinical use. Can a simple system be possible? With eight different systems already proposed, it doesn’t seem so. But this new system called the Thoracolumbar Injury Classification and Severity Score (TLICS) may just fit the bill.

    In the TLICS system, points are given for three basic characteristics of the injury: type of injury, neurologic status, and condition of the ligament. For example, a simple compression fracture would be assigned one point. A burst compression fracture would get an additional point for a subtotal of two points. If the X-ray or other imaging studies show a rotation or translation of the segment, that’s another three points. Four points are added to the subtotal if the fracture has separated and the two ends of the fracture have moved apart.

    Values ranging from zero to three are given based on morphology (type of injury: compression, burst) neurologic status (spinal cord or nerve root involvement), and ligament integrity (intact, torn). The condition of thse soft tissues is important because they can create additional problems if not treated. For example, a distracted fracture with jagged edges increases the risk for nerve damage. A partially or fully torn ligament puts the patient at risk for instability.

    The authors provide a table with columns outlining each of the injury characteristics and points for easy assessment and calculation. The points are all totaled and the final value (indicating severity) guides treatment. Less than four points suggests a nonsurgical approach to treatment is possible. More than four points requires surgery. Patients with zero to four points fall in the middle: they could be candidates for surgical or nonsurgical treatment. In those middle-of-the-road patients, the surgeon must evaluate all factors before making the final treatment decision.

    To help surgeons see the value of the TLICS system, the authors made up another table comparing and contrasting the other commonly used classification schemes. They show who the author of each study was, how many patients it was tested on, and the main classification variables used (e.g., X-ray patterns, mechanism of injury, location of injury, clinical deformities present). A final column in the table describes treatment or prognostic value for each of the eight systems. They also provide several case examples to show surgeons how the TLICS system works.

    The ability to share data that can be compared from one study to another is another great advantage to the TLICS. But the authors warn this new classification system does have some limits in how it can be used. It is only intended to be used with adults who have traumatic injuries that lead to fractures. Fractures caused by tumors or infection or that occur without a known cause cannot be assessed using the TLICS system until the tool has been tested and validated on those types of injuries.

    In summary, the value of a single system that all surgeons can use to classify thoracolumbar spinal fractures is obvious. The Thoracolumbar Injury Classification and Severity Score (TLICS) will help surgeons share one system, use the same words to describe the injury, and come out with the same results predicting the optimal treatment approach.

    Affected Chromosomal Spot Located in Males with Familial Idiopathic Scoliosis

    Familial idiopathic scoliosis, curvature of the spine that runs in families, but occurs for no known reason, affects about two to three percent of children in the western hemisphere. Although more girls are affected with the more severe curves, they do occur in boys as well. As a result most of the research and treatment on treating moderate to severe idiopathic scoliosis has been on girls. When research focuses on one sex, the other sex may not be served well by the treatments because of specific differences and parameters.

    There has been a good bit of research into finding that genetics may play a role in children developing scoliosis. The the authors of this study wanted to look at a specific part of a chromosome, 17p, to see if they could find something that was related to scoliosis, using information from families where men had already undergone surgery for scoliosis correction.

    Researchers studied 1,198 individuals from 202 families, each family had at least two children who had been diagnosed with idiopathic scoliosis and 17 families had boys who had had surgery. The researchers took blood samples and extracted the DNA for examination.

    The results of the DNA analysis showed that there was a consistent spot on chromosome 17 among the boys in the study who had familial idiopathic scoliosis. Research like this shows promise because as scientists begin to better understand who is at risk for certain disorders, research can lead to identification of the high risk groups, better treatment, or even prevention.