News Category: General Spine

The United States leads the world in diagnostic technology yet for many patients, doctors can’t accurately diagnose their back pain. Relying on MRIs and/or surgery to help identify the problem isn’t working either. Half the patients with abnormal MRIs feel perfectly normal — no back pain at all. And for those with chronic back pain who have surgery the expected pain relief never comes. In fact, they may end up with worse pain than before. Why is that?

Well, diagnosis of back pain is complex and challenging. Studies done so far show that in many cases, there isn’t just one single pain generator. The discs, ligaments, muscles, bone, nerve roots, and even the coverings and linings of these structures can all turn on a pain signal. When more than one area is affected, the pain messages can overlap, creating back pain that may not respond to one single treatment technique.

What can physicians do to help sort out the causes of back pain and select the most effective treatment plan for each patient? Let’s go back to the issue of the diagnosis. MRIs may not answer the question of what’s really triggering pain messages but fluoroscopy-guided injections can.

Fluoroscopy is a type of real-time X-ray that allows the physician to see the location and pathway of the needle being used to inject the spine. Injecting the nerve, joint, disc, or other likely cause of the pain with a numbing and antiinflammatory agent helps confirm the diagnosis and treat the problem all at the same time.

Fluoroscopy has also made it possible to cut or heat the small sensory nerves that transmit pain signals in order to turn those signals off. The procedure is called a neurotomy. Other fluoroscopic-guided pain procedures include epidurals, adhesiolysis, nerve blocks, and intradiscal electrotherapy. These treatment methods all fall into a category called interventional pain procedures.

And there’s more! Sacroiliac injections, radiofrequency ablations (using radio waves to heat up and destroy tissue), vertebroplasty and kyphoplasty for vertebral compression fractures, and implantable therapies (electric stimulators inside the spine to override pain messages to the brain) are all examples of interventional pain procedures used to help alleviate chronic back pain.

You can see there are many possible surgical interventions to choose from. How does the surgeon decide? Right now, doctors are using available evidence from research studies that report the results of these procedures. A key factor in the process is choosing the right patient for the procedure. These same studies help determine who is (and who isn’t) a good candidate for one procedure over another.

The American Society of Interventional Pain Physicians (ASIPP) is assisting in determining treatment pathways for patients with chronic low back pain. They say that the best person to perform any of these specialized interventional pain procedures is a physician who has advanced training in the area of interventional pain treatment. Likewise, members of the ASIPP say these physicians are better able to conduct the necessary research needed to formulate treatment guidelines.

By reviewing currently available evidence, the ASIPP has published a summary of evidence-based guidelines for each of these interventional pain procedures. They systematically reviewed recent studies and offered their own ASIPP treatment guidelines for each of these therapies. Here’s a brief summary of what they offer:

When conducting any medical study, before and after results are used to measure the success of the treatment. Many times patients are asked to fill out surveys that measure their responses to treatment as the primary outcome or measure of results. A surprising thing has been noticed about back pain patients from before to after surgery. They have less pain and better function, but they rate their progress as worse than before treatment. They seem to see themselves as more disabled even though tests show they are stronger and more active. What’s going on here?

Social research scientists call this the response shift phenomena. The patient has adapted to the new level of ability and then his or her expectations change. It’s a bit like a moving goal post or using a shorter yardstick for measuring desired outcomes. Showing the benefit of treatment becomes a challenge because patients change their internal standards for how they view their pain or other symptoms. They may reassign importance of one symptom over another.

Take for example the patient with back and leg pain from degenerative disc disease who has surgery to remove the disc. After surgery, the leg pain is gone but the back pain is still there. Even though half the pain is gone, the patient rates pain-related disability as much worse than before surgery when there was back AND leg pain. This patient has had more than just one type of response-shift phenomena. Besides changing internal standards of pain, now he or she has reprioritized the relative value of pain severity. In other words, in the absence of leg pain, suddenly the same level of back pain is much worse and more disabling.

You can see how this could skew research results after treatment. The patient really got better as a result of the surgery. But self-reported ratings suggest treatment made the person worse. Measuring the value of the treatment is like trying to hit a moving target. What can researchers do to reflect the accurate benefit of treatment in patients who experience a shift in the meaning or impact that pain has had on their daily activities and function?

The first step was just recognizing this as an event that happens as patients adjust to a change in their health status. And when they took a look around, scientists discovered the response shift occurs in all medical research whether the health condition being studied is multiple sclerosis, diabetes, dental disorders, joint replacements, cancer, or back pain. The next step was to find ways to adjust for the response shift when analyzing data. Various models have been proposed over the past 10 years to help understand, explain, and measure this phenomenon.

Some scientists have taken a closer look at the factors that might influence how patients cope and adapt. These factors might change a patient’s frame of reference or the way quality of life is rated. How long the symptoms have been present might be a factor. Work status and level of income are two other possible factors affecting how and when patients shift in their perspectives about their health from before to after treatment. There may be personality traits involved. And it’s possible that even the type of treatment (e.g., exercise versus steroid injections) used affects how patients view their results.

Another group of scientists have evaluated the tests used to measure outcomes. Maybe there’s a better way to assign value or ratings to before and after results that incorporates or avoids the response shift phenomena. Scales used to measure pain are always subjective (patient opinion). Tests like the Oswestry Disability Index (ODI) commonly used to measure results don’t reflect when change is clinically significant. There are no normal standards for the ODI based on age or gender. This is a limitation of the test that should be noted.

The authors of this article suggest that spine researchers take a closer look at measuring outcomes — maybe even come up with a better way to evaluate pain that changes because of the response shift phenomena. Or perhaps re-evaluate other measures currently available (e.g., the Pain Impact Short-Form) to see if the response shift affects the ability of this tool to measure outcomes.

At the same time, there is a need to look at different types of patients and compare their response shifts. For example, Worker’s Compensation patients may have a very different response shift compared with non-Worker’s Comp patients. Or looking back at the example of the patient who had back and leg pain who rated results worse even though overall pain was improved. It’s possible that patients who have a partial cure like this are more likely to develop response shifts. It’s possible that data only has to be adjusted for the response shift phenomena in some (not all) patients. The patient who has a total cure (all symptoms gone completely) may rate their results very differently than those who get a partial recovery.

In summary, as a result of discovering that the response shift phenomena exist, response shift researchers are now looking for ways to detect this effect. They are considering all of the variables and factors discussed in this article. The goal is to find a reliable and sensitive way to measure response shift. Hopefully one tool can be developed that could be used with all patients regardless of diagnosis, age, gender, or treatment. That’s a pretty tall order. It’s more likely different detection methods will be discovered and/or developed that can be applied appropriately for each patient group.

Technology is changing the world and medicine is no different. As new applications are discovered and refined, they are finding their ways into medical and surgical treatments, making the treatments more reliable and with more favorable outcomes. The authors of this study wanted to see how image-guided spinal navigation with a computed tomography scanner (CT scan) could improve the safety and accuracy of spinal stabilization surgery.

To do the study, researchers looked at the data of 94 patients who had undergone surgery to stabilize the mid to lower part of the back (thoracolumbar) or the upper part (cervicothoracic). All patients had the surgery done along with computed tomography so the surgeons could have images of the spine, even after the screws were inserted.

The results of the study showed that adding CT scans to the surgery procedure added an average of 14 minutes to the length of time it took. Among the 94 surgeries, there were 216 scans. One hundred were done before the surgery and 116 during the surgery. This works out to 70 patients had two scans, 20 patients had three scans, and four patients had four scans.

The scans did show 20 screws, out of a total of 414 among all patients, were off by about 2 millimeters in placement. In 65 screws, there was a bit of perforation of less than 2 mm. In four cases, it was 2 mm or more.

For eight patients, the CT scan images affected how the surgery proceeded, with the surgeon correcting 10 of the screws right away. In some surgeries, where there were tumors, the CT scan was used to see if the tumor tissue had been removed successfully.

Repeat surgeries was at an 8.5 percent rate (four wound infections, two fistulas (tunnels in the tissue), and two epidural hematomas (collection of blood in the epidural space of the spine). The stabilization surgery was not the first one for two of the patients who had wound infections. A third patient with infection was an insulin-dependent diabetic. None of the repeat surgeries had to be done because of the screws.

Two patients experienced passing neurologic (nerve) complications within three months of the surgery.

The researchers also looked at 182 patients (781 screws) who had similar surgery done without CT scans in surgery. The results of those surgeries showed that 10.4 percent had to have repeat surgeries, with 4.4 percent needing the screws to be moved because they were not in the proper place. The average amount of time between the original surgery and the revision surgery was 52.6 days, although the days ranged from one day after surgery to 225 days after.

The authors concluded that the navigation available through CT scans is easy and rapid to perform, and results in good outcomes for patients undergoing spinal stabilization surgery. The scans do not interfere with the operating time and can be installed into an operating room without special equipment.

Improvements in technology continue to change the way medicine is practiced. In this study from Japan, physicians used ultrasound instead of X-rays to guide a needle in performing a nerve block. The procedure was effective for 75 of the 78 patients in the study. And the method proved to be safe as no one felt pain during the procedure or had any negative effects from the treatment.

Switching from using X-rays to ultrasound when doing nerve blocks is possible now that today’s ultrasound machines produce high quality images. And the devices are small enough to be portable making the procedure available in a clinic rather than in the radiology department. Best of all, both patients and medical staff are no longer exposed to so much radiation from the previously used X-ray technique.

Nerve blocks are used for patients with chronic pain. In this study, the patients had a L5 radicular syndrome. L5 is the fifth lumbar segment of the lumbar spine (low back). Radicular tells us that the spinal nerve root that exits from the spinal cord at that level is compressed or irritated. This compromise of the nerve tissue sends pain from the back into the buttock and possibly down the leg.

The cause of the syndrome can be from a herniated disc, spinal stenosis, or spondylolisthesis. Most people know what a herniated disc is but spinal stenosis and spondylolisthesis may not be as familiar. Stenosis refers to a narrowing of the spinal canal where the spinal cord is located. Spondylolisthesis is the slippage of a vertebral body forward over the segment below it. This change in the spinal alignment can put a traction (pulling) or compressive (pinching) force on the spinal cord in the spinal canal and/or spinal nerve roots as they leave the spinal canal.

Pain messages are sent when there is pressure on the nerve tissue from any of these conditions. Applying electrical stimulation to the nerve identifies correct placement of the needle used to inject a numbing agent to stop pain signals from traveling up the spinal cord to the brain. The patient feels a tapping sensation that is not painful when the probe delivers an electrical stimulus around the nerve root. The probe is slowly pushed through the skin and soft tissues entering the spine near the L5 nerve root. At the same time, the multibeam ultrasound unit transmits pictures to a TV or computer monitor to guide the physician’s forward advancement of the probe to the correct spot.

By using this ultrasound technique, the patient is spared the intense pain that accompanies the X-ray guided technique. With the X-ray technique, a dye is injected into the nerve (under the outer layer of the nerve) to help identify the exact location of the nerve and placement of the numbing agent. When the nerve is injected with the dye, the nerve endings register pain that is intense. Using an electrical probe eliminates the need to touch the nerve. The researchers also found that placing the injected numbing agent around the nerve root and not directly into it works quite well and is more comfortable for the patient.

The authors provide photos of the ultrasound-guided lumbar nerve block to give the reader an idea of what the patient set up looks like (patient position, location of probe/needle entry into the spine). There are also photos of the ultrasound images with labels to help viewers see what the surgeon sees.

Since L5 nerve root blocks are fairly common, replacing X-ray-guided methods with ultrasound and electrical nerve stimulation is a major breakthrough in pain management. The location of the L5 nerve deep in the spine has made it difficult to reach the nerve root in order to treat this syndrome. Injection without damaging other nearby soft tissues or puncturing the targeted nerve is a positive outcome of the ultrasound-guided technique.

Despite the many advantages of the ultrasound method, the author noted there were three patients who did not respond to the treatment. There was an anatomical reason for these treatment failures. These patients had a larger than average transverse process (a bony protuberance out to the side of the vertebral body). The size of the process made it impossible to get a needle into the proper area to numb the nerve.

Although ultrasound-guided nerve blocks do not utilize X-rays, the use of X-rays is not completely eliminated with nerve block procedures. Fluoroscopy (real-time, 3-D X-rays) is still required as a pre-scan before ultrasound-guided injection. The surgeon uses these X-rays to look for any anatomical variations in form or structure of the spine that could prevent accurate probe/needle placement. And the X-rays help the surgeon find the best spot for probe/needle advancement and placement.

Not everyone will qualify for the ultrasound-guided technique. Besides not finding a clear pathway to the nerve eliminating potential patients, obesity and osteoporosis (brittle bones) may also exclude some patients from benefiting from this treatment approach. But for the majority of patients who need a nerve block for lumbar radiculopathy, ultrasound-guided techniques may very well replace X-ray guided methods that are currently in use.

Surgeons removing synovial cysts from the spine have noticed some interesting things about these structures. Sometimes they are located quite a bit away from the joint they originate from. Sometimes they are on both sides of the joint. Sometimes they contain bits of joint cartilage, scar tissue, and even fragments of bone. These unusual findings led the researchers who wrote this article to study these cysts more closely and report on what they are made of and how they are formed.

A synovial cyst is a mass linked with a joint. It is formed when leakage of synovial fluid from inside the joint forms a gel-filled pouch lined withepithelial cells or cells that are epithelial-like. Epithelial cells are special cells that line cells the cavities and surfaces of structures throughout the body, including cysts. In the case of these cysts, there is a channel connecting joint to cyst. The channel may be long enough that the cyst isn’t even next to the joint.

The cysts studied by these researchers were located within a spinal ligament called the ligamentum flavum. Because this ligament stretches the length of the spine and is located along the inside of the spinal canal, any thickening of the ligament can put pressure on the spinal cord inside the spinal canal. Cysts such as these synovial cysts when embedded within the ligamentum flavum contribute to a painful condition called spinal stenosis. Stenosis is a narrowing of the spinal canal.

Specimens removed from 27 patients were microscopically examined in the lab to determine structure and biologic makeup. These sections were compared with similar tissue samples taken from cadavers (bodies preserved for study after death). None of the cadavers had any evidence of spinal stenosis, so could be considered normal from that perspective and therefore function as the control or comparison group. The authors were particularly interested in finding out if the breach in joint integrity leading to fluid leaking and cyst formation could contribute to the development of joint osteoarthritis. Spinal joints are referred to as facet joints.

The cysts could be divided into four different types based on form and structure. Some did not have a lining and were very inflexible (lacking elasticity). Those that with a lining varied from having a very thin to a very thick lining made of synovial cells. Some of the cysts had walls that had calcified or hardened. Others had new formation of tissue with a good blood supply that turned clots into fibrous scar tissue.

In about three-fourths of the cysts (75 per cent), a channel formed between the cyst and the joint supplying the cyst with fluid from the joint. As a result of this direct connection, a large percentage of those cysts (89 per cent) had bone and cartilage debris from the osteoarthritic process embedded in the cyst wall. Some of the cysts were pressed up against osteophytes (bone spurs) that had formed around the joints. The cysts were filled with blood and scar tissue and surrounded by a layer of additional scar tissue. Some of the cysts did not have a connecting channel with the joint.

In addition to examination of the cysts, the joints were also X-rayed and classified using the Kellgren and Lawrence grading system for osteoarthritis. For the cadavers without cysts, the same grading system was applied to the facet joints for comparison. X-rays were also used to view alignment of the vertebral bones because it is suspected that one of the major causes of synovial cysts in the spine is degenerative spondylolisthesis.

Spondylolisthesis is the forward slippage of one vertebral body over the one below it. As the vertebra moves forward, the spinal canal narrows. Anything that narrows the spinal canal can cause pinching (impingement) or compression of soft tissue structures such as the spinal cord and spinal nerve roots. The shift in the bodies of the vertebral bones also changes the normal alignment of the spinal (facet) joints. Any change in joint alignment can contribute to uneven wear and tear and the eventual formation of bone spurs, disruption of the joint integrity, and escape of joint fluids leading to cyst formation. So you can see, one thing leads to another and another and another.

Treatment for synovial cysts causing spinal stenosis is often surgical with a procedure called decompression. The surgeon removes any structures compressing the neural tissue. If the spondylolisthesis is severe enough, it may be necessary to fuse the spine to keep it from slipping further.

You may be wondering, what about the cadaver control group? What did they find there? Well, there were no cysts and no stenosis. Some of the cadavers did have severe facet joint arthritis. There were similar communicating channels present even when no cysts were present leading the authors to suspect these channels are normally present and serve some function. Clearly, they are used to form cysts when arthritic changes in the joints results in synovial leakage and subsequent cyst formation.

It appears that the risk of synovial cysts in the ligamentum flavum is greatest in the lower lumbar spine where the arthritic changes are the most severe. It is here that debris collects and blocks the channels. Arthritic changes seem to be the first step in the formation of these cysts. The new discovery of communicating channels from this study helps explain how these cysts can develop some distance away from the joints. For now, these channels are being called intraligamentous bursa-like synovial channels. Future studies may help identify their purpose in the normal anatomical spine structures. For now, they help explain the formation of the cysts under investigation here.

So, you or someone you know is planning on having a spinal fusion. Lots of thoughts go through your mind as you prepare for the big day. Meanwhile, your surgeon is also giving the procedure some preplanning and preparation. Everything that can be done to minimize infection or other postoperative problems is considered. The surgeon will choose what type of bone graft material to use. Bone chips placed alongside and between the vertebral bodies help jump start the healing process and successful fusion.

By now you may be wondering what type of bone graft materials are there to choose from? Which one will you be getting? The two basic bone grafts are either autografts (harvested from the patient) or allografts (obtained from a donor bank). The allografts may be irradiated as part of the sterilization process since they come from someone else. Allografts can also be nonirradiated. That leave three choices: autografts, irradiated allografts, and nonirradiated allografts.

Each type of grafting material has its own advantages and disadvantages. Autografts are often considered the best choice or the gold standard. Using your own bone means there won’t be any issues with tissue rejection. And since it’s live bone when it’s harvested, it helps stimulate new bone growth at the surgical site much faster and more efficiently than allografts. The major disadvantage of autografts is persistent and sometimes disabling pain at the donor site. A minor inconvenience is the extra time during surgery to collect the bone from some other site. Autografts for spinal fusion usually come from bone removed from the spine (e.g., laminae or spinous process) or from the crest of the pelvic bone.

Allografts on the other hand create no donor site problems, but fusion takes longer and there is a risk of transferring an infection from the donor tissue to the recipient. That’s why donors are screened very carefully before being accepted and the donor tissue is sterilized with gamma irradiation techniques. Advantages of allografts include shorter surgical time, availability of preformed shapes and sizes of donor tissue, and as mentioned, there’s no pain from bone collection.

But what about infection? Is the risk of postoperative infection any greater with one type of graft over another? That’s the main question surgeons from the Mayo Clinic in Rochester, Minnesota addressed with this study. In fact, they say this is the first study to even look at the risk of infection based on graft type. Over 1,000 patients were included (1,435 to be exact). They all had a spinal fusion with one of the three graft types. Most had the autograft (850) but there were 144 who received an irradiated allograft and 441 with nonirradiated allograft.

Infection in the early days, weeks, and months after spinal fusion with bone grafting isn’t just an isolated problem. With it can come osteomyelitis (infection enters the bone), failure of getting a solid fusion, and pseudoarthrosis (movement at the fusion site). And graft type is only one potential risk factor. Patient age (older than 60 years old), tobacco use, diabetes, obesity, and alcohol abuse also increase the risk of infection. Length of surgery and surgical technique can also add to the risk of infection postoperatively.

When all the data was collected and analyzed for this large group of patients, there was NO difference in postoperative infection rates based on type of bone graft used. That means the surgeon can choose the type of bone graft based on the patient’s needs, availability of autograft versus allograft, and what’s needed for the particular surgical procedure planned. Patients were followed for at least one full year after surgery. The overall infection rate for all three types of grafts was only five per cent. Most of the infections that did occur developed within the first 60 days.

The authors suggest other areas in need of investigation include whether irradiation affects fusion (not infection) rates and whether type of graft used affects fusion rates. This one study does not prove conclusively that infection is never linked with the type of bone graft material. There may be risk factors or other predictive factors associated with graft type that increases the likelihood of postoperative infection. There is plenty of room for further study of this matter.

Even simple spinal surgeries can result in serious problems when infection occurs. Despite sterile techniques, any open incision leaves the patient at increased risk of wound infection. The use of minimally invasive spinal surgery (MISS) may be changing the picture.

In this study, surgeons found that the rate of postoperative surgical site infections (SSI) was significantly less with minimally invasive spinal surgery (MISS) compared with the more traditional open approach. In fact, out of the 1,338 minimally invasive spinal surgeries (MISS) in this study, there was a less than one per cent chance of SSI — that’s 10 times less than for open incision procedures. In dollars and cents, the reduced hospital time, decreased use of antibiotics, and avoidance of further surgery can amount to a drastic savings in health care costs.

The average age of the patients in this study was 55 years old. Patients ranged in age from 18 to 97 years old. Most of them had low back pain from degenerative spine disease (e.g., spinal stenosis, degenerative disc disease, arthritis). The most common procedure performed was a simple spinal decompression. In this operation, the surgeon removes part of the vertebral bone called the lamina. By cutting some of the bone out, pressure is removed from the spinal cord or spinal nerve roots. Other surgeries performed included spinal fusion, tumor removal, and shunt insertions. A shunt is a thin, plastic tube used to drain excess cerebrospinal fluid (CSF) from around the brain and/or spinal cord.

For this study, MISS was defined as any spinal surgery done using a tubular retractor type system. A very tiny incision is made in the skin. A special tubular instrument is inserted through the incision down to the bone. Surgical tools are then passed through the tube down to the surgical site. A tiny TV camera on the end of the system allows the surgeon to see the area.

The few infections that occurred were the result of either strep or staph bacteria. Patients presented with skin changes, fever, back pain, or urinary tract infection. All were treated successfully with antibiotics. Even though all patients are given antibiotics to prevent these kinds of problems, SSIs after spine surgery do occur. Known patient risk factors for SSIs include diabetes, incontinence, and obesity. Risk factors related to the surgery include posterior approach and poor timing or inappropriate dosing of the preoperative antibiotics.

The authors propose four reasons why MISS results in such improved infection rates: 1) decreased exposure of deep tissues, 2) the surgical tube blocks transport of bacteria, 3) small incisions close up and heal faster than large incisions that can pull apart more easily and 4) smaller incisions means less chance of wound drainage or blood pooling where infection can form.

In summary, the combination of sterile technique, preoperative antibiotics, and MISS has reduced the rate of postoperative infection linked with spinal surgery. Rates in this study were compared with rates reported in other published studies. There is a need for further research to verify these findings.

Surgical fusion of the spine for degenerative disease is becoming a popular way to treat this problem. And that’s because surgeons now have at their disposal better ways to perform the surgery and improved hardware such as pedicle screws and locking plates to hold the bones together. Even so, there is a major concern about the number of failed spinal fusions requiring revision (a second) surgery.

In this review article, orthopedic spine surgeons from George Washington University Medical School bring us up-to-date on the problem of pseudarthrosis after spinal fusion. Pseudarthrosis means false joint and refers to movement that occurs at the fused site. It can occur without symptoms so the patient doesn’t even know he or she has it. Or it can cause back and leg (or arm) pain, depending on whether the fusion is at the cervical (neck) or lumbar (low back) level.

There can be other causes of failed spinal fusion such as the hardware coming loose or infection and poor wound healing, but pseudarthrosis accounts for almost one-fourth of all revision fusion surgeries. To help us understand why this happens, the authors present the many possible risk factors, and then walk us through the diagnosis and follow-up treatment.

So, who’s at risk for pseudarthrosis? Smokers and patients who do not follow the guidelines for movement restriction during the post-operative period are at the greatest risk of failed fusion. But anyone who has reduced blood supply or metabolic disorders such as heart disease or diabetes can also experience delayed wound healing or infections that can leave patients with lower fusion rates.

How does the physician diagnose pseudarthrosis? It can be discovered in the patient who doesn’t have any real symptoms when dynamic imaging studies are done. Dynamic means the X-rays are taken as the patient is moving. But this method isn’t very reliable and wouldn’t be done routinely after surgery if the patient wasn’t having any problems.

When it comes to diagnostic imaging, there just isn’t a good way to tell if the fusion failed. When reading dynamic radiographs, the radiologist knows that just because there isn’t any obvious motion doesn’t mean the fusion is complete. And just how much motion constitutes a failed fusion remains fuzzy. There’s a lot of debate about what is and what isn’t a solid fusion. Some experts think there’s a difference in springiness between a fusion with and without hardware to hold it together during the healing phase.

Thin-slice CT scans have been used to assess the fusion site. But the results don’t really add anything more than what is seen on the X-rays. The one exception to this is in the case of locked pseudoarthrosis. Thin-cut CT scans help show this problem more clearly than dynamic radiographs. Locked pseudoarthrosis describes a situation in which the top and bottom of the cage inserted between the two vertebrae has fused solid but the middle (inside the cage) has not filled in with bone and solidified.

MRIs can be a bit iffy in patients with hardware in place because the implants cause artifacts (unexplained shadows and altered densities). Those changes interfere in judging whether or not the fusion is completed. There has been some question about the use of ultrasound and bone scans to help diagnose pseudarthrosis. Not enough study has been done to clear up any questions about these modalities. When imaging studies do not aid in the diagnosis, the surgeon can rely on a follow-up surgical procedure to confirm any diagnostic suspicions. Only patients with painful, disabling symptoms would undergo a second (diagnostic) procedure.

Once the diagnosis has been made, what is the treatment for pseudarthrosis? What can the surgeon do for this problem? Some of the decision depends on how the first fusion was done and the location (neck or low back). If there are no symptoms, then it might warrant a wait-and-see approach. But for the patient with painful symptoms, if no graft was used in the first procedure, the surgeon may choose to take bone from a donor bank or from the patient and place it around the fusion site. There are advantages and disadvantages for each choice.

Allograft (donor bone from a bank) is dead and doesn’t produce new bone. It just gives a scaffold or place for the patient’s body to fill in with bone produced during the healing phase. That’s the down side. The up side is that there are no problems at the donor site with pain, infection, or poor wound healing. Autograft (bone taken from the patient) are still alive and capable of producing more bone cells. That’s a benefit as the body fills in the fusion site faster. But then there’s the risk of donor site morbidity (problems) as described.

If bone graft was used (and failed) in the first surgery, then metal plating or a device called a cage may be used. Plating anteriorly (from the front of the neck) is usually advised when there are multiple levels being fused. Cages have been made of titanium for the most part. But newer implants made of plastic or porous tantalum are being tried in hopes that fusion rates can be improved with better bone in-growth.

For both the cervical and lumbar spine, human bone morphogenetic protein (rhBMP-2) has been tried with mixed results. Its use is still in the experimental phase. There hasn’t been much published yet on results of this technique. And research is ongoing in an attempt to find bone graft substitutes. Products commercially available that have been approved for use are showing some improved results in early studies but there are reported side effects with cervical fusion (e.g., neck swelling, difficulty swallowing) that have raised some concern.

Finally, how well does it work to try a different approach when treating failed fusions? Studies show that fusion is almost always possible but symptoms don’t always change as a result. Risk factors, psychologic issues, and type of graft enter into the mix and affect the outcomes. Risk factors for revision spinal fusion are similar to first-fusion procedures but also include worker’s compensation status, active lawsuits, use of narcotics before surgery, and neurologic problems present before surgery.

There isn’t a one-size-fits-all method of recovery after a failed first fusion. Each patient is evaluated on an individual basis. Surgeon preferences and experience can also make a difference in choosing type of revision surgery performed. The bottom line is: if the revision surgery is successful, the outcome is better than if the person remained unfused.

Medical doctors rely on evidence from scientific studies to help guide their treatment decisions. Without evidence, they fall back on consensus-based best practice. That means they do what they have seen works well and what others have reported based on surveys and questionnaires. Sometimes there’s a gap between what the evidence shows and what the current practice is. As this study shows, that’s what may be happening for patients undergoing spinal surgery who have osteoporosis.

Osteoporosis means the bones are less dense than normal. They have less bone mass than they should. That makes them fragile and can put them at risk for fragility fractures. A fragility fracture means the bone breaks without a traumatic event or unexpected force. Just the stress of movement and everyday activities causes the bone to break.

For the surgeon who is performing spinal fusion or fracture care for someone with metabolic bone disorders like osteoporosis, osteoporosis can lead to failure of the procedure. It would be a good idea to find out before performing spinal surgery if a patient is osteoporotic or has osteomalacia. Osteomalacia refers to a softening of the bones from a mineral deficiency (often a lack of Vitamin D).

Pre-operative osteoporosis screening can be done by ordering several tests. One is the dual-energy X-ray absorptiometry (DEXA or DXA scan). This test is a reliable way to gauge bone density by scanning the bone and determining mineral content. Measurements can be taken from the wrist or heel with a portable scanning device. For a more complete and accurate bone assessment, a scan of the hip and spine can be done. Those two areas tend to lose bone mass more rapidly than the peripheral areas of wrist or heel. Blood can also be drawn and tested for vitamin D levels, parathyroid hormone, and calcium (all important ingredients for strong bones).

To document spine surgeons’ practices in this area, a survey was conducted of spine surgeons attending a special spinal disorders conference in Canada. Surgeons completed a 10-question survey asking about their treatment practices when it comes to treating patients with fragility fractures of the spine. The survey was designed to find out how often and when surgeons perform routine osteoporosis/osteomalacia screening assessments of these patients.

They were asked if they routinely order a DEXA scan before doing a spinal fusion on someone who might have osteoporosis. They were asked if they routinely order blood work to check vitamin D, parathyroid hormone, and calcium levels on anyone at risk for osteoporosis. They were also asked if they refer patients to other specialists for an osteoporosis workup. Participating surgeons were asked to explain their policies and/or give reasons why they did not incorporate these screening tools in their routine practice.

About 30 per cent of the surgeons were neurosurgeons with advanced training. The remaining 70 per cent were orthopedic surgeons who had completed a spine fellowship. Everyone worked in a private practice or academic setting with the majority (68%) in private practice. The level of experience varied from less than five years in practice (about one-third of the group) to more than 15 years of experience (one-third of the group). The remaining surgeons had between five and 15 years of experience.

An analysis of the data collected showed that DEXA scans were ordered most often for patients with vertebral compression fractures or for odontoid fractures. The odontoid is a pillar of bone that’s part of the second cervical vertebrae. The odontoid fits up inside the first cervical vertebra from below. The first cervical vertebra is a circular ring of bone that fits over the odontoid like a collar. Surgeons were much less likely to order any blood work for these patients. Level of expertise and training didn’t seem to dictate who ordered DEXA scans.

Similar results were reported for surgeons treating patients with spinal fusion. DEXA scans were more likely to be ordered when the surgeon was planning to use metal plates, screws, rods, or other hardware to hold the spine together. But again, the use of metabolic bone markers such as vitamin D, parathyroid hormone, or calcium was not relied upon. It didn’t matter if it was a neurosurgeon, orthopedic surgeon, someone in private practice, or in an academic program — those lab values were not routinely ordered. The reasons for this varied from unfamiliarity with what the test results mean to the belief that there wouldn’t be any change in treatment, so there’s no need to order extra tests.

For patients with pseudoarthrosis after spinal fusion, the use of DEXA scans and lab values for metabolic bone markers was slightly more. Pseudoarthrosis refers to patients who still have some movement at the fusion site after healing is complete. Neurosurgeons and all surgeons with more experience were more likely to rely on bone laboratory tests for this patient population group. The surgeons completing the survey said they would refer patients with osteoporosis for specialty care before surgery when instrumentation was going to be used.

The results of this study confirm that osteoporosis is an undertreated condition in many older adults who have already had at least one orthopedic episode involving the spine. Not ordering blood tests to evaluate blood levels of metabolic lab markers is not in keeping with current evidence that says bone strength is directly linked to vitamin D levels. Fractures are more likely to occur in people with low vitamin D. Supplementation can improve bone density especially during fracture healing when new bone must be put down to heal the old.

The information in this study should be viewed in light of the fact that other studies also show that when tested, more and more younger adults (50 to 70 years old) are also osteoporotic heading into spinal surgery. Since bone quality is an important factor in healing after spinal fusion, pre-operative testing for osteoporosis is advised for anyone at risk for this disease.

Treatment for osteoporosis may not change the immediate problem of a fragility fracture but it can benefit future health concerns. Surgeons may change the type and location of instrumentation used when screws or other hardware are needed. This change in surgical technique could help prevent loosening, nonunion of the fracture, and loss of deformity correction.

The authors conclude that there is a need for better education of surgeons regarding osteoporosis screening when treating elderly patients who need care for spinal fractures or who are undergoing spinal fusion for some other reason. Routine screening is advised when there has been a fragility fracture and when patients are at risk for osteoporosis. There is already some movement toward government regulation by the Center for Medicare and Medicaid Services to set quality standards for the preoperative screening, assessment, and treatment of osteoporosis in patients undergoing spinal fusion and who have pseudoarthrosis or fragility fractures.

It’s time. It’s been 20 years since surgeons started using vertebroplasty (VP) to treat vertebral compression fractures and 10 years since kyphoplasty (KP) was developed. It’s time to take a look back and see how well these treatments are working. In this article, researchers from The Johns Hopkins Department of Neurosurgery review all the published articles on VP and KP. They summarize the level evidence (fair to good) for both of these minimally invasive procedures.

Patients with osteoporosis, spinal tumors, or trauma can develop compression fractures in the spine bones, or vertebrae. The front of a vertebra cracks under pressure, causing it to collapse in height. These fractures often cause poor back posture, debilitating pain, and difficulty completing routine activities. Vertebroplasty restores the strength of the fractured bone, thereby reducing pain. More than 80 percent of patients get immediate relief of pain with this procedure.

A vertebroplasty is done by making a small incision in the skin on each side of the spinal column. A long needle is inserted through each opening. The surgeon slides the needles through the back of the spinal column into the fractured vertebral body.

A fluoroscope is used to guide the needles. This is a special X-ray television camera adjusted above the patient’s back that lets the surgeon see the patient’s spine on a screen. Metal objects show up clearly on X-rays. The needles are easy for the surgeon to see on the fluoroscope screen. This helps the surgeon confirm that the needles reach the correct spot.

Once the needle is in place, special acrylic bone cement is injected through the needle into the fractured vertebra. A chemical reaction in the cement causes it to harden in about 15 minutes. This fixes the bone so it can heal. Bandages are placed over the small openings where the needles were inserted.

A kyphoplasty is done with the same minimally invasive technique. But instead of a needle injecting cement into the bone, a hollow tube with a deflated balloon on the end is slid into holes drilled in the vertebrae. The balloons are inflated with air. This restores the height of the vertebral body and corrects the kyphosis (hunchback) deformity that can occur with vertebral compression fractures. Then surgeon removes the balloon and injects bone cement into the hollow space formed by the balloon. Once the cement hardens, the bone is held in its corrected height and position.

These procedures provide rapid pain relief, but is the final outcome of treatment any different or better than standard medical care? Can the cost of these procedures be justified? That’s what these authors tried to find out by doing a systematic review of all available literature. They looked at the treatment of vertebral compression fractures for three separate conditions: osteoporosis, trauma, and tumors.

They found that in the short-term (within the first two weeks to three months) patients experienced significant improvement in pain, mobility, and quality of life. No wonder because they could stand up, sleep, sit, get dressed, go shopping, take a bath and participate in their usual activities once again. But when compared with standard medical care, the results weren’t any different in the long-run (two years later).

Looking at the comparisons a little closer, there were some other benefits of VP and KP. Patients could use less pain medication, their general health improved in the first three months, and there were very few complications with the treatment. Patients with tumor-related compression fractures did not respond as well as patients with osteoporosis or trauma-induced fractures.

Vertebral compression fractures are painful enough that many people in the studies crossed over from standard medical care to the surgical procedure despite being assigned to the standard care group as part of the study. Seeing immediate pain relief and greater improvement in physical functioning in other patients after only 24 hours was the reason some patients insisted on crossing over.

Given those results, telling patients that standard care will have the same results as VP or KP in 12 to 24 months loses some of its punch. Although the evidence isn’t always consistently high-level, the results of this systematic review support the use of VP and KP. Rapid pain relief, earlier mobilization, fewer and shorter hospitalizations all add up to improved care at a reduced cost.

The authors suggest further study is needed now. First, to confirm with a high-level of evidence (not just fair-to-good evidence) the positive findings so far. Second, to evaluate the risk of treatment failure over time. For example, are patients able to maintain the restored vertebral height? Is there a transfer of load to adjacent levels that causes problems above or below the fractured level?

Since almost one million vertebral compression fractures occur every year in the United States, better, faster treatment would be appreciated by everyone affected. The fact that many spine surgeons are now using minimally invasive procedures such as VP and KP also means more studies are already being published each year to show the benefits of this management approach.

For over 30 years now, doctors have used spinal cord stimulation (SCS), also called neurostimulation, to help relieve chronic neuropathic (nerve) pain. A stimulator is implanted into the patient’s body, which then sends out impulses to interrupt the pain signals and prevent them from reaching the brain.

The treatment doesn’t eliminate pain. The electrical impulses from the stimulator override the pain messages so the person doesn’t feel the pain so acutely or so intensely. In essence, the stimulator masks the pain. SCS is generally only used if nothing else in treatment seems to be working. It must be done on a trial basis first before the stimulator is permanently implanted.

The success of this treatment has increased its use for chronic pain patients in the United States and Canada. But before we go too far with this treatment tool, it’s important to look at the total cost (not just the initial implantation cost). Third party payers such as private insurance, Blue Cross/Blue Shield (health maintenance plan), and Medicare have asked physicians to show that the benefit of this treatment is worth the cost.

That’s a reasonable request considering the basic cost of the unit and implantation ranges from $21,595 to $57,800 (depending on who is paying for it). That figure does include the preoperative evaluation and the trial before permanent implantation. But what this study shows for the first time are the added costs of maintenance, upkeep, and complications.

The cost of uncomplicated annual care to maintain the system starts at $3500 in Canada, goes to $5000 under Medicare, and tops at $7277 for Blue Cross/Blue Shield patients. Each time a new patient receives a spinal cord stimulator, the total cost for actively managed patients is increased.

The annual maintenance costs cover things like hardware, professional fees (doctors, nurses), X-rays or other advanced imaging studies, pulse generator replacement, and any costs associated with hospitalization for complications. That doesn’t include the cost of medications used for drug therapy. Different complications have different average costs associated with them. Obviously replacing the batteries is much less costly than a hospitalization for infection or implant failure.

These costs do not reflect out-of-pocket money spent by patients pursuing this type of treatment. Since spinal cord stimulation is not readily available at every hospital, it is necessary for some patients to travel far distances to benefit from this specialized pain control. Travel costs, lodging, and meals are not included in these figures.

The are some things that can be done to bring the costs down. One is to develop a rechargeable system that lasts for more than a few years. Some companies manufacturing these devices are already promising a battery life of 10 to 25 years. The second is to recognize that different manufacturers charge different selling prices to different geographical markets. And the third is to study which models function without breaking down and use those instead of poorly designed, short-lasting units.

The authors present a formula that can be used when first calculating the cost of a spinal cord implant. A second equation calculates the add-on costs of annual maintenance and complications. It turns out that the added costs amount to about 18 per cent of the initial implantation cost. Health care centers can use this information when planning budgets and cost-versus-benefit ratios.

Have you ever heard of therapeutic proteins? You probably have without knowing it because insulin is a therapeutic protein. People who are missing important proteins like insulin develop problems like diabetes. They can be treated with exogenous (coming from outside the person’s own body) proteins such as insulin made from animal (or human) sources.

Another example of therapeutic proteins are bone morphogenetic proteins (BMPs) used in spinal fusions. BMPs as a bone graft substitute are a fairly new development. Unlike the diabetic who doesn’t have enough insulin, the bone-making proteins aren’t deficient in adults who have one or more spinal segments fused. In other words, it’s not that the body isn’t making its own bone cells. But rather, in the case of spinal fusion (or bone fracture), the patient needs extra bone-generating proteins to speed up regeneration and repair.

Scientists have developed something called recombinant human bone morphogenetic proteins (rhBMPs). They have used modern DNA technology to create highly purified protein products to enhance spinal fusion and fracture healing.

That all sounds great, so what’s the problem? Just one word: immunogenicity. That’s the body’s immune (allergic) response to anything introduced exogenously (outside the body). The natural response is for the immune system to mount a defense against what it sees as a foreign invader. It creates antibodies to fight against rhBMPs. So the challenge is to find a way to create an rhBMP that does not create an allergic reaction.

The use of rhBMP is still in its experimental or investigational phase. It’s not routinely used yet because no one knows for sure if the body really does mount a defense against locally administered proteins. And if it does, what effect does it have? We say locally administered because the bone protein is placed in the spine at the time of the fusion — not given systemically by pill or intravenously into the bloodstream.

The next dilemma is finding ways to measure the immune reaction. Right now, we have a blood test (called bioassay) to show antibodies in the blood. But we don’t have a reference standard — a consistent way to measure what is normal from study to study.

Studies so far on the immunogenicity (strong immune reaction) to rhBMP have been done mostly in animals. Results of the first studies in humans were published in the early 21st century (year: 2000). Blood tests from those studies did not shown antibodies to a specific therapeutic bone-producing protein (rhBMP-2) made from cows and used in spinal fusions.

Later studies did report a very low number of cases in which antibody formation against rhBMP-2 occurred, but there were no apparent adverse effects or any change in clinical outcomes as a result of those antibodies. In other words, the fusion didn’t fail because of rejection of the bone. The next step was to compare the responses and results using different amounts of rh-BMP-2. Assays for antibodies showed only a small number of patients developed antibodies and no one had any signs of an allergic response.

The lack of immunogenicity of rhBMP is encouraging. The hope is that these therapeutic proteins can be used instead of bone taken from some other part of the patient’s body. Using your own bone from one place in the body to help create new bone in another part of the body is called autogenous transplantation. It works well but often leaves the patient with problems at the donor site. Using bone-stimulating protein like rhBMP could make it possible to speed up bone healing with no adverse side effects.

Right now, the focus is on improving the assay testing so that it is sensitive enough to screen for antibodies and give the same results no matter who uses the test. This would make it possible to compare studies done in one lab with other similar studies elsewhere. And long-term results are needed.

Just because antibody production is not evident at first, doesn’t mean there couldn’t be delayed reactions much later. The belief is that bone formation fostered by rhBMP occurs rapidly with new bone developing long before antibodies develop. So when and if antibodies are formed, there’s nothing for them to do. They just circulate in the blood and remain inactive. All indications are that even if the body produces these antibodies, they don’t interfere with bone formation or cause any adverse effects.

In summary, with recombinant DNA technology, it’s possible to produce almost identical (to human) bone-forming proteins, thus eliminating any hypersensitivity reactions. But there are still some antibodies produced. New subclasses of BMPs are being developed and tested to eliminate antibody formation.

Slight structural differences between the rhBMPs might result in a product that is more effective (produce stronger bone faster) without antibody formation. Studies will be done to see if someone has one bone graft using rhBMP for spinal fusion or bone fracture and then has another one later, does the added exposure to these therapeutic proteins increase the risk of an immune reaction? Safety and effectiveness are the primary concerns right now. These products are not considered safe for use in pregnant women (or women who could get pregnant).

Removing giant cell tumors of the sacrum (bone at the base of the spine) can be dicey work. Taking the entire sacrum and tumor can leave the patient with unpleasant changes in bowel and bladder function due to nerve damage. But anything less can mean the tumor will come back. If the sacral nerve roots aren’t removed, tiny tumor cells left behind may cause tumor recurrence.

Giant cell tumor (also known as giant cell myeloma or osteoclastoma) are seen under the microscope as having large bone-like cells with more than one nucleus (center). Giant cell tumors affect the distal ends of long, tubular bones such as the femur (thigh bone at the knee) and radius (forearm bone at the wrist) most often.

Such tumors of the sacrum are uncommon. They are usually benign but they can grow very large putting pressure on the nearby nerves and other soft tissues. Sometimes they do become malignant and metastasize to the lungs. Giant cell tumors occur more often in Chinese people (up to 20 per cent of the population are affected) compared to Caucasians in Western countries.

In this study from China, researchers proposed that conservative surgery with good control of bleeding would reduce the rate of tumor regrowth or recurrence. Conservative surgery refers to sparing (partial removal) of the nerve roots when the tumor is located at the S3 sacral level and below. By leaving the S3 sacral nerve root intact, bowel and bladder function can be maintained. Tumors involving S1 and S2 can be completely excised (cut out).

Using special hemorrhage control measures during the surgery reduced the risk of tumor recurrence. Intraoperative occlusion of the abdominal aorta was the method used to control bleeding. The aorta is the large blood vessel (artery) that delivers blood from the heart down to the legs.

The method for bleeding control required several steps. First, the arteries were mapped out using an arteriograph. This procedure involved injecting dye into the blood vessels and viewing them on a special real-time X-ray called fluoroscopy. Arteries were closed during the operation by encircling them with nylon tape until no blood could be seen passing through.

In order to get to the tumor, various sacral and pelvic muscles were cut. The bone was also cut through at the level of the tumor. Once these musculoskeletal tissues were out of the way, the tumor could be located.

Limiting bleeding made it possible for the surgeon to see the outline of the tumor and remove it without contaminating (spreading) tumor cells in the area. Surgical sponges were packed around the outside of the tumor to keep any cells from spilling into the area.

In every patient, the fourth sacral nerve root (S4) was killed on both sides. Whenever possible, they left at least one, if not both, of the S3 sacral nerve roots alone. For patients with S3 nerve damage or loss, intermittent catheterization and bowel medications were often required. Catheterization refers to the use of a thin plastic tube inserted into the bladder to remove urine. Intermittent means the catheter is not left in place but just used when needed.

If too much bone had to be removed that the sacral spine became unstable, then a spinal instrumentation system (rods and screws) were used to support the spine. When the procedure was completed, the nylon tape was slowly removed from around the blocked blood vessels and blood flow was gradually restored.

Although the primary focus of the study was the rate of tumor recurrence following surgery with intraoperative hemorrhage control, the authors collected data of all kinds on the patients to use in the analysis. Information on the tumor included location, size, and involvement of sacral nerves. Information from the surgery itself included amount of blood loss, level of sacral nerve roots left intact (spared any surgical damage), and method used to control hemorrhage during the operation.

Data collected on the patients included age, gender, symptoms and how long the patient had those symptoms. The most common symptoms were low back, buttock, and/or leg pain; and changes in bowel and bladder function. Complications from the surgery were also recorded. Almost half of the group had some problem such as deep vein thrombosis (blood clots), wound infections, wound dehiscence (delayed wound healing with surgical site re-opening), or cerebrospinal fluid leakage.

Compared to the results reported for other studies, this study had a low tumor recurrence rate (29 per cent instead of 47 per cent). The authors give the credit to better control of intraoperative bleeding. The patients in their study had much lower blood loss compared to patients in other studies. They also pointed to the use of a new operative instrument (Helix Hydro-Jet) for quickly and easily removing the tumor with little to no damage to the nearby nerves or blood vessels.

By preserving both of the S3 nerve roots, bowel and bladder problems were avoided for almost everyone. Even when only one S3 nerve root could be spared, bowel and/or urine function was present in more than half the group.

The authors concluded by recommending conservative surgery with partial removal of important sacral nerve roots. This approach can reduce neurologic problems affecting bowel and bladder function. Using a blood saving method of complete occlusion of the abdominal aorta is advised to limit bleeding during the operation. With less blood in the surgical site, the surgeon has a clear view of the tumor and can remove it more carefully and completely.

Spine surgeons (both orthopedic and neurosurgeons) often use bracing for their patients after fusion of the neck or low back. But with today’s evidence-based practice, there’s been a question about this practice. Is it really needed? Is there any evidence to support external immobilization of this type? Or is it just a matter of doing what we’ve always done because we’ve always done it?

The authors of this study set out to see what are the bracing patterns of spine surgeons. They developed a one-page questionnaire and gave it to surgeons attending a Disorders of the Spine conference in Canada. The survey asked what type of procedures the surgeon performed and whether or not bracing was used postoperatively for each operation.

Type of brace (soft, hard, custom-made, off-the-shelf, corset) and length of use were also recorded. A separate column of questions on reasons for bracing (e.g., increase fusion rate, reduce pain, restrict patient activity) was also part of the questionnaire.

And a little bit of information about the surgeon was collected. Type of surgeon, practice setting, education, number of years in clinical practice, and location were biographical questions analyzed. They looked at each surgical decision made in relation to the surgeon’s background.

What they found was that no matter what background, the frequency of bracing was about the same. That was true whether the surgeon was in an academic vs. private practice setting and regardless of the number of years of experience. There were some slight differences based on whether the surgeon had completed a spine fellowship. The more highly trained fellows were more likely to use bracing. Bracing was also more common among surgeons in the United States compared to surgeons practicing in other countries.

Bracing was used more often following cervical (neck) fusions, especially when more than one-level was involved. It didn’t seem to matter what type of fusion was done (anterior vs. posterior, with or without internal fixation). As for how long bracing was used, surgeons agreed that they used bracing for three weeks or less in cases of a single-level cervical fusion. Longer periods of immobilization were used for multi-level fusions. Soft collars were used for single-level fusions. Rigid collars were more common for complicated and multilevel surgeries.

When bracing was used for the lumbar spine, it was discontinued earlier when rods were used internally to hold the spine in place during the healing/fusion process. Surgeons reported using a canvas-material corset for lumbar spine procedures that didn’t involve fusion. Rigid bracing was used more often for fusion procedures. It didn’t appear to matter whether or not a custom-made brace was used versus an off-the-shelf model.

The results of this study show there is continued reason to doubt the need for postoperative bracing after spinal fusion. There’s no evidence that bracing really prevents motion of the fused vertebral segments. Likewise, there’s no support for the idea that bracing slows the patient down, reduces pain, or improves the fusion rate. There are risks associated with wearing a brace such as nerve palsies, difficulty breathing or swallowing (neck brace), and skin reactions.

It is the opinion of some surgeons that proper surgical technique and the use of rigid internal fixation (rods, screws, metal plates) to hold the spine in place should be enough. The bone will fill in and create a solid fusion without the support of an external brace.

The authors point out the need for valid studies to prove this assumption. On the flip side, studies are needed to show that bracing improves outcomes. If bracing is found to be effective, details of when to use them, with which patients, and for how long will need to be answered as well.

You’ve probably heard about the recent recalls on baby food, pet food, and peanut butter. But have you ever heard of a recall on allograft (donated) bone? The Centers for Disease Control (CDC) and the Food and Drug Administration (FDA) report almost 60,000 allograft tissue samples were recalled over the last 15 years. All of those were musculoskeletal tissue specimens.

In this study, researchers from the Neuroscience Institute, Center for Spine Health at the Cleveland Clinic in Ohio investigated and reported the type and reasons for these recalls. Types and incidence of disease transmission in spine surgeries were also examined. They set out to answer the question: is the use of allograft bone safe in spine surgery? They also provide guidelines for surgeons to follow to improve the safety of bone grafts from donor sources.

What they found was that allograft tissues have been recalled from more than 60 tissue banks. The recalls were on a variety of tissues (e.g., heart valves, corneas, veins) but mostly musculoskeletal. The reasons for recall included improper recovery from the donor, poor donor selection, and positive blood tests for diseases or bacterial infections that could be passed to the recipient.

Only one case of viral disease transmission (HIV) from allograft bone in a spine fusion patient has ever been reported. Antibody testing has been available since 1985, so the risk of HIV transmission has been eliminated.

Sometimes it is impossible to trace the infection to its source — whether that’s from the allograft or something else. And if it’s from the allograft, how did that happen? It could have been a problem during the donor screening process, during actual recovery of the donor tissue, or an error in serologic (blood) testing of the donor tissue. Other areas of consideration include methods and safety in transporting, delivering, and implanting the donor tissue.

But there’s more to the story than the known cases. No one knows for sure if infections that develop later (postoperatively) are from the graft, something in the operating room, or other health factors. Patients with diabetes, heart disease, or other health problems seem prone to infections. Blood transfusions can be a potential source of contamination.

Since 1993, there have been government regulations in place to safeguard donor tissue. Safety rules, on-site inspections of tissue banks, and reporting of adverse effects of allograft tissue are now in place. All donor tissue must be tested for hepatitis and HIV. In addition, hospitals and surgery centers are required to follow a standard method for handling all donor tissues.

Surgeons are also responsible for following all safety measures as these relate to allograft tissue. For example, they must know where the tissue came from (e.g., morgue, operating room, funeral home) and make sure the recovery facility is practicing all recommended steps in assuring safety of the donor tissue. This includes proper donor screening and valid methods of tissue sterilization. Both of these steps are important in reducing the risk of donor tissue contamination.

They are advised to deal only with tissue banks that have been inspected by the Food and Drug Administration and/or are accredited by the American Association of Tissue Banks (not all are). And they must be prepared to report their concerns or any adverse events that occur.

Given the fact that there is only one known case of infection transmission among patients who received allograft (donor) bone during spinal surgery, the use of these tissues seems safe. The fact that not all tissue banks are regulated and inspected raises the concern for improper or even illegal means of obtaining, processing, and distributing donor tissue.

The authors advise surgeons to remain alert and responsible for assuring the safety of all tissue used in spinal surgeries. It must not be assumed that all the necessary steps in processing and sterilization have been carried out. Dealing with an accredited tissue bank directed by a physician is the best way to make sure tissues used are safe for patients.

You would think that the increased safety measures in motor vehicles these days would mean fewer injuries after accidents. But, in fact, the number of spine fractures has actually gone up. With the use of both a seat belt and an air bag, it seems like the opposite should be true. Why is that?

In this study, researchers take a look at the effect of combined seatbelt use and air bags on passengers in the front seat of automobiles. They report that in other studies, the use of these safety measures has reduced the number of deaths and bodily injuries. The use of an air bag without a seat belt results in more cervical neck spine and thoracic (upper back) fractures.

After studying crash data from police reports and hospital records, the authors found that the use of an air bag with the seatbelt produced more spinal fractures. But the severity of the fractures was less. The study took place in Wisconsin. Here’s how the numbers broke out:

Guidelines regarding the use of prophylactic antibiotics (antibiotics given to avoid an infection rather than to treat one) in spinal surgery help spinal surgeons in using the antibiotics for the best outcomes possible. The authors of this article discuss how the guidelines came to be and graded the recommendations to show how effective the guidelines are.

Researchers broke down the development of the guidelines into 12 steps. For step one, doctors who were using the guidelines were asked to submit a list of questions that focused on concerns of using antibiotics prophylactically when doing spinal surgery. Step two was for orthopedic and neurology surgeons to answer the questions. Step three was for researchers to identify which search words and terms they needed to do a literature search and step four was doing the literature search. In step five, the researchers reviewed the abstracts they found in the literature search, step six summarized the conclusions, found strengths and weaknesses, and judged the level of evidence (strong down to weak).

In step 7, work groups looked at the if expert recommendations were needed. Step eight was when the guidelines were submitted to the North American Spine Society’s Evidence Based Guideline Development Committee, the council director and an advisory panel. By step 10, revisions were approved. Step 10 saw the board submitting their guidelines to the over all guidelines clearinghouse. Step 11 is for recommendations to be submitted to the American Medical Association Physician Consortium for Performance Improvement. And, finally, step 12 is the recommendation that the guidelines be reviewed regularly at three-year intervals.

When looking through the literature, researchers were looking at the efficacy, protocol, redosing, discontinuation, wound drains, body habitus (shape and size), and comorbidities (other disorders that are also present) in order to back up the guideline recommendations. The study findings were graded on an A to C letter of recommendation or I to IV in level of evidence. On the whole, most studies scored a grade B for recommendation, while a few scored C. One study rated II as a level of evidence, three were level III, and another rated IV.

The authors found that the guidelines were developed with the best available evidence available in the literature and that the guidelines are useful to spinal surgeons in trying to prevent or reduce the risk of surgical infections.

If you’ve ever suffered from chronic (day in and day out) neck, back, shoulder, or other muscle pain, you may have tried trigger point therapy. Needles are placed in painful areas of the muscles. Then a numbing agent and/or inflammatory drug such as steroids is injected at that spot. This treatment technique is the form of treatment we call trigger point therapy. Some people swear by it. Others receive little or no apparent benefit.

Does this treatment work? Is it safe? Who can benefit? When and how? After 50 years of use, study, and experimentation, these questions remain unanswered. So says, N. Ann Scott, PhD of the Institute for Health Economics in Alberta (Canada). Dr. Scott and associates performed a systematic review of studies on the use of trigger point injections for chronic musculoskeletal pain.

Only studies with patients who had muscle pain caused by a nonmalignant (noncancerous) source were included. There were a total of 15 randomized controlled trials (RCTs) found in the published literature. Randomized means the patients were assigned to a group without any criteria. They were just as likely to be in one group as in another.

Controlled means there were other people in the study matched to the patients by age, weight, gender, or other distinguishing features. The control group does not receive the treatment given to the experimental group. Results between the two groups are compared after a period of time. This gives a better (unbiased) view of the true effects of the treatment.

Back, neck, or shoulder pain was the topic of the majority of studies. The remainder included patients with whiplash syndrome, osteoarthritis, and headache affecting the head and neck. All received some type of trigger point injection therapy.

But there were too many factors that varied from one study to another. The authors said the heterogenous nature prevented any large-scale synthesis of the results. If the studies aren’t conducted in similar ways, then it’s like comparing apples to oranges. The results aren’t helpful in answering the questions posed.

Overall, the safety of trigger point injections was never a problem. This was true when the treatment was applied by trained health care professionals. The actual benefit of the treatment is what remains unknown. No further conclusions can be made until enough quality evidence can be produced to support or refute trigger point injection therapy.

Future studies of good design must be conducted in similar enough ways to be included in the analysis of a systematic review. Injections into trigger points may be both safe AND effective. But until the research can prove it, the subject remains controversial and inconclusive.

Two professors of medicine offer five key questions to consider when evaluating patients for ankylosing spondylitis (AS). Making an early diagnosis is important in developing a plan of care that will control symptoms. But making the diagnosis early can be a challenge because hallmark signs of AS seen on X-rays don’t show up for seven to 10 years. These five questions can help doctors stay alert to the possibility of AS:

Recently, a researcher, B.K. Weiner, published an article that focused on back pain being deemed biopsychosocial, related to biology, psychology, and social aspects of life. He combined this with the heuristic approach, which means problem solving for the most appropriate solution one step at a time, not necessarily the best solution. In his article, he also wrote about the strengths and weaknesses of this approach, as he saw them, but he focused on the strengths and why this model should be discouraged. The authors of this article disagreed with Weiner’s discussion, particularly the weaknesses, and wrote to present why they disagreed.

Weiner had suggested that there is a weakness in relying on patients to self-report problems, which is when they keep track or answer questions about how they felt or what they did. This article’s authors suggest that self-reporting is necessary using the biopsychosocial model because of the very issues that are covered: the patients’ behavior, how they felt, how they coped, how they worked, and so on). The authors do point out that researchers can’t rely on self-reporting alone, but it does have its place in an overall study and that self-reporting can’t be considered as more important or less important than any other type of study measurement.

The next point that Weiner makes is that historically, as medicine progressed, has made several errors in connecting certain illnesses and diseases to some aspects of psychology. By doing this, doctors and researchers lost valuable research time by believing the wrong things. He then says that using the biopsychosocial model will also fall into this trap. The authors of this article point out that Weiner incorrectly uses the Type A personality and blood pressure connection. Weiner says that believing that Type A personalities had higher risk of high blood pressure slowed down research. The authors here argue that knowing that Type A personalities have a higher risk of high blood pressure has actually spurred on research, particularly in the realm of stress.

The authors continue by pointing out that using this model, researchers were able to connect the dots when it came to learning about type 2 diabetes and lifestyle, asthma, and some other disorders. By using the biopsychosocial model, researchers were able to look beyond the physical issues and see what else could be contributing to various problems.

Another point made by the authors is that the chronic diseases don’t have cures but are merely managed. In respect to spinal problems, there too are no cures in the offing. But, by knowing that some lifestyle changes can affect the progress of spinal injuries, they can make life easier for the patients, if not cure the problem. But, to make those changes, researchers need to know what causes the problems in the first place.

Weiner points out that in science, the answers need to be proven or disproven; there has to be a yes or no, and if you take into account the biopsychosocial model, researchers don’t have the clarity of a testable or falsifiable aspect to fall back on. The authors disagree with this argument, saying that it is possible to test for variable issues, although researchers do have to take into account that the are, in fact, variable.

One very helpful outcome of the biopsychosocial model is the newer team, all-inclusive, method of treating patients. When at one time only one specialty or specialist would manage a patient, now a multidisciplinary team is common.

As many treatment options are tried, doctors are learning by trial and error which are most effective. While Weiner suggests that this is only for the biopsychosocial model, the authors of this article point out that this is so for most treatments for back pain. They also point out that there can be great differences between different clinical treatment teams running the studies in different countries or environments. The actual studies remain identical, the medications or procedures, but the social and psychological issues can differ from place to place, as can the biology of the patients. Therefore, this teaches researchers a lot when findings come in differently from different areas.

The last concern that the authors take issue with is the complaint that by using the biopsychosocial model, the medical community is “medicalizing” patients with spinal problems. The authors argue that doctors can’t isolate the back pain and to do so would make it much more difficult to provide adequate treatment. To treat back pain, it’s essential to treat the whole person, including the social and psychosocial issues that could be contributing to back pain.