News Category: General Spine

Adults who need spinal deformities corrected can present a problem for surgeons because of the inflexibility of most of the deformities. There are many deformities that need this type of correction, ranging scoliosis (curvature of the spine, side to side) and different types of arthritis in the spine. that can result in hyperkyphosis (humped back or rounded back). To be able to treat these though, surgeons must understand the advantages and disadvantages of major spinal osteotomies, surgery where bone is cut, and which is best for which deformity.

The authors of this article reviewed the different types of osteotomies and how they affect the patients’ horizontal gaze. The horizontal gaze is how the patient can look straight out in front, parallel (in line with) the floor. If a patient’s back is too hunched, they may be unable to look out that way and always have a downcast view.

Patients who have sagittal or coronal imbalances. Sagittal imbalances refer to the spine as you see it from the side while coronal is when you look at the spine from the front or the back. These can be stage I, where they are still balanced if a plumb line was held from their neck and hung down along the back, or stage II when this plumb line doesn’t fall straight along the back. A patient who has a kyphosis is unbalanced along the side, but if you look at it straight from the back, it could be stage I. On the other hand, if the back is curved in such a way that the patient has to adjust the stance to balance, this is stage II.

To correct these imbalances, surgeons have to manipulate how the spine is by either cutting bone or lengthening it. The different types of osteomies available all offer different approaches and outcomes. These are picked by the surgeons after taking into account the location of the deformity, the type of deformity, the angles to be corrected, and if bone needs to be removed or lengthened. These, of course, also all lead to how well the patient will be able to look out straight, the horizontal gaze.

As with all surgeries, there are complications associated with osteotomies. Spinal surgery, because of how long it can take and how complicated it is, has several risks that are common to all surgeries and some that are only for spinal surgery. The more common complications are infection and bleeding. The spinal complications include nerve damage. In osteotomies that shorten the bones, there are other issues. For example, one procedure, called the Smith-Peterson osteotomy is one that shortens the posterior column (back) while lengthening the anterior column (front). But, this can cause a injury to the main artery of the heart, the aorta, among others.

Some types of surgery have a higher rate of complications. For example, the Pedicle subtraction osteotomies are done for patients who aren’t candidates for the Smith-Peterson procedure. Bone is removed to help straighten the spine. However, this is a technically difficult procedure. A study that examined 46 patients who had the pedicle subtraction found that they were seven times more likely to have a major complication than patients who had different spinal surgeries. These complications included neurological problems, infections, pulmonary embolus (clot that entered the lungs), pneumonia, and heart attacks.

The authors concluded by writing that it’s “important to be able to recognize the type and underlying cause of the deformity so that the most appropriate osteotomy can be chosen.” While some procedures are more simple than others, they may be not be the best choice given the correction needed.

Every year, physicians involved in treating spine patients come together at the Spine Society’s Annual Meeting. Experts in the field bring information and updates on studies done in a wide variety of topics. In this report, six areas of interest were reviewed, summarized, and presented. A brief recap of these six areas is offered below:

1) Assessing Psychologic Factors in Spine Patients

In this report, physicians are reminded not to rely on their own memory by asking favorite questions when interviewing patients to assess the patient’s psychologic state. There are better, more accurate tools available to do this. One of those tools is a psychologic questionnaire called the Distress Risk Assessment Method (DRAM).

According to a recent study, experienced surgeons aren’t any better than less experienced physicians in assessing patients’ psychologic stress. This type of evaluation is important because past research has shown there is a significant impact of a patient’s psychologic health on their response to treatment for spine-related back pain.

To come to this conclusion, eight spine doctors (equal numbers of surgeons and physiatrists) interviewed 50 patients each (for a total of 200 patients in the study). The doctor-patient interview was meant to do a psychologic assessment and determine who needed psychologic help. Each of the 200 patients also filled out the DRAM questionnaire. The results of these two measures were compared. Categories used to classify patients’ psychologic risk included normal (N), at-risk(AR),distressed depressive (DD), and distressed somatic (DS).

It turned out that nonoperative spine specialists (those who offer conservative, nonsurgical care) were much better at recognizing when patients had significant levels of psychologic stress to be at risk for a poor treatment result. Surgeons relying on their own instincts were less likely to detect patients who were at-risk or distressed.

It was suggested that physicians use the DRAM for better results in this area of assessment. The DRAM has been validated by research studies. This means it is both reliable and effective in measuring psychologic distress in spine patients.

2) Comparing Cervical Spine Fusion to Cervical Total Disc Replacement

Total disc replacement is still a fairly new innovation in the treatment of degenerative disc disease of the cervical spine (neck). Studies are ongoing to compare the results of spinal fusion with disc replacement. Disc replacement has the major advantage of preserving neck motion. But does it improve overall function better than a spinal fusion?

That was the focus of a small study (51 total patients) comparing anterior cervical fusion with the Kineflex-C total disc system. Everyone in the study had a one level cervical disc problem caused by degenerative disc disease. The main measures used to compare the results were return-to-work status and narcotic use for pain. The number of days patients were off work was tracked along with frequency and dosage of narcotic medication used over time.

Patients in the cervical disc replacement group were back on the job three times faster than the fusion group. This was true even for manual laborers (not just those on light duty). Not only that, but this same disc replacement group were off the narcotic pain relievers much sooner than the fusion group.

Using these two measures of function offered some added valuable insight into the rehab and recovery of cervical spine patients opting for surgery. Instead of just using the standard Visual analogue scale (VAS) to measure pain and the Neck Disability Index to assess function before and after surgery, work and drug status offer additional helpful information.

3) Benefit of Lumbar Fusion By Age

Six months after lumbar spinal fusion, older adults (65 years old and older) have better results than younger adults. These findings apply to patients who had a single-level fusion. X-rays and CT scans showed better fusion rates for the Medicare-age group. They also reported more improved function compared to the younger group. These improvements were still present two years after the surgery.

The older adults did have more complications and problems after surgery. But overall, the study confirmed that lumbar spinal fusion is an acceptable and helpful procedure in Medicare recipients. The impetus for the study came from the Centers for Medicare and Medicaid. This government organization is reviewing outcomes of different procedures for this age group and requiring evidence that the treatment is both effective and cost-effective.

4) Exercise May Be Better Than Fusion For Spondylolisthesis

Spondylolisthesis is a spinal disorder that often causes pain, dysfunction, and disability. Surgery may be needed to fuse the spine and keep the condition from getting worse. In this condition, a supporting column of the vertebra called the pars interarticularis has a break or fracture in it.

Two sets of spinal bones form a bony ring around the spinal cord. Two pedicle bones attach to the back of each vertebral body. Two lamina bones complete the ring. The place where the lamina and pedicle bones meet is the pars interarticularis, or pars for short. There are two such meeting points on the back of each vertebra, one on the left and one on the right. The pars is thought to be the weakest part of the bony ring.

Spondylolisthesis alters the alignment of the spine. The affected vertebra slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. Exercises are often prescribed to strengthen the core trunk muscles and maintain proper posture to keep the vertebra from slipping forward even more. An alternative approach is surgery to fuse the spine and keep the bone from slipping any further.

Which one works best? What’s the impact of adjacent segmental disease (ASD)? Adjacent segmental disease refers to the break down of the next vertebral bone above or below the area of spondylolisthesis. Two groups of patients with spondylolisthesis were included in this study. One group had a one-level lumbar spinal fusion. The second group were given standard exercises for spondylolisthesis.

The presence and severity of ASD were measured using two types of digital X-rays. The results showed that the fusion group lost disc height and the quality of the adjacent disc material declined compared to patients in the exercise group. Patients in both groups were followed for 10 years. No one in the exercise group developed ASD.

5) Bracing No Longer Needed After Neck Fusion

It’s fairly routine to give a patient a cervical neck brace after neck fusion. But according to the results of a study done in multiple U.S. centers, bracing isn’t always needed. Fusion rates and return-to-work status were the same with or without the bracing.

These findings apply to patients who had a single-level anterior cervical disc fusion (ACDF). Surgeons involved in the study say these results makes sense because the fusion was done with a metal plate along the front of the spine that was combined with bone graft at the same site. Bracing used to restrict motion isn’t needed because the plate and graft material have the same effect of preventing motion.

Surgeons performing an ACDF should not give patients cervical bracing unless there is a specific need for it. They should rethink the policy of prescribing a cervical brace for everyone after this type of surgery.

6) National Registry of Surgery Results Helps Identify Patterns of Results

Instead of conducting 100s of small studies tracking the results of surgical procedures, it makes good sense to create a national registry (central database) that everyone can contribute to. If data on all patients having a particular surgical procedure could be downloaded into a registry, then the results of individual studies could be combined together for better analysis.

Procedures such as cervical and lumbar total disc replacement for degenerative disc disease or balloon kyphoplasty for vertebral compression fractures are common among older adults. Spinal surgeries of this type can be invasive and expensive. We need studies that show if these treatment methods are really safe and effective.

The Swiss government has required the use of a national spine surgery registry to track the results of spine treatment. It tracks cost and effectiveness of these procedures as well as revision rates. After two years of collecting data, the researchers were able to say that total disc replacement does reduce pain and improve quality of life. More patients were able to stop taking narcotic pain medications sooner compared with patients who had a spinal fusion.

Similar benefits were reported for patients having balloon kyphoplasty. Balloon kyphoplasty is a treatment that involves the placement of a balloon into a collapsed vertebra. A special bone cement is injected into the space created by the inflated balloon. The cement hardens and helps restore the bone’s natural height and shape.

Results for balloon kyphoplasty reported over the past two years since the registry was started have not shown any changes. But even this kind of information is helpful. It reflects the combined efforts of many surgeons, educators, and the health care industry to track treatment results and report them. This informs health care profesionals how effective treatments are and provides evidence-based best care for patients.

SUMMARY: The brief summaries offered here of six key areas in the advancement of orthopedic research only represent a small portion of the work that’s being done around the world. The North American Spine Society offers a conference every year with updates like this for both the physicians who can attend and for those who look for updates in summaries such as this.

While technically all surgeries are invasive, some surgeries are more invasive than others. Usually, the more invasive the surgery, the higher the risk of complications and the longer the postoperative recovery period. Surgeons have a lot to consider when they choose a particular approach for each patient. Some candidates need more invasive surgery but might not be good candidates, so a lot must be taken into consideration. This is often the case with spinal surgery. Although the surgery is medically necessary for the patient to manage his or her pain, it’s not usually a surgery that would be done in a life-threatening situation. This makes it possible for the surgeon to weigh the pros and cons of the different approaches.

The types of complications that may happen as the result of spinal surgery is one thing to consider, but comparing different types of surgeries and their complications is easier said than done. The patients vary too much from study to study for researchers to be able to draw general conclusions. As well, the type of surgery is affected by the surgeon and the operating room staff, as well as the facilities. The authors of this article felt that having an index that could grade the risks would make it easier for surgeons to identify who would benefit more from more invasive treatment and who should likely avoid it. To do this, they had to develop a quantitative (measurable) description of how invasive the procedures were.

To design the index, researchers used six criteria:
1- The anterior decompression score (ad), which looked at the number of vertebrae (bones in the spine) that needed to be removed, either partially or completely taken from the anterior (front) approach.
2- The anterior fusion score (af), which looked at the number of vertebrae that needed to be grafted (have a piece joined to them) for replacement or strengthening.
3- The anterior instrumentation score (ai), which took into account how many vertebrae needed hardware (screws, plates, etc).
4- The posterior decompression score (pd), which took into account how many vertebrae needed laminectomy or foraminotomy, pieces of bone removed or if the disc was removed using the posterior approach.
5- The posterior fusion score (pf), which looks at the number of vertebrae that were grafted in certain spots.
6- The posterior instrumentation score, which looks at the number of vertebrae that have hardware attached to certain spot.

If a surgery didn’t involve any of the above or only needed to be debrided (dead and damaged tissue removed) or irrigated, the invasiveness score was considered to be zero.

The researchers looked at 1745 patients who had had spinal surgery and their operating room logs and ended up with 1723 patients in all. Each patient was evaluated for one surgery. Among this group, 873 patient were actively monitored and 850 were in the passive surveillance group. There were 802 patients who participated in follow-up interview, 668 were from the active group.

The results showed that there was “a strong association with blood loss,” as much as 44 percent between the different levels of invasiveness. There wasn’t any connection between blood loss and the sex of the patients, their body mass index, smoking, or alcohol use. What did make a difference was the number of vertebral levels that were operated on, how long the surgeries were, the way the surgeon approached the surgery, and the type of surgery.

In all, the study authors concluded that there was an increase in blood loss of up to 11.5 percent and surgery time was lengthened by 12.8 minutes for each level up on the invasiveness index. This finding may be useful to match the right surgery to the right patient, limiting complications in the long run.

Your spine is made up of small bones that stack one on top of the other. These are called vertebrae. Some people have a benign (not harmful) abnormality called butterfly vertebrae. Butterfly vertebrae have a cleft, an indentation or opening, through the middle. If you look at it with an x-ray, the shape reminds you of a butterfly. Usually, this doesn’t cause any problems and goes undetected unless there is a reason to x-ray that part of the back. Sometimes, however, there may be pain, but not from the abnormality itself.

The authors of this article described a 46-year-old woman who had lower back pain, made worse by bending forward or standing for long periods. When she had an x-ray, the doctors saw butterfly vertebrae in the middle section of the back, the thoracic spine, but this was just a coincidence because the pain was actually being caused by pressure between two nearby discs. Her doctors treated her for lower back pain and she was assured that although she had been diagnosed with the abnormality, there was no need for any treatments.

Researchers believe that the butterfly vertebrae occur when the fetus is between three and six week gestation and, although most butterfly vertebrae are in the lumbar spine (the lower part of the back), the can happen in other parts, as with the patient just described. There are some syndromes that may also have this abnormality, such as Alagille syndrome (arteriohepatic dysplasia>), Pfeiffer syndrome, Crouzon syndrome, and Jarcho-Levin syndrome. Since the patient in the case study didn’t have any signs of any of the syndromes, nor did she have any other back abnormalities, like spina bifida, diastematomyelia, or kyphoscoliosis, the doctors felt that her condition was benign.

The authors point out that butterfly vertebrae can be easily confused with a fracture on an x-ray, but magnetic resonance imaging (MRI), which can show images of soft tissue, show that there is no soft tissue damage around the vertebrae, which means there’s no break in the bone. Although the actual butterfly vertebrae doesn’t cause pain, it can protrude (stick out) enough to cause the spine to be a bit out of line. This alteration in alignment can end up causing back pain. The authors discuss one patient who had butterfly vertebrae in the lumbar spine but complained of pain in the thoracic spine.

The authors also write that although thoracic butterfly vertebrae are rare, they do occur. So if a doctor is examining a patient for back pain, they should carefully examine the x-rays and MRIs to see if there’s any evidence of trauma. If there isn’t, there’s a good chance what the doctor is seeing is the butterfly vertebrae. By recognizing this possibility, patients could be spared unnecessary tests and perhaps even surgery.

For over 30 years now, doctors have used spinal cord stimulation (SCS), also called neurostimulation, to help relieve chronic 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. It’s important to understand that the treatment doesn’t eliminate pain, but it prevents the person from feeling it as much, thus masking it. SCS is generally only used if nothing else seems to be working and must be done on a trial basis first before the stimulator is permanently implanted. Patients also must have a psychological assessment to be sure that they are ready for this type of treatment.

Some doctors working with patients who have failed back surgery syndrome have tried using SCS to treat the pain experienced by their patients, however there aren’t many studies that have looked into this use and if it is a cost efficient treatment. The authors of this article reviewed studies that looked at the pain reduction and cost effectiveness of SCS in this patient group. To do this, researchers searched the medical literature to find randomized controlled trials that included patients with failed back surgery syndrome. Some studies that were observational were included if there was a control group.

Patients in the studies had chronic pain lasting more than six months, due to failed back surgery syndrome. The study follow ups lasted anywhere from six to months to eight years. Cases had at least 50 patients who had received stimulators and were followed for at least one year. In order to assess patients’ pain and level of functioning, the researchers depended on scales and questionnaires, such as the McGill Pain Questionnaire (MPQ) and the VIsual Analog Scale (VAS). The researchers also looked at the economic impact of the pain and the treatment.

After reviewing the appropriate studies and cases, the researchers found that the studies and cases consistently found that it was cost effective to use SCS in treating failed back surgery syndrome, although several studies did report complications. The complications included mostly technical problems with the hardware.

The studies included a low-quality study that found no differences in the number of patients who were given the stimulators and the control group (those who didn’t receive a stimulator) returning to work after six months of treatment and another low-quality study that found that patients with stimulators woke less often at night than controls after one year of treatment. Another seven low-quality studies found that there were improvement in activities of daily living in patients with stimulators after one year of treatment, but only one had improvement in sleep findings. Another study concluded that their patients who were depressed saw an improvement in the depression after being treated. Several studies measured drug use for pain relief before and after treatment. They all found that there was no significant changes in the use of medications, except for one that did find treated patients used fewer medications.

In terms of satisfaction with treatment, those who received treatments were much more satisfied than the control groups in two moderate-quality studies and three low-quality studies reported 60 percent of the treated patients or more were satisfied after three years of treatment.

When the researchers examined the economic aspect of SCS, one study found that the mean cost for the treatment, over five years, was higher in the initial treatment phase because of the cost of obtaining and implanting the stimulator. However, once the initial expenses were taken care of, the cost of treatment leveled off.

The authors wrote that the studies they reviewed did show that there was a significant benefit to SCS in terms of reducing pain and improving quality of life in patients with chronic pain from failed back surgery syndrome. There was also indication that, despite the high initial cost of the treatment, SCS over the long-term was more cost effective than other treatments.

Back pain is one of the most common chronic pains in the Western world. It’s estimated that just about everyone will complain of some sort of back pain at some time in their life. Researchers who are looking for ways to manage and prevent back pain also are trying to find how to prevent uncomplicated back pain from becoming chronic back pain – pain that lasts for more than three to six months.

In one study done in France, by Celine Bouton, MD and colleagues, the files of 72 patients with chronic back pain were reviewed. The patients had experienced their back pain for an average of 85 to 86 months and had been treated for about four years by their own doctor. For treatment, the patients had tried using analgesics (pain relievers) from over-the-counter to opioids (controlled medications, like morphine), and anti-depressants, which do help many people with chronic pain. The patients also tried physiotherapy, saw a rheumatologist, and/or had surgery for their back pain. Many of the patients were unable to work.

The researchers pointed out that the time from injury to the time the patients were seen by a multidisciplinary approach, a team of health care professionals from different aspects of medicine, was long and that this is one of the issues that patients often face. The researchers wrote that general practitioners need to be encouraged to refer their patients with back pain earlier rather than later.

There are some guidelines regarding referring patients who have back pain that hasn’t responded to traditional, non-invasive (non-surgical) treatments. Generally, if there doesn’t appear to be a good recovery within six to 12 weeks of the original injury, the patients should have a thorough assessment, according to the Low Back Pain Group of the Bone and Joint Health Strategies for Europe Project.

One of the problems that block referrals for back pain is that chronic back pain isn’t a red flag in many situations. So many patients who have chronic back pain do visit their doctor that it’s considered to be one of the most common complaints seen in the doctors’ office. It might also be that it’s hard to tell the difference between common back pain and back pain that is caused by something more serious. It’s the more serious back pain that can develop into severe and debilitating problems if not identified, though.

Primary care doctors are considered to be the gate-keepers of the medical system. It’s through them that patients are assessed, treated, or referred on for further, more specialized care. This is also true for back pain. What adds to the problem is that there isn’t a lot of access for patients who require specialized back care, so the doctors are having not only to recognize when a patient needs referral, but to find someone who the patient can be referred to.

There are many different types of rheumatological diseases. A rheumatological disease is an inflammatory arthritis that affects the entire body as a whole. Rheumatoid arthritis (RA) is the most common rheumatologic disease. Certain types of rheumatoid arthritis seem to target specific joints.

When a rheumatological disease affects the spine, the resulting conditon is called a spondyloarthropathy. The term is made up of Greek words: Spondylo means vertebra, arthro means joint and pathos means disease. When other more peripheral joints are affected (such as in the arms and legs), the rheumatologic arthritis is referred to as an spondyloarthritide.

In this article, Dr. Philip J. Mease from the Division of Rheumatology, University School of Medicine in Seattle, Washington gives us an update on two of the more common spondyloarthropathies: psoriatic arthritis (PsA) and ankylosing spondylitis (AS). Psoriatric arthritis affects the peripheral joints. Ankylosing spondylitis affects the spine.

New findings in the field have brought these conditions and their treatment to our attention. The first major breakthrough in understanding and treating these diseases is in the area of pathophysiology. Pathophysiology tells us what went wrong at the cellular level to cause these problems.

Researchers are identifying specific differences between rheumatoid arthritis and spondyloarthropathies. Their work in the field of osteoimmunology is helping determine what’s going on between the bone cells (osteo) and the immune system. This knowledge has led to more refined development of specific drug treatments for these two types of arthritis. That’s good news for anyone suffering from any kind of rheumatologic disease.

For example, MRIs of patients with spondyloarthropathies show bone edema before any actual bone damage occurs in the joints. At the same time, they have found nests of lymphocytes (white blood cells), bone cells, and blood in the bone marrow (inside bones) of patients with ankylosing spondylitis. Though the exact meaining of these findings are unknown, they point in a direction to help drug manufacturers develop medications that could stop this process.

Measuring the effect of therapy on disease activity is one way to assess new treatments. Studies look at before and after outcomes of therapy on affected joints, skin, pain, function, fatigue, and quality of life. The therapeutic effects of treatment on disease activity can be difficult to measure — especially when those changes occur at the cellular level. MRIs and X-rays may be helpful.

Patient-reported outcomes using various surveys can help track patient perceived changes, too. Some of these tools include the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Function Index (BASFI), and the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire.

Standard treatment of mild spondyloarthropathies starts with antiinflammatory drugs and topical skin creams. With more severe disease, disease modifying anti-rheumatic drugs (DMARDs) are prescribed. The most common DMARDs include methotrexate (MTX), sulfasalazine (Azulfidine), and leflunomide (Arava).

If these drugs don’t reduce symptoms from disease activity, then anti-TNF agents are used. Anti-TNF stands for anti tumor necrosis factor. TNF causes inflammation. Anti-TNF turns off this response.

The most commonly used anti-TNF agents are adalimumab (Humira), entercept (Enbrel), and infliximab (Remicade). These medications usually give patients quick relief from all major rheumatologic symptoms (skin lesions, joint pain, morning stiffness, fatigue). At the same time, they have been shown effective in reducing disease activity and joint destruction.

Most of the time, doctors prescribe a single drug type (either a DMARD or an anti-TNF). But if one doesn’t work, then a combination of two or more drugs are used. It may take some time to sort out which drug or drug combination works best for each individual patient. Results are measured using patient-reported outcomes, X-rays, and MRIs.

There are newer agents being studied right now. For example, Golimumab is a new anti-TNF agent that only has to be taken once a month. It’s an injection that is placed just under the skin. It may be helpful for patients with psoriatic arthritis who have both skin and joint problems.

Some researchers are also investigating ways to signal immune cells to block or inhibit inflammatory cells. This type of therapy is called immunomodulation. Several of these agents are being tested in the treatment of ankylosing spondylitis.

These new and more targeted therapies may help patients who do not respond to the standard treatments used in mild to moderate disease. The ultimate goal is to prevent irreversible joint damage. The result should be less pain and better function with improved quality of life over a longer period of time for affected individuals.

A major concern after any type of major surgery, particularly orthopedic (bone) surgery, is development of blood clots. Called venous thromboembolisms, they can cause severe health problems and even death. These clots can result in deep vein thrombosis (DVT) and pulmonary embolism. A deep vein thrombosis is a clot that forms in a vein deep in the body, well below the skin surface. Although they can happen anywhere, deep vein thrombosis is usually found in the lower leg or thigh. The danger of such a clot is that it can break away from the vein and travel in the blood stream. Once it has broken away, it’s called an embolus. The embolus can travel to the lungs and cause a pulmonary embolism.

When someone is awake and moving about, the muscles in their legs help push the blood around and promote blood circulation. When a patient is lying on the operating table, the blood is not being encouraged to move about and this is made worse when the patient lies in bed recuperating from the surgery. The blood circulation in the legs can be sluggish and the blood may begin to clot. Also, surgery often involves positioning and pulling back on the veins to reach the areas to be worked on and this increases the likelihood of a blood clot forming.

According to the authors of this article, each year in the United States, deep vein thrombosis occurs in 48 out of every 100,000 patients and two are fatal, causing death. Pulmonary embolism occurs in 69 out of every 100,000, causing death in 17. Not only do these blood clots affect the patients, they have an economic cost in terms of lost productivity, health care costs, and increased risk of the patients having a second thrombosis or embolus. Because of the large impact, many researchers have conducted studies to try to find ways to minimize the risk of developing a blood clot after surgery. The researchers have looked at using anticoagulants (blood thinners) prophylactically (to prevent) blood clots. These include medications such as low-molecular weight heparin and low-dose heparin. Researchers have also looked at devices such as compression sleeves, that promote blood circulation in the legs. Unfortunately, this type of treatment has complications that can be serious, such as bleeding or hemorrhaging from the surgical wound and blood building up in the spinal area, causing nerve damage.

Venous thromboembolism is a problem that doctors recognized as early as the mid-1800s, but it was only in the mid-1900s that it was really written about in the medical literature. Doctors were able to identify some patients who were at higher risk of developing the blood clots, including people with abnormalities in their blood clotting ability, such as antithrombin deficiency. There are other health problems that may affect blood clotting, such as cancer and treatments, such as hormone replacement therapy.

In 1966, a researcher, Prothero, and colleagues, reported on 1000 patients who had undergone lower back (lumbar) surgery without any prophylactic treatment for blood clots. In the first group of 500, 4.2 percent of the patients developed a blood clot. Ten years later, the second group of 500 patients who had undergone the same type of surgery had a rate of 2.2 percent. Another study that examined the use of compression to prevent blood clots. The researcher, Epstein, found that 2.8 percent of the patients who had back surgery developed clots.

Not all surgeons use medications to try to prevent blood clots when they perform elective back surgery. Their reluctance includes the worry of prolonged bleeding during and after surgery, and a build up of blood in the epidural space. These concerns were examined in a study of almost 2000 patients who had elective back surgery. The researcher, Gerlach and colleagues, found that there was a 0.05 percent risk of venous thromboembolism and a 0 percent risk of pulmonary embolism if the patients wore compression stockings after surgery and were given a dose of low-molecular weight heparin within 24 hours after having had surgery. There were some complications, however. A build up of blood (hematoma) in the epidural space occurred in 0.4 percent of the patients. Of those patients, 77 percent experienced a neurological deficit, or problems with the nerves.

Warfarin, a different type of anticoagulant that patients take in a pill form, hasn’t been studied very much for this type of use. One study of 110 patients included 35 patients who were given warfarin and used elastic stockings after back surgery. The researchers didn’t find any blood clots, but two of the 35 patients did experience heavy bleeding after surgery.

One important issue in preventing blood clots is to be able to identify patients who may be at greater risk of developing them. Some risk factors that have been identified include having had a blood clot before, not being able to move about after surgery, increased age, and a long surgery. Surgeons have also noticed that how they approach the spine for surgery makes a difference in blood clot risk.

Blood clots are not limited to patients who had elective surgery. A study done of 101 patients who had been injured found a 30 percent rate of blood clots, but there wasn’t a difference found between patients who were receiving prophylactic anticoagulants and those who weren’t. The did find a higher rate among patients who were obese or over 40 years old, and in those who couldn’t move about for more than three days or who had broken their back or bones below the waist. The authors of that study suggested that traumatic injury increases the rate of blood clot formation that could last up to a month after the accident. However, in another study, 45,000 patients who had been injured one year earlier were found to only have a 0.36 percent risk of developing a blood clot.

After a spinal cord injury, blood clots are very common. Up to 80 percent of patients with traumatic spinal cord injury develop a thrombosis if they haven’t had prophylactic anticoagulation or if mechanical means (stockings, pressure) haven’t been used. When pressure was used, the rates dropped to about 40 percent, according to one researcher, Green and colleagues. Heparin, both low-dose and low-molecular weight, dropped the incidence as well. Interestingly, in one study of 119 patients with spinal injuries, those who underwent six weeks of rehabilitation had a 2.5 percent higher risk of developing blood clots if they were given low-dose heparin than if they received low-molecular weight heparin.

Patients with spinal cord injuries at a higher risk for blood clots overall, with paraplegia (paralysis from the waist down) having a higher rate than quadriplegia (from the chest down). Jones and colleagues found in one study that 11 percent of patients who were complete paraplegics developed blood clots compared with 7.8 percent who were complete quadriplegics. Of course, being older is also a risk,

Overall, the American College of Chest Physicians have recommended that surgeons not prescribe prophylactic anticoagulants to patients who do not have any risk factors for blood clots and who are about to undergo elective spinal surgery. If, however, there are any risk factors, the College recommends that patients be given low-molecular weight heparin and use pressure after surgery to reduce this risk. The heparin should begin within 24 hours of the surgery, but the patients must be watched closely for any signs of a hematoma. The College also recommends this approach for patients who have a fracture or dislocation of the spine and those who had traumatic injury to the spine. How long the heparin is used depends on the doctor and the extent of the patients’ injuries or the type of surgery and risk factors, but the generally accepted time is three to four months, which is how long it can take for most blood clots to form.

Another way to deal with patients who are at a particularly high risk of developing blood clots is by using inferior vena cava filters, a filter that is implanted into the large vein (vena cava) that carries blood back from the lower body to the heart. The blood is then filtered to prevent clots from entering the heart.

If a patient does develop a blood clot, treatment can be challenging since doctors don’t all agree with the best type of treatment.

The authors of this article concluded that one of the reasons it is difficult to prevent venous thromboembolism is the differences between the patients who are having spinal surgery and the different options available to the surgeons. There has been a drop in blood clots because of early treatment, heparin, and mechanical methods, such as pressure stockings. Therefore, there is enough evidence to show that prophylactic treatment does help reduce the risk of blood clots after spinal surgery. That being said, it has also been shown that low-weight-molecular heparin is the best choice, along with outside pressure, for most patients. The authors do point out that there are complications that may be associated with the treatments, but that risk versus benefit must be taken into account. If a hematoma in the epidural area does form, then immediate surgery is the best response and provides the best long-term outcome for the patient.

Much progress has been made in spinal fusions since 2002 when the FDA approved the use of bone graft substitutes. Bone graft substitutes replace bone harvested from the patient or from a donor.

At first, bone morphogenetic protein referred to as rhBMP-2 was just used for single level spinal fusions. The surgery is done from the front of the body. The procedure is called an anterior lumbar interbody fusion (ALIF).

Over time, results with rhBMP-2 have been so good, its uses have expanded. Surgeons started using less total BMP dose, using it in posterior spinal fusions, and for two-level lumbar spinal fusions. Surgery time was less, blood loss was reduced, and hospital stay was shorter.

Now, in this study, the first set of results using rhBMP-2 with multiple levels is reported. In the past, solid fusion of long spinal segments was difficult to achieve. This was true even with autograft harvest (bone taken from the patient’s pelvis). The procedure is called an iliac crest bone graft (ICBG).

Too many risk factors interfered with the results. Osteoporosis, not enough bone for the graft, previous failed fusions were just a few of the problems encountered with spinal fusions. The current use of RhBMP-2 placed on an absorbable collage sponge (ACS) and put in the disc space has been very successful with one and two segment levels.

Three groups of patients were included in this study. All patients had multilevel spinal deformities requiring multilevel spinal fusion. The fusion went down to the sacrum.

The first group had an anterior(through the abdomen) spinal fusion with rhBMP-2. The material was placed on a collagen sponge. The sponge was placed inside a titanium mesh cage. The cage was inserted into the interbody spaces (between the vertebrae where the discs used to be). Metal supports (rods and screws) were used posteriorly to help hold the bones in place until healing occurred. This part of the surgery is called posterior instrumented fusion.

The second group also had rhBMP-2 but it was applied to the posterolateral (side and back) spine. Use of rhBMP-2 in the posterolateral location has not been approved specifically by the FDA. So this use is called off-label. In this group, bone removed was ground up and used as a bone extender. This is done by combining harvested bone with the rhBMP. The mixture is placed on the sponge and placed in the interbody space.

The third group had a posterolateral spinal fusion with BMP but without the bone extender. This group had previous failed spinal fusions. They made up a special category called compassionate use surgeries. High-dose BMP-2 was used but without adding any of the patient’s bone to extend it. Instead a special graft extender or bulking agent in granule form called TCP-HA was added to the BMP.

Number of spinal levels fused averaged from two to five levels among the three groups. Average dose amount of rhBMP-2 used ranged from 10 mg/level to 40 mg/level.

Everyone was followed on a regular basis for at least two years. X-rays were used to assess the fusion. CT scans were only used when there were questions about the fusion as seen on X-rays. CT scans are more expensive than plain X-rays and expose patients to more radiation.

The fusion site was scored with a number (one through five) and given a grade (A through E). The scoring and grading was based on the description of the fusion. For example, Grade A (fusion score of one) was given to solid fusions present on both sides (bilateral). Grade D (score of four) indicated the graft was probably not fused. Grade E (score of five) was given when the fusion could not be assessed. Intermediate grades (B and C) are on a continuum from definite fusion to no fusion with special qualifiers for each.

The results showed that rhBMP-2 had excellent fusion rates (95 per cent) in all three groups. Solid fusion was achieved with low-doses, high-doses, and when combined with local bone or an extender. Pseudoarthrosis (formation of a false joint with movement at the fusion site) was very low using BMP. No known causes or risk factors could be determined to help predict in advance who might be affected by pseudoarthrosis.

Outcomes were equally good when performed using an anterior or posterior approach. At the end of two years, no one had any complications (loosening, shifting, pullout, or breakage) of the instrumentation used (rods, screws). And results were good even when patients smoked, had other health issues, or had previous (failed) spinal fusion.

BMP may actually be a superior choice over iliac crest bone graft (ICBG). A 95 per cent fusion rate with BMP is higher than reported in other studies using ICBG. The factors that can interfere with successful ICBG don’t seem to influence results with BMP.

In summary, the authors did, indeed, show that BMP fusion rates for multiple level lumbar spinal fusions are equal (if not better) than iliac crest bone grafts (ICBG). And lower amounts of BMP were used with the same good outcomes. Likewise, BMP used alone had the same results as BMP used with graft extenders.

The authors make note of the fact that sometimes fusion failures (pseudoarthrosis) occur as much as four years after the surgery. For that reason, the patients in this study will continue to be followed up to see what the long-term results are with rhBMP-2 as a substitute for bone graft.

Patients should participate in physical therapy after having spinal surgery on the lower back for degeneration injuries in order to help improve the success of the surgery, recommends the North American Spine Society. Because surgery can be done a considerable amount of time after the back pain has begun, by the time the patient has had surgery, there is a good chance that the muscles in the back have begun to weaken due to limited use. If you are feeling pain, you try to avoid making certain movements to aggravate the pain, for example. The limited movements mean the muscles aren’t worked as often or as much as usual. Because of this, the muscles need to be retrained and the strength needs to be increased.

Despite the recommendations, some patients don’t follow through with physical therapy after surgery and it could be better for surgeons if they could have a way of screening which patients would be more compliant than others in participating in post-surgery rehabilitation. It’s known that patients with certain types of characteristics may be less likely to follow through with rehabilitation in general. This includes patients who are depressed, who have depressed attitudes, and who don’t appear to have any motivation to work at recovery. It’s also known that patients who see their physical therapy as an extension of their recovery management are more likely to participate actively.

Patient activation is a term that was coined to define how likely a patient may be to participate in actions and behaviors that will improve their chances of recovery. According to the authors of this article, “an active patient is one who is armed with the skills, knowledge, and motivation to be an effective member of the healthcare team.” As patients are more apt to participate, their recovery rate usually rises, and this – in turn – can affect their psychological state. That being said, patient activation isn’t something that has been tried with physiotherapy following surgery for lower back injuries.

The researchers in this study wanted to determine the association between patient activation and the success of physical therapy after lower back surgery for degenerative injuries. The researchers enrolled 65 patients who were a mean age of 58 years. There were slightly more females than men (58 percent were female) in the group. All patients had undergone spinal surgery for the first time. The patients participated in the six-week study by attending regularly scheduled physical therapy sessions. Three patients ended up not attending any sessions. It turned out that one wasn’t able to pay for the sessions and the other two were not able to schedule convenient appointments.

The patient activation was measured using the Patient Activation Measure, a measure of 13 items. Each item is a statement, such as: When all is said and done, I am the person who is responsible for managing my health condition and I understand the nature and causes of my health conditions. For each statement, the patient is asked if they think the statement is true for them or not true for them.

Patients were also assessed using the Life Orientation Test, which measures optimism. For this test, the patient is told a positive statement and a negative statement, and are asked which is more true for them. Another measure was the Trait Hope Scale, which measured the patients’ perceived ability to figure things out in order to reach their goal or goals. The researchers also had to measure the efficacy of the physical therapy and if the patients were showing any signs of depression. Finally, the patients were assessed during their final physical therapy session using the Hopkins Rehabilitation Engagement Rating Scale and they were asked to self-report how often they went to physical therapy.

In gathering the results, the researchers found that there were no differences in results between males and females, age, marital status, other illnesses, or education. However, they did find that nonwhite patients were more likely to score low marks on the Patient Activation Measure as were patients in the lower income scales. The income level was a major finding. In fact, nearly 75 percent of those who scored low on the measure had a yearly household income of less than 50,000 dollars, while 69 percent of the patients who scored highest were from households of more than 50,000 dollars per year. When looking at depression and patient activation, the researchers found that those who were more active, the less likely they were to be depressed or have symptoms of depression.

Whether a patient was active (showed up for and participated in physical therapy sessions) was clearly seen by the results that showed patients who did not actively participate also had lower confidence and hope for improvement. Patients who scored well in the Patient Activation Measurement, did well in physical therapy participation. The more self-assured and self-confident the patient, the better the attendance and participation rates.

The authors did point out that here were some limitations to their study. These include that there was no follow up with the patients to see how they did over the long term, the patients came from one particular medical group, and that the researchers relied on the patients reporting if they attended physiotherapy sessions or not. The authors also mentioned that the sample size was small, so making a general statement regarding patient attributes and physical outcome may not be that reliable. However, they pointed out that this study was a good start in showing that there is a relationship between how patients feel about themselves and how well they participate in rehabilitation following spinal surgery.

Scoliosis, a curvature of the spine occurs most often in older children and teenagers. But it can develop in older adults with serious complications. The cause is usually age-related degenerative changes in the spine. Sometimes there is no known cause. In this study, surgeons from the Department of Neurosurgery at the University of Virginia examine how often scoliosis occurs in older adults and the treatment needed.

Adults over the age of 60 with spinal deformity were included in the investigation. Patients were examined thoroughly with a detailed personal and family history, physical exam, and additional neurological exam. A full-length spine X-ray was taken to show the complete scoliosis. Each patient filled out a series of surveys to judge pain levels, function, and disability.

The patients were divided into two groups based on the chosen treatment approach. The nonoperative management included physical therapy, steroid injections, antiinflammatory drugs, and narcotic pain relievers. The operative group had spinal surgery to correct the spinal deformity.

Conservative care was advised for everyone first. Many patients have had nonoperative care that didn’t help. But the treatment may not have been enough or inconsistent at best. Entering a formal pain management program often makes the difference. And addressing issues such as deconditioning can be very helpful.

But failure to reduce pain, deformity, weakness, and bowel/bladder problems was an indication that surgery was needed. The decision to have surgery was not taken lightly. Complications from this type of surgery can be serious in this age group. The patients and surgeons talked together at length before taking this step.

All patients were advised that surgery can provide about a 50 per cent improvement. In other words, it’s not a cure, and it doesn’t result in a 100 per cent reduction of pain. There’s no way to predict how much bowel or bladder function will improve (or if it will even improve at all). The majority of patients stayed in the nonoperative group. Out of 319 patients, only 74 had surgery.

Those who had surgery had much greater disability compared with the patients who stayed with nonoperative care. The surgical group were more likely to have severe back and/or leg pain, leg weakness, and loss of normal bowel and bladder function. About 15 per cent of the patients who were originally in the nonoperative group crossed over to the operative group. These patients had surgery during the follow-up portion of this study.

The authors concluded that pain, neurologic symptoms, and the loss of function that occurs because of these problems are the most common reasons to pursue surgery. Older adults should be encouraged to try an adequate course of nonoperative care before considering surgery.

All the pros and cons of surgery should be discussed. The patient makes the final decision, but the surgeon plays an important role in the counseling and management portion of treatment. It’s a difficult and complex decision that must take many factors into consideration.

This study points out the importance of three of those factors: pain, weakness, and deformity. Surgery is more likely in the presence of these three things. Further study is needed to identify other factors in the decision-making process. Evaluation of the long-term results may provide additional helpful information for future patients facing this difficult treatment decision.

Fragility fractures have been shown to be associated with increase in mortality. One of the more common fragility fractures is of the hip. Early operative surgical interventions for patients with hip fractures have been shown to reduce mortality. Because kyphoplasty after vertebral compression fracture has a positive improvement in pain, mobility and function should be allowed earlier than with non-operative care. Therefore, it seems likely that mortality with kyphoplasty would be reduced compared to treatment with conservative care.

Since the incidence of vertebral compression fracture is 700,000 per year, the authors of this study were interested in the effect of kyphoplasty on mortality. Studies have shown mortality rates after vertebral compression fracture are between 23 percent, and 67.5 percent.

The authors of the study retrospectively reviewed the charts of subjects with vertebral compression fractures between June 2000, and June 2004. The subjects were divided into two groups, those who underwent kyphoplasty, and those who chose conservative care to include oral analgesics and back brace All subjects were from the practice of one orthopedic surgeon. The study ended September, 2006. The end point that was evaluated was patient death within the study time period.

There were 94 subjects who chose kyphoplasty to treat vertebral compression fracture. There were 90 patients in the group that chose conservative care

Thirty-eight of the patients who underwent kyphoplasty died. Twenty-six of the patients who chose conservative care died. Age was a significant difference, with those undergoing kyphoplasty having an average age of 76.9 years, and those choosing conservative care, 68.6 years.

The authors concluded that kyphoplasty did not seem to effect the survival of patients after vertebral compression fracture. However, there was a significant difference in age between those treated with kyphoplasty, and those that chose conservative care in this study population that could have affected outcomes. The length of the study was also relatively short. Other co-morbidities were not significantly different, nor were gender between the two groups.

The authors suggest that while their study does not show that kyphoplasty reduces mortality from vertebral compression fracture, it does allow for a more comfortable return to activities of daily living.

1. Is there a significant risk of mortality following vertebral compression fracture?

Yes, a recent study evaluated available literature. The authors found that the mortality rate ranged between 23 and 67 percent.

2. What treatment options are available for vertebral compression fracture?

The usual two options are conservative care and kyphoplasty. An orthopedic surgeon who recently authored an article, compared the mortality between these two treatment options. Kyphoplasty is the placement of bone cement into the vertebral body using a needle that is guided by x-ray. Conservative care usually involves the use of oral analgesics, activity restriction, and bracing.

Osteoporosis is common in Americans older than age 50. This is often the cause of fragility fractures. Most fragility fractures of the vertebral body, proximal femur, and distal radius. In fact, more than 50 percent of women, and 30 percent of men will have a vertebral compression fracture at some point in their life. Ten to twenty percent will have another fragility fracture within one year following a vertebral fragility fracture.

There are several well-proven treatment options for osteoporosis. Treatment of osteoporosis with medication therapies can reduce the rate of subsequent fragility fracture by 50 percent. Morbidity following a fragility fracture is significant. The authors make the point that providers, particularly orthopedic surgeons, are missing opportunities to evaluate and treat osteoporosis following fragility fracture.

The authors of the study reviewed medical records from a military healthcare system with a computerized medical records data base. The authors were interested in evaluating intervention for evaluation and treatment of osteoporosis in the year following vertebral osteoporotic fragility fracture in patients 50 years or older. The records of 156 patients, 78 men and 78 women, meeting the inclusion criteria were evaluated. The authors were looking for referral for dual energy X-ray absorptiometry, DEXA scan, endocrinology, or prescribing of medications approved by the FDA for active treatment of osteoporosis.

The authors found that while sixty percent of women in the study were prescribed medications for active treatment of osteoporosis, only fifteen percent of men in the study were treated with medications for active treatment of osteoporosis. Forty seven percent of women were referred to endocrinology compared to 23 percent of the men. Additionally, 47 percent of women underwent DEXA scan compared to 31 percent of males.

The authors concluded that there is significant disparity among genders in the evaluation and treatment of osteoporosis following vertebral compression fracture. Given that the risk of subsequent fragility fractures following vertebral compression fracture in men is nearly double the risk in women, this gender disparity has even greater significance.

It is suggested that 30 percent of vertebral compression fractures in persons with osteoporosis is due to falling.
Compliant flooring may be a promising way to reduce impact force during a fall and reduce vertebral fracture risk during a fall.

Previous studies have shown that peak impact backward forces are 6.4 to 9.0 times body weight in a fall onto a bare floor. Elderly male lower thoracic and upper lumbar spines have been shown to fracture at loads of 3009 to 4150 Newtons at 6.5 milimeters per second.

The authors of the study evaluated forces generated in staged falls of 11 healthy young males onto various surfaces. The falls were considered worst case. This means that they were not allowed to absorb the impact of the fall by using their arms, or by rolling. The subjects were trained to fall from a vertical position directly onto their buttocks. A force plate on the floor where the buttocks landed was used to measure the force of the fall.
The authors compared the force plate measurements when the subjects fell onto a foam surface of three different thicknesses. The foam flooring had layers of closed cell cross linked ethylene vinyl acetate, EVA. The depth of the foam used was 4.5 cm, 7.5 cm, and 10.5cm thickness.

Unlike some of the previous studies, this study measured force at the buttocks rather than the spine. Mean peak vertical force at the buttocks when landing on 4.5 cm foam flooring was 5.7 to 7.5 times body weight. This was 15 percent less than the proposed forces generated from falling on a hard surface.

This may be enough of a reduction in force to be under the threshold for fracture. The force attenuation from the 7.5cm foam flooring was 20 percent. The force attenuation from the 10.5 cm flooring was 24 percent. These findings were similar to reduction in forces at the femoral neck in other studies.

The authors are aware that while closed cell foam my reduce the risk of compression fractures from falls among the elderly, it may not be feasible to use it in a facility. Balance, rolling wheelchairs and furniture may be more difficult with this surface type. The authors feel that testing other materials such as viscoelastic flooring would be worthwhile. This would be a surface that may be viable in hospitals and nursing homes to reduce risk of compression fractures from falls.

More and more older adults are starting to develop scoliosis without a clear reason. Scoliosis is a curvature of the spine. De-novo scoliosis is a term used to describe the start of a new condition that was not there before. This is applied to scoliosis in older adults because most cases of scoliosis occur during childhood and adolescence. Another term used to describe this condition is adult degenerative scoliosis.

This report offers a review of adult degenerative scoliosis. From the studies that have been done so far, it looks like this type of scoliosis may be caused by unilateral (one-sided) disc degeneration. This can occur in the thoracic (mid-back) or lumbar (low back) spine. With a loss of disc height on one side, pressure is increased on the facet (spinal) joint on the same side. Muscle imbalance occurs and bone spurs form.

The patient is over the age of 50 (usually 65 or older) and often has other spinal problems such as spinal stenosis. Spinal stenosis is a narrowing of the spinal canal. De-novo degenerative scoliosis combined with spinal stenosis can lead to severe back and/or leg pain. The pain is worse when walking. This symptom is called intermittent claudication.

The best treatment for this type of scoliosis remains unknown at the present time. Each patient must be assessed individually. Treatment must be matched to each person based on clinical presentation and patient expectations. A complete assessment will include personal and family history, psychologic status, and a structural evaluation of the body and spine.

Because of the muscle imbalance that can occur, muscles must be tested carefully and thoroughly. Joint function, motion, and flexibility should also be evaluated. Nerve and muscles are tested and bowel and bladder function are reviewed. Many older adults who have difficulty walking may also have loss of blood supply to the legs causing similar symptoms of leg pain and intermittent claudication. Therefore, the physician must also assess vascular status.

Treatment is guided, in part, by imaging studies. Standard X-rays are still relied upon when making decisions about surgery to correct the deformity. Information about curve flexibility and segmental stability can be gained from X-rays.

MRIs and CTs have some useful purpose in this diagnostic process. MRIs show the full extent of the stenosis. Pre-operative bone mineral density studies are necessary because of the risk of fractures in patients who have osteoporosis.

Before surgery is considered, each patient is advised to try a conservative approach. Nonoperative treatments such as physical therapy, bracing, and injection therapies may be helpful. But there hasn’t been enough studies of high quality to show what treatment protocol works best. Treatment guidelines for conservative care are fairly limited at this time.

Surgery is done to reduce pain, stabilize the spine, and improve function. Pressure is taken off the spinal cord and spinal nerves by removing bone from around these tissues. This procedure is called surgical decompression. Patients must be selected carefully for this operation. The presence of any spinal instability may prevent the patient from having surgery that could make the instability worse.

Spinal fusion is often the best answer. Using instrumentation such as metal rods can help decompress and support the spine at the same time. Any spinal deformity is also corrected with this approach.

There are many factors to consider and many decisions to make with fusion surgery. The patient’s mental and physical health, bone density, and number of segments involved must be evaluated. Where to start and stop the fusion is important. Each of these decisions has its own factors to consider. For example, the longer the fusion, the greater the risk of blood loss, increased cost, and risk of developing motion at that level called a pseudoarthrosis. The presence of a pseudoarthrosis is a sign of fusion failure and spinal instability.

Types of surgeries to achieve the goals can include anterior fusion, posterior fusion, or both at the same time. The authors prefer an all-posterior approach. Their patients receive nutritional support and intensive rehab after surgery.

Special transforaminal lumbar interbody fusion (TLIF) grafts are used. TLIF fuses the front and back section of the spinal column through a single posterior approach. Usually a fair number of spinal segments are involved (five or more). Fusion corrects spinal deformity and restores mechanical stiffness of the spine.

The authors provide specific ways in which they use iliac screws. A diagram is provided of the placement of iliac wing screws. Putting the screws deep into the iliac bone helps reduce problems with the hardware. Attention to the details of any procedure can help reduce complications. Paying close attention can reduce the risk of revision surgery, too. That’s important in this group of patients who are often quite fragile and can’t tolerate much surgery.

Keeping in mind the goals of increased function and decreased pain doesn’t always ensure 100 per cent success. But it’s a good place to start when rebalancing the spine in older adults who have painful degenerative scoliosis.

Lesions of the spine are often biopsied in order to make an accurate diagnosis. The problem could be a tumor, infection, or cancer metastases. During the biopsy, a small piece of tissue is removed and sent to the lab for proper identification.

Treatment is based on these findings. Open-incision biopsy is quickly being replaced by fluoroscopic- or CT-guided percutaneous biopsy. In this report, the effect of the inner diameter of the biopsy needle is summarized. The authors present their findings from a meta-analysis done using 25 published reports.

Percutaneous means through the skin. During a percutaneous biopsy, a very long, thin needle is inserted through the skin and soft tissues and then into the bone. A sample of the suspicious tissue is removed and analyzed by the pathologist.

In order to guide the needle to the right spot, the surgeon uses an X-ray device called fluoroscopy. This type of imaging allows the surgeon to see while moving the needle. The advantage of this type of biopsy is that the muscles aren’t cut open. The surgeon can also avoid damaging nearby nerves. The disadvantage is that it is less accurate than an open biopsy.

CT scan is another method used to guide biopsies. CT scans give the surgeon a more accurate image of the structures. But the technique isn’t real-time like it is with fluoroscopy. The use of CT scans to guide the process takes longer than fluoroscopy. But it is more accurate for difficult to reach areas such as the thoracic or cervical (neck) spine.

After reviewing all relevant articles, the authors summarized the findings. The use of CT-scans to guide the needle was slightly more accurate and safer (fewer complications) when compared with fluoroscopic-guided biopsies. The difference wasn’t huge (3.3 per cent complication rate with CT scan compared with 5.3 per cent for fluoroscopy). There aren’t many studies to go by, so these findings might be different if a larger number of patients were involved.

Besides comparing results with different guidance systems, the authors also investigated the results comparing different sized needles used to do the biopsies. One challenge in performing biopsies is to get enough of the pathologic tissue to make a diagnosis. This is called adequacy. Accuracy is also important. Usually the accuracy of a biopsy is confirmed after surgery when the removed tissue is examined more thoroughly.

The inner diameter of the needle was evaluated as a factor in adequacy and accuracy of percutaneous spinal biopsies. Most of the studies were done with spinal metastases. Radiation before the biopsy complicated the diagnosis. In general, a smaller diameter needle had better results. The needle didn’t block the surgeon’s view or damage the soft tissues it passed through. Larger diameter needles were better for taking samples from sclerotic (hardened) bone lesions.

The authors conclude that when doing percutaneous spine biopsies, the surgeon may have a choice between fluoroscopy and CT-guided biopsy. There are pros and cons to each one. Choosing the right one for the most accurate diagnosis depends on the type of lesion, location of the problem, and level (cervical, thoracic, or lumbar spine). The expertise of the surgeon is also an important factor in the outcome.

In this article, two surgeons well known for their work in this area review the spinal manifestations of achondroplasia. Their specific focus was on the treatment of spinal problems linked with this condition.

Achondroplasia is a genetic disorder that results in a common type of dwarfism. Children who are born with this condition have a variety of deformities, including several in the spine. The most common spine problems include foramen magnum stenosis, thoracolumbar kyphosis, lumbosacral hyperlordosis, and spinal stenosis.

The authors discuss the treatment of each one of these conditions. They review previous studies done and summarize their findings. The first deformity to appear in the infant or young child is foramen magnum stenosis. This refers to narrowing of the opening at the base of the skull where the spinal cord exits.

Many problems can occur when the narrowing is enough to cause pressure on the spinal cord. Children may have difficulty swallowing, reduced muscle tone, muscle weakness, and delays in development. Surgery is often needed to take pressure off the neurologic structures. This type of procedure is referred to as surgical decompression.

Thoracolumbar kyphosis is a curved mid-lower back from the way the children slump-sit. If uncorrected, the anterior (front) section of the vertebrae get pushed into a wedge-shape. Surgery isn’t usually needed but prevention is important.

As the child grows and develops, he or she assumes an upright position. This has the effect of improving trunk strength. The child starts to walk. Both of these factors work to overcome the forces that created slumping and wedging. Bracing is used during the interim. The child is not allowed to sit unsupported.

When these efforts fail to prevent progressive kyphosis, then surgery is done to stabilize the spine. Multiple pedicle screws are used to fuse vertebral segments together. Screw size and angles are important in this population.

The authors describe the successful results of previous studies they have done using a two-stage anterior and posterior spinal fusion for this problem. They also discuss studies done by other surgeons using a one-stage anterior procedure, posterior alone surgery, and reconstructive surgery for adults with thoracolumbar kyphosis from achondroplasia.

Lumbosacral hyperlordosis is an increase in the normal swayback position of the low back area. The more thoracic kyphosis is present, the more the body tries to compensate with increased lordosis. When viewed from the side, the child with these two features has a prominent abdomen (belly) and buttocks.

The best way to treat lumbosacral hyperlordosis is unknown. Conservative (nonoperative) care with muscle stretching has not helped. Surgeons have tried releasing hip flexor muscles and bone lengthening procedures without success. This is an area for future study.

Spinal stenosis (narrowing of the spinal canal) is the final spinal manifestation of achondroplasia that is presented. In this condition, not only is the spinal canal narrow, but the vertebral bodies are also short and thick.

The effect of these changes is to reduce the distance between the vertebrae, discs, ligaments, and other soft tissues. At the same time, the spinal cord and spinal nerves are all a normal size. The mismatch between these structures increases the risk that the stenosis will cause painful symptoms.

Children can be affected by spinal stenosis, but more often, this condition develops during the adult years. Most of the time, it’s the lumbar spine that’s involved. But stenosis can also affect the cervical (neck) spine, too. When symptoms are severe, surgery may be needed. This happens in about one-fourth of the achondroplasia patients with cervical or lumbar stenosis.

Studies show that simple decompression is not successful with these patients. There are many complications reported such as dural tears, wound breakdown, and infections. Instrumentation used to fuse the spine such as screws or plates are also at risk for breaking, shifting position, or coming loose. Kyphosis (forward curvature of the spine) is a typical complication in children. This is especially common after decompression at multiple levels.

The authors conclude there are many difficulties in treating spinal problems in children with achondroplasia. Even so, it is possible to manage this condition safely and effectively. Treatment at a center where the surgeons and staff have experience with this diagnosis is strongly advised.

Five contortionists who trained in the circus school in Inner Mongolia were evaluated by magnetic resonance imaging, MRI. The authors of the study were interested in the effect of extreme body contortions on the spine. The subjects were all females, between the ages of 20 and 49 years. Each started intense training between the ages of six to 12.

Interestingly dynamic, whole spine MRIs were acheived in two of the subjects. These subjects were in contorted positions when imaged.

The authors discovered that anterosuperior limbus avulsion fractures were found in three out of the five subjects. One subject had limbus fractures at two levels. A limbus fracture involves a fracture of the end plate of a vertebral body. Risk factors for limbus fractures include young age and skeletal immaturity. Prior to complete fusion as the skeleton becomes mature, the junction of the disc and the vertebral body can be prone to injury. In these subjects, it is hypothesized that chronic and repetitive stresses into spinal extension resulted in the limbus fractures.

Straightening of the cervical lordosis in supine was noted in all five of the subjects. Dextroscoliosis was also noted in all five subjects. Older athletes demonstrated more severe degenerative changes of the spine. They also had more complaints of back pain. Osteophytes, disc bulges and annular tears were also found on imaging. While range of motion in flexion was perceived as normal, extension of the spine was increased.

The Beighton system to grade hypermobility was used on the subjects. The maximum score is nine, meaning greater hypermobility. A score greater than or equal to five is considered hypermobile. Four of the five subjects had a score of nine, and the fifth subject had a score of seven.

In summary, the authors felt that the degree of pathology in the spines of the contortionists was limited considering the degree of stress placed on their spines, particularly in extension.

Osteochondroma is a form of benign bone tumor. It is the most common form of benign bone tumor. Osteochondroma are composed of a bony component surrounded by a cartilaginous component. While most are found toward the ends of long bones, they have been found in the spine also. Most of the time in when found in the spine, they involve posterior elements such as the facet joints.

Some osteochondroma are hereditary, others are not. It is felt that some may occur as a result of trauma. They are also known to occur following radiation, particular in children who had radiation exposure when younger than age two. Spinal osteochondromas are discovered at an average age of 30 years. They occur more than twice as often in men than women.

These usually benign tumors can become malignant. Those that are herditary are most likely to be malignant. Those that are most often malignant have a cartilaginous cap that is greater than three centimeters thick.

The most common symptom that prompts work up is myelopathy. Myelopathy is weakness due to injury of the spinal cord. The authors discussed three case studies of subjects with spinal osteochrondromas. They ranged in age from 17 to 40 years. All of them had weakness of one or more extremities. One of the three subjects also experienced bladder dsyfunction. One half of the time, spinal osteochondromas involve the neck. The recommended treatment is removal of the tumor surgically. The cartilaginous cap should be completely removed for best results.

Patients who don’t get better after back surgery may be diagnosed with “failed back surgery syndrome”. They either don’t get any pain relief or there’s not enough relief of pain to improve function or quality of life. About 80,000 people in the United States fall into this category every year.

A second operation may not be the answer, either. Only 30 per cent of patients who have another surgery improve. The rate of success goes down dramatically for third and fourth operations.

Chronic, disabling symptoms may be best treated using a multidisciplinary approach. The team of health care specialists should include the primary care physician, surgeon, physical therapist, and pain management specialist.

There isn’t enough evidence in the medical literature to support a specific approach to failed back surgery syndrome. Physicians don’t have good guidelines to help them direct patients.

More research is needed to identify the best way to approach the diagnosis and management of the back pain patient who has a poor response to back surgery.