Lumbar disc surgery in a fixed compensation population: a model for influence of secondary gain on surgical outcome

The top-cited military relevant spine articles

Introduction

Historically musculoskeletal injury has substantially affected United States (US) service members. Lumbosacral spine injuries are among the most common sites of injury for service members across all US military branches and usually presents with pain in the lower back and extremities. The aim of this study is to identify and describe the 50 most-cited articles relevant to military medicine on the subject of the spine.

Methods

In April 2020 Web of Science was used to search the key words: spinal cord injury, spine, thoracic spine, lumbar spine, cervical spine, sacrum, sacral, cervical fusion, lumbar fusion, sacral fracture, combat, back pain, neck pain, and military. Articles published from 1900 to 2020 were evaluated for relevance to military spine orthopaedics and ranked based on citation number. The 50 most-cited articles were characterized based on country of origin, journal of publication, affiliated institution, topic, military branch, and conflict.

Results

1900 articles met search criteria. The 50 most-cited articles were cited 24 to 119 times and published between 1993 and 2017. 30 articles (60%) originated in the United States. Aviation, Space, and Environmental Medicine accounted for the most frequent (n = 10) destination journal followed by Spine (n = 8). 37 institutions contributed to the top 50 most-cited articles. The most common article type was clinically focused retrospective analysis 36% (n = 18), clinically focused cohort study 10% (n = 5), and clinically focused cohort questionnaire, cross-sectional analysis, and randomized study 8% each (n = 4). 90% of articles were non-surgical (n = 45). The US Army had the greatest number of associated articles. Operation Iraqi Freedom and Operation Enduring Freedom were the most-cited conflicts.

Conclusion

The 50 most-cited articles relevant to military spine orthopaedics are predominantly clinically focused, arising from the US, and published in Aviation, Space, and Environmental Medicine, Spine, and The Spine Journal.

Lumbar Fusion for Active Duty Service Members Performed at an Overseas Military Treatment Facility: A 2-Year Retrospective Analysis

INTRODUCTION

Among U.S. Military active duty service members, low back pain (LBP) and lumbar radiculopathy are common causes of disability and effect job performance and readiness and can lead to medical separation from the military. Among surgical therapies, lumbar fusion is an option in select cases; however, elective lumbar fusion performed while serving overseas has not been studied extensively.

MATERIALS AND METHODS

A retrospective analysis of a prospectively collected surgical database from an overseas military treatment facility (MTF) over a 2-year period (2019-2021) was queried. Patient and procedural data were collected to include single and 2-level lumbar fusion, indications for surgery, military rank, age, tobacco use, pre- and postoperative Visual Analog Scale (VAS) scores for pain, and the presence of radiographic fusion after surgery. Chi-square and Student's t-test analyses were performed to identify variables associated with return to full duty.

RESULTS

A total of 21 patients underwent lumbar fusion with an average follow-up of 303.2 days (110-832 days). Eleven (52.4%) were able to return to full duty without restriction. Four (19%) patients ultimately required medical separation from the military, and six (28.6%) remained in a partial or limited duty status. Three (14.3%) patients required tour curtailment and return from overseas duty prematurely. Older age (40.2 ± 5.9 years), rank of E7 or greater, and reduction in VAS of 50% postoperatively were all associated with return to full unrestricted active duty. Three surgical complications occurred; all patients were able to recover overseas within a 3-month postoperative period.

CONCLUSIONS

Low back pain (LBP) and lumbar radiculopathy may ultimately require treatment with instrumented lumbar fusion and decompression. In this series, we demonstrate that overseas duty with treatment at a community-sized MTF does not preclude this therapy and should be considered among treatment options.

Factors associated with return to duty and need for subsequent procedures after calcaneus open reduction internal fixation in the military

INTRODUCTION

Calcaneus fractures can be devastating injuries, and operative treatment is fraught with complications. We are unaware of any studies evaluating all calcaneus fractures, both open and closed, treated operatively in the military. The purpose of this study is to evaluate all calcaneus fractures that required open reduction internal fixation to determine soldiers' ability to return to work and the need for additional surgeries.

METHODS

All active-duty patients undergoing open reduction internal fixation of calcaneus fractures from 2010-2016 were identified utilizing the Military Health System Management Analysis and Reporting Tool (M2). Armed Forces Health Longitudinal Technology Application (AHLTA) was utilized to determine comorbid medical conditions, subsequent procedures, surgical outcomes, and duty status within the military.

RESULTS

Three hundred seventy-five active-duty service members who met our inclusion/exclusion criteria were identified. One hundred fifty-one patients (55.1%) sustained their calcaneus fracture as a result of a blast injury. One hundred sixty (59.3%) patients required separation from the military as a result of their injury. Among patients who required a subsequent procedure, thirty-four patients (9.1%) required a subtalar arthrodesis, and thirty-two patients (8.5%) eventually required a below knee amputation. Blast as mechanism of injury was the single most predictive variable for patients requiring separation from the military (Odds Ratio 16.2, p< .001), requiring a subsequent procedure (Odds Ratio 8.4, p < .001), and for requiring a below knee amputation (Odds Ratio 47.3, p < .001).

CONCLUSION

Calcaneus fractures treated operatively in the military are often caused by blast injuries, and have a high rate of requiring subsequent procedures, amputation, and separation from the military.

The Effect of Health Insurance Coverage on Orthopaedic Patient-reported Outcome Measures

INTRODUCTION

Patient-reported outcome measures (PROMs) are used to assess performance and value. The type of health insurance coverage may influence outcomes scores. The goal of this study was to determine if the type of insurance coverage is associated with the trends in PROMs within an orthopaedic cohort.

METHODS

We reviewed the electronic medical records of 10,745 adult foot and ankle patients who completed PROMs questionnaires from 2015 to 2017. Patients completed the Foot and Ankle Ability Measure, PROMIS Global-Mental, PROMIS Global-Physical, and PROMIS Physical Function Short Form 10a. Descriptive analyses, analysis of variance, and Tukey HSD (honest significant difference) post hoc analyses were conducted.

RESULTS

Patients with commercial insurance consistently had the highest outcomes scores, whereas those with Workers Comp/Motor Vehicle and Medicaid had the lowest. PROMs of patients with commercial insurance were statistically significantly higher than the pooled scores of all other patients. Markedly poorer scores were also seen for Workers Comp/Motor Vehicle and Medicaid. In addition, these differences in PROMs for Workers Comp/Motor Vehicle and Medicaid exceeded the minimal clinically important differences. Patients with Medicare or Free Care had generally lower scores than the pooled averages, but these results were not statistically significant.

DISCUSSION

PROMs scores vary between the patients with different insurance types in an orthopaedic foot and ankle cohort. These data suggest that patient insurance type may affect patient-reported outcomes.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort.

Can Anything Good Ever Come From Bearing Migraine Attacks? Suggestions for a Comprehensive Concept of Gain in Migraine

PURPOSE OF REVIEW

The purpose of this review is to summarise the current state of knowledge concerning known types of gain, the reasons why patients might seek it, as well as implications for headache disorders.

RECENT FINDINGS

Even though the subject has been studied in the past, it received less attention in recent years. There is no doubt that migraine is a highly disabling disorder. However, attacks sometimes may be beneficial for the migraine brain as a time-out from the daily routine. On the other hand, patients are often stigmatised as trying to satisfy other needs through their disease. These "other needs" may be the exaggerated seeking for attention and affection or an undue official sickness certificate and were named secondary gain. Striving for secondary gain denotes a behaviour that aims at benefiting from a disease in a way that is seen as inappropriate by others. The fact that the term has persisted in doctors' vocabulary for decades probably indicates that it designates a concept considered relevant by many. However, its usage is complicated by its usually imprecise definition. We found in a literature search that the strive for secondary gain is not limited to neurosis, might both occur consciously and unconsciously, sometimes may aim at financial gain and sometimes at social gain, and can either be potentially expected or readily obtained. This behaviour mainly seems to aim at shaping one's interactions with the environment. Its causes have not been elucidated completely, though, but "unrequited demands for love, attention and affection" have been postulated. The desire for social gain can be influenced by approaches based upon behavioural psychology. Broaching the issue of secondary gain may be beneficial in the daily clinical routine.

Effect of Social Factors on Surgical Outcomes in Cervical Disc Disease

Background

Daily clinical practice shows us how diametrically different surgical outcomes can occur in particular groups of patients sharing the same diagnosis and being subjected to the same treatment. Patient-reported outcomes appear to be significantly influenced by social factors and patients’ emotional status. Data on such variables were collated and analyzed statistically with the aim of confirming our clinical observations.

Methods

We analyzed a group of 100 patients following cervical disc surgery. The clinical evaluation was based on a visual analog scale (VAS) for pain and the neck disability index (NDI). Non-clinical data comprised education status, employment status, body mass index (BMI), and history of depressive episodes in the period immediately preceding the surgery, which was investigated using the Beck Depression Inventory (BDI).

Results

Patients who had completed university or secondary school education had a significantly lower BMI and lower BDI scores and they reported less pain at 12 months postoperatively than patients with vocational or elementary school education only. Patients who were employed at the time of the study or were retired demonstrated significantly lower NDI scores both before the surgery and at 12 months postoperatively, as well as lower BDI scores compared to those who were unemployed or drew disability pensions. Factors such as age or BMI score did not exert a direct effect on treatment outcomes assessed as changes in the VAS and NDI scores.

Conclusions

Surgical treatment for the cervical disc disease decreases pain and improves patients’ quality of life. Treatment outcomes are also influenced by social factors and patients’ emotional status.

Editorial Commentary: Hip Arthroscopy in a Military Population: Are the Results Comparable to an Athletic Population?

Hip pain is common in the military population and has led to an increase in hip arthroscopy as a means of therapeutic treatment. Return to duty (RTD) is the measure by which military surgeons tend to judge their outcomes; could the servicemember "get back in the fight?" Return to play (RTP) is a common metric in sports medicine for assessing the effectiveness of a surgical intervention. The results of prior studies of RTD hip arthroscopy in the US military population have been underwhelming when compared with RTP in athletic cohorts. This discrepancy in outcomes likely has more to do with the differences in RTD and RTP as outcome measures than any surgeon, pathology, or demographic factors.

Long-term Outcomes of 2-Level Total Disc Replacement Using ProDisc-L: Nine- to 10-Year Follow-up

STUDY DESIGN

A prospective clinical data analysis.

OBJECTIVE

To determine the long-term clinical success of 2-level total disc replacement (TDR) in patients with degenerative disc disease.

SUMMARY OF BACKGROUND DATA

Early successful clinical results of 2-level TDR have been reported. Few studies exist that have described this procedure's durability in the long term.

METHODS

Fifteen patients underwent 2-level lumbar TDR with the ProDisc-L as part of a randomized trial, 13 of whom were available for follow-up. The patients were assessed preoperatively and at 2 years, 5 years, and more than 9 years postoperatively using visual Oswestry Disability Index. At the last follow-up visit, 2 additional questions were asked: satisfaction with surgery and willingness to undergo the same treatment. Finally, clinical success was assessed using a previously described definition.

RESULTS

Mean follow-up time was 9.6 years (range, 9.2-10.3 yr). Postoperatively there was a significant improvement in Oswestry Disability Index score from baseline (70.0 vs. 15.7 at 2 yr, P = 0.002) that remained unchanged during the period of follow-up (19.8 at 5 yr, P = 0.003 and 12.9 at 9-10 yr, P = 0.002). Ninety-two percent of patients were "satisfied" or "somewhat satisfied" with treatment and the same number would undergo treatment again. Eighty-five percent of patients achieved clinical success.

CONCLUSION

This prospective study demonstrates the durable clinical success of 2-level lumbar TDR as assessed at more than 9 years postoperatively.

LEVEL OF EVIDENCE

4.

Effectiveness of cognitive behavioral therapy for depression in patients receiving disability benefits: a systematic review and individual patient data meta-analysis

Objectives

To systematically summarize the randomized trial evidence regarding the relative effectiveness of cognitive behavioural therapy (CBT) in patients with depression in receipt of disability benefits in comparison to those not receiving disability benefits.

Data Sources

All relevant RCTs from a database of randomized controlled and comparative studies examining the effects of psychotherapy for adult depression (http://www.evidencebasedpsychotherapies.org), electronic databases (MEDLINE, EMBASE, PSYCINFO, AMED, CINAHL and CENTRAL) to June 2011, and bibliographies of all relevant articles.

Study Eligibility Criteria, Participants and Intervention

Adult patients with major depression, randomly assigned to CBT versus minimal/no treatment or care-as-usual.

Study Appraisal and Synthesis Methods

Three teams of reviewers, independently and in duplicate, completed title and abstract screening, full text review and data extraction. We performed an individual patient data meta-analysis to summarize data.

Results

Of 92 eligible trials, 70 provided author contact information; of these 56 (80%) were successfully contacted to establish if they captured receipt of benefits as a baseline characteristic; 8 recorded benefit status, and 3 enrolled some patients in receipt of benefits, of which 2 provided individual patient data. Including both patients receiving and not receiving disability benefits, 2 trials (227 patients) suggested a possible reduction in depression with CBT, as measured by the Beck Depression Inventory, mean difference [MD] (95% confidence interval [CI]) = −2.61 (−5.28, 0.07), p = 0.06; minimally important difference of 5. The effect appeared larger, though not significantly, in those in receipt of benefits (34 patients) versus not receiving benefits (193 patients); MD (95% CI) = −4.46 (−12.21, 3.30), p = 0.26.

Conclusions

Our data does not support the hypothesis that CBT has smaller effects in depressed patients receiving disability benefits versus other patients. Given that the confidence interval is wide, a decreased effect is still possible, though if the difference exists, it is likely to be small.

The influence of secondary gain on surgical outcome: a comparison between cervical and lumbar discectomy

Although the expectation of monetary compensation has been associated with failures in lumbar discectomy, the issue has not been investigated in patients undergoing cervical disc surgery. The authors analyzed the relationship between economic forms of secondary gain and surgical outcome in a group of patients with a common pay scale, retirement plan, and disability program. All procedures were performed at the Portsmouth Naval Medical Center between 1993 and 1995; active-duty military servicepersons treated for cervical radiculopathy were prospectively included. Clinical, demographic, and financial factors were analyzed to determine which were predictive of outcome. Financial data were used to create a compensation incentive, which is proportional to the patient's rank, years of service, potential disability, retirement eligibility, and base pay and reflects the monetary incentive of disability. The results of cervical surgery were compared to a previously reported companion population of patients treated for lumbar disc disease. A good outcome was defined as a return to active duty, whereas a referral for disability was considered a poor surgical result. A 100% follow-up rate was obtained for 269 patients who underwent 307 cervical operations. Only 16% (43 of 269) of patients who underwent cervical operation received disability, whereas 24.7% (86 of 348) of patients who underwent lumbar discectomy obtained a poor result (p = 0.0082). Although economic forms of secondary gain were not associated with a poor outcome in cervical disease, both the rank (p = 0.002) and duration (p = 0.03) of an individual's military career were significant factors (p = 0.02). Of the medical variables tested, multilevel surgery (p = 0.03) and revision operations at the same level (p = 0.03) were associated with referral for medical discharge. Secondary gain in the form of economic compensation influences outcome in lumbar but not cervical disc surgery patients; the increased rate of disability referral in patients who underwent lumbar discectomy may reflect an expectation of economic compensation. Social factors that are independent of the anticipation of economic compensation seem to influence the outcome in cervical disc surgery patients.

Preoperative Zung Depression Scale predicts outcome after revision lumbar surgery for adjacent segment disease, recurrent stenosis, and pseudarthrosis

BACKGROUND CONTEXT

Persistent back pain and leg pain after index surgery is distressing to patients and spinal surgeons. Revision surgical treatment is technically challenging and has been reported to yield unpredictable outcomes. Recently, affective disorders, such as depression and anxiety, have been considered potential predictors of surgical outcomes across many disease states of chronic pain. There remains a paucity of studies assessing the predictive value of baseline depression on outcomes in the setting of revision spine surgery.

PURPOSE

To assess the predictive value of preoperative depression on 2-year postoperative outcome after revision lumbar surgery for symptomatic pseudarthrosis, adjacent segment disease (ASD), and same-level recurrent stenosis.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

One hundred fifty patients undergoing revision surgery for symptomatic ASD, pseudarthrosis, and same-level recurrent stenosis.

OUTCOME MEASURES

Patient-reported outcome measures were assessed using an outcomes questionnaire that included questions on health-state values (EQ-5D), disability (Oswestry Disability Index [ODI]), pain (visual analog scale), depression (Zung Self-Rating Depression Scale), and 12-Item Short Form Health Survey physical and mental component scores.

METHODS

One hundred fifty patients undergoing revision neural decompression and instrumented fusion for ASD (n=50), pseudarthrosis (n=47), or same-level recurrent stenosis (n=53) were included in this study. Preoperative Zung Self-Reported Depression Scale score was assessed for all patients. Preoperative and 2-year postoperative visual analog scale for back pain and leg pain scores and ODI were assessed. The association between preoperative Zung Depression Scale score and 2-year improvement in disability was assessed via multivariate regression analysis.

RESULTS

Compared to preoperative status, VAS-BP was significantly improved 2 years after surgery for ASD (8.72±1.85 vs. 3.92±2.84, p=.001), pseudoarthrosis (7.31±0.81 vs. 5.06±2.64, p=.001), and same-level recurrent stenosis (9.28±1.00 vs. 5.00±2.94, p=.001). Two-year ODI was also significantly improved after surgery for ASD (28.72±9.64 vs. 18.48±11.31, p=.001), pseudoarthrosis (29.74±5.35 vs. 25.42±6.00, p=.001), and same-level recurrent stenosis (36.01±6.00 vs. 21.75±12.07, p=.001). Independent of age, BMI, symptom duration, smoking, comorbidities, and level of preoperative pain and disability, increasing preoperative Zung depression score was significantly associated with less 2-year improvement in disability (ODI) after revision surgery for ASD, pseudoarthrosis, and recurrent stenosis.

CONCLUSIONS

Our study suggests that the extent of preoperative depression is an independent predictor of functional outcome after revision lumbar surgery for ASD, pseudoarthrosis, and recurrent stenosis. Future comparative effectiveness studies assessing outcomes after revision lumbar surgery should account for depression as a potential confounder. The Zung depression questionnaire may help risk stratify patients presenting for revision lumbar surgery.

What is different about workers' compensation patients? Socioeconomic predictors of baseline disability status among patients with lumbar radiculopathy

STUDY DESIGN

Combined analysis of 2 prospective clinical studies.

OBJECTIVE

To identify socioeconomic characteristics associated with workers' compensation in patients with an intervertebral disc herniation (IDH) or spinal stenosis (SpS).

SUMMARY OF BACKGROUND DATA

Few studies have compared socioeconomic differences between those receiving or not receiving workers' compensation with the same underlying clinical conditions.

METHODS

Patients were identified from the Spine Patient Outcomes Research Trial (SPORT) and the National Spine Network (NSN) practice-based outcomes study. Patients with IDH and SpS within NSN were identified satisfying SPORT eligibility criteria. Information on disability and work status at baseline evaluation was used to categorize patients into 3 groups: workers' compensation, other disability compensation, or work-eligible controls. Enrollment rates of patients with disability in a clinical efficacy trial (SPORT) and practice-based network (NSN) were compared. Independent socioeconomic predictors of baseline workers' compensation status were identified in multivariate logistic regression models controlling for clinical condition, study cohort, and initial treatment designation.

RESULTS

Among 3759 eligible patients (1480 in SPORT and 2279 in NSN), 564 (15%) were receiving workers' compensation, 317 (8%) were receiving other disability compensation, and 2878 (77%) were controls. Patients receiving workers' compensation were less common in SPORT than NSN (9.2% vs. 18.8%, P < 0.001), but patients receiving other disability compensation were similarly represented (8.9% vs. 7.7%, P = 0.19). In univariate analyses, many socioeconomic characteristics significantly differed according to baseline workers' compensation status. In multiple logistic regression analyses, gender, educational level, work characteristics, legal action, and expectations about ability to work without surgery were independently associated with receiving workers' compensation.

CONCLUSION

Clinical trials involving conditions commonly seen in patients with workers' compensation may need special efforts to ensure adequate representation. Socioeconomic characteristics markedly differed between patients receiving and not receiving workers' compensation. Identifying the independent effects of workers' compensation on outcomes will require controlling for these baseline characteristics and other clinical features associated with disability status.

Outcome evaluation of surgical and nonsurgical management of lumbar disc protrusion causing radiculopathy

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To assess health-related quality of life (HRQOL) following either lumbar discectomy or nonoperative care for lumbar disc protrusion causing radiculopathy (LDPR).

SUMMARY OF BACKGROUND DATA

Although LDPR is a prevalent disorder, little progress has been made in defining the optimal treatment strategy.

METHODS

A total of 497 patients (333 in the lumbar discectomy group and 164 in the nonoperative group) were analyzed. Patients completed baseline as well as 6- and 12-month generic (SF-36) and disease-specific (NASS Lumbar Spine Instrument) HRQOL measures. Demographic comparisons between groups, using standard descriptive statistics, were made. Multivariate analysis was used to obtain a regression coefficient for the primary outcome: the neurogenic symptoms score (NSS) from the NASS instrument. Outcome measures were compared between groups and to published normative data.

RESULTS

The mean baseline score was lower in the surgical group (30.9 nonoperative, 25.3 surgical), indicative of greater baseline disability. The scores at follow-up were approximately equivalent (44.6 nonoperative, 43.8 surgical). However, neither group returned to an age-matched normative NSS (51.6) within the timeframe of the study. Using regression analysis, the outcome "change in NSS" was not associated with variable "treatment group."

CONCLUSIONS

HRQOL after LDPR, as measured in this study by NASS NSS, demonstrated similar improvement in both groups and was not meaningfully associated with the treatment received, within the timeframe of this study. At follow-up, all outcome measures remained lower than population normative scores, suggesting that, irrespective of treatment, an element of disability remained.

Predictors of surgical outcome and their assessment

The relatively high rate of failed back surgery has prompted the search for "risk factors" to predict the result of spinal surgery in a given individual. However, the literature reveals few unequivocal predictors and they often explain a relatively low proportion of variance in outcome. This suggests that we have a long way to go before being able to rest easily, having refused someone surgery on the basis of unfavourable baseline characteristics. The best recommendation is to ensure, firstly, that the indication for surgery is absolutely clear-cut (i.e. that surgically remediable pathology exists) and then to consider the various factors that may influence the "typical" outcome. Consistent risk factors for a poor outcome regarding return-to-work include long-term sick leave/receipt of disability benefit. Hence, every effort should be made to keep the individual in the workforce, despite the ongoing symptoms and plans for surgery. In patients with a particularly heavy job, consultation with occupational physicians might later ease the patient's way back into the workplace. Patients with degenerative disorders and/or comorbidity should be counselled that few of them will have complete/lasting pain relief or a complete return to pre-morbid function. Patients with a high level of distress may benefit from psychological treatment, before and/or accompanying the surgical treatment. The opportunity (time), encouragement (education and positive messages), and resources (referral to appropriate support services) to modify risk factors that are indeed modifiable should be offered, and realistic expectations should be discussed with the patient before the decision to operate is made.

Is autograft the gold standard in achieving radiographic fusion in one-level anterior cervical discectomy and fusion with rigid anterior plate fixation?

STUDY DESIGN

A review of 66 consecutive patients at a single institution who underwent one-level anterior cervical discectomy and fusion (ACDF) with rigid anterior plate fixation with allograft or autograft.

OBJECTIVES

To address the efficacy of allograft to autograft with primary respect to fusion rate and secondary attention to risk factors and clinical outcome in patients undergoing one-level ACDF with rigid anterior plate fixation.

SUMMARY OF BACKGROUND DATA

Although autograft is considered the gold standard in achieving optimal fusion, when compared with allograft in noninstrumented one-level ACDF and in plated and nonplated multilevel ACDF, the efficacy of allograft to autograft in one-level ACDF with rigid anterior plate fixation is not thoroughly understood.

METHODS

Sixty-six consecutive patients (mean age, 45 years) at a single institution who underwent one-level ACDF with rigid anterior plate fixation with allograft (n = 35) or autograft (n = 31) were reviewed for radiographic fusion (mean, 12 months), risk factors, and clinical outcome (mean, 17 months). Smokers entailed 33.3% of the patients, and 45.5% of all patients presented with a work-related injury. An independent blinded observer reviewed at last follow-up lateral neutral and flexion/extension plain radiographs for radiographic fusion and instrumentation integrity. Clinical outcome was assessed on last follow-up and rated according to the Odom criteria. The threshold for statistical significance was established at P < 0.05.

RESULTS

Solid fusion was achieved in 63 patients (95.5%). Fusion was noted in 100% of the allograft patients, whereas 90.3% of the autograft cases achieved fusion. No statistically significant difference was noted between allograft to autograft with regard to fusion rate (P > 0.05). Three patients developed nonunions (1 smoker; 2 nonsmokers) and entailed Orion instrumentation. In the one patient who was a nonsmoker with a nonunion, slight screw penetration into the involved and uninvolved interbody spaces was noted. No other intraoperative, postoperative, or radiographic complication was noted. All of the nonunions occurred early in the series. Postoperatively, excellent results were reported in 19.7%, good results in 71.2%, and fair results in 9.1% of the patients. Satisfactory clinical outcome was noted in all nonunion patients. A nonstatistically significant difference was noted with regard to clinical outcome of fused and nonfused patients, demographics, and the presence of a work-related injury (P > 0.05). The impact of smoking was not a factor influencing fusion or clinical outcome in this series (P > 0.05). A statistically significant difference was noted in plate-type on fusion rate (P < 0.05).

CONCLUSION

A 100% and 90.3% radiographic fusion rate was obtained for allograft and autograft in one-level ACDF procedures with rigid anterior plate fixation, respectively. Although autograft achieved a higher incidence of nonunion than allograft, this may be attributed to the use of autograft early in the experience of plate application and fixation in this series. The effects of smoking were not found to be a significant factor influencing fusion in these plated patients. In 90.9% of the patients, excellent and good clinical outcome results were reported. The use of allograft in one-level ACDF with rigid plate fixation yields similar and high fusion rates as autograft. The use of allograft bone eliminates complications and pitfalls associated with autologous donor site harvesting. However, the use of autograft is a viable alternative to avoid the risk of infection, disease transmission, and histocompatibility differences associated with allograft. The use of allograft or autograft bone in properly selected patients for one-level ACDF with rigid anterior plate fixation can result in high fusion rates with excellent and good clinical outcomes.

Correlation of Short Form-36 and disability status with outcomes of arthroscopic acetabular labral debridement

BACKGROUND

Arthroscopic debridement is the standard of care for the treatment of acetabular labral tears. The Short Form-36 has not been used to measure hip arthroscopy outcomes, and the impact of disability status on hip arthroscopy outcomes has not been reported.

HYPOTHESIS

Short Form-36 subscale scores will demonstrate good correlation with the modified Harris hip score, but patients undergoing disability evaluation will have significantly worse outcome scores.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The records of active-duty soldiers who underwent hip arthroscopy at the authors' institution were retrospectively reviewed. Forty consecutive patients who underwent hip arthroscopy for the primary indication of labral tear formed the basis of the study group. Patients completed the modified Harris hip score, the Short Form-36 general health survey, and a subjective overall satisfaction questionnaire.

RESULTS

Thirty-three patients, with a mean age of 34.6 years, were available for follow-up at a mean of 25.7 months postoperatively. Fourteen (43%) patients were undergoing medical evaluation boards (military equivalent of workers' compensation or disability claim). Pearson correlation coefficients for comparing the Short Form-36 Bodily Pain, Physical Function, and Physical Component subscale scores to the modified Harris hip score were 0.73, 0.71, and 0.85, respectively (P < .001). The mean modified Harris hip score was significantly lower in patients on disability status than in those who were not (92.4 vs 61.1; P < .0001). The Short Form-36 subscale scores were significantly lower in disability patients (P < .02). Patient-reported satisfaction rates (70% overall) were 50% for those undergoing disability evaluations and 84% for those who were not (P < .04). There was no significant difference in outcomes based on patient age, surgically proven chondromalacia, or gender for military evaluation board status.

CONCLUSION

The Short Form-36 demonstrated good correlation with the modified Harris hip score for measuring outcomes after arthroscopic partial limbectomy. Arthroscopic debridement yielded a high percentage of good results when patients undergoing disability evaluations were excluded. Disability status may be a negative predictor of success after hip arthroscopy.

The relations between social support, life stress, and quality of Life following spinal decompression surgery

STUDY DESIGN

Assessed social support, life stress, and quality of life among degenerative spine disease patients.

OBJECTIVE

To examine how social support and life stress relate to quality of life following spinal decompression surgery among patients with degenerative spine disease.

SETTING

Neurosurgical clinic at Saint Michael's Hospital in Toronto, Canada.

METHODS

A total of 19 patients with degenerative spine disease who had undergone spinal decompression surgery within the past 14 months filled out social support, life stress, and quality of life questionnaires. Correlational techniques were used to assess the relations among the variables.

RESULTS

The correlations between social support scores and health-related and nonhealth-related quality of life scores were r=0.72, P=0.001, and r=0.50, P=0.028, respectively. The correlations between life stress scores and health-related and nonhealth-related quality of life scores were r=-0.83, P<0.001, and r=-0.72, P=0.001, respectively.

CONCLUSIONS

Degenerative spine disease patients experiencing more social support and less life stress tend to report greater satisfaction in medical outcome and overall quality of life following spinal decompression surgery than those with less social support and more life stress. Assessing social support and life stress in patients with degenerative spine disease and including a consideration of social support and life stress in the management of patients with degenerative spine disease could help to improve patients' satisfaction with their medical outcome and general quality of life following spinal decompression surgery.

Comparing outcomes of anterior cervical discectomy and fusion in workman's versus non-workman's compensation population

BACKGROUND CONTEXT

Anterior cervical discectomy and fusion (ACDF) is an accepted surgical procedure to treat degenerative conditions, including disc herniations and spinal stenosis. The literature on lumbar spine surgery reports that patients with a workman's compensation claim have less successful clinical results. Regarding the cervical spine, however, different conclusions have been drawn.

PURPOSE

The purpose of this study was to directly compare the functional outcomes of ACDF in patients with and without a workman's compensation claim and to determine whether a compensation claim adversely affected the clinical outcome.

STUDY DESIGN

This is a retrospective study examining the long-term results of ACDF in the workman's and non-workman's compensation populations.

PATIENT SAMPLE

Eighty consecutive patients undergoing ACDF were retrospectively analyzed. The patients were divided into two groups: 30 patients in Group 1 (workman's compensation) and 50 patients in Group 2 (non-workman's compensation). The average age of Group 1 was 45 years (range, 31 to 57) and Group 2 was 45 years (range, 30 to 79). The patients were followed for an average length of 4 years (range, 2 to 7 years).

OUTCOME MEASURES

We evaluated the surgical results using a functional outcome scoring system (Odom's Criteria), visual analog scale and a radiographic grading scale. The questionnaire was independently administered in a standard question-answer format at the 1-year follow-up. Statistical analyses was performed using a Levene's test.

METHODS

All surgeries were performed by the same attending physician. A left-sided approach and Smith-Robinson fusion technique with autograft or allograft without instrumentation was used in all cases. A hard cervical orthosis was used postoperatively for 8 weeks. Radiographic examination including lateral flexion and extension views were obtained at a minimum of 12 months postoperatively. Furthermore, radiographic analysis was performed each subsequent postoperative year. The radiographs were analyzed by two independent physicians in a blind fashion for evidence of radiographic fusion.

RESULTS

At follow-up no discernible difference was noted for functional outcomes. Eighty-three percent of patients in Group 1 and 90% of patients in Group 2 noted excellent or good results. This was not statistically significant (p=.280). In Group 1, 97% of patients returned to work at an average of 18 weeks, whereas 98% of patients in Group 2 returned to work at an average of 10 weeks postoperatively. Upon radiographic evaluation, 64% of patients in Group 1 were determined to have a solid fusion (Grade 3). The fusion rate in Group 2 was 72%. This was not statistically significant. However, the fusion rate among smokers was 50%, and among nonsmokers it was 80%. This was statistically significant (p=.001).

CONCLUSIONS

Workman's compensation claims did not adversely affect the functional outcome of ACDF. It should be noted that a significant increase in pseudarthroses was noted with the smoking population. Patient selection is a critical factor in determining functional outcome, with 83% good to excellent results if the pathology, clinical presentation and radiographic findings correlate

A blind spot for secondary gain affecting therapy outcomes

BACKGROUND

A study to determine whether the expectation for secondary gain held by psychiatric outpatients was associated with therapy outcomes.

METHODS

The study was conducted at a Dutch psychiatric outpatient department. Our investigation set out to explore the expectation of obtaining secondary gain by directly asking the patient and clinician via questionnaires whether the patient anticipated to get specific "benefits" from being in therapy.

RESULTS

From 166 patients, 70 (42.2%) reported to expect secondary gain while in therapy. We found a significant relation between expectation for secondary gain and treatment outcomes. Patients with expectations for secondary gain were significantly more prone to poor therapy outcome. Only in nine of 147 cases (6%) did patients explicitly express their expectations for secondary gain towards a psychiatrist. Moreover, expectations for secondary gain did not appear to be related to Axis I and Axis II diagnoses.

DISCUSSION

Secondary gain appeared to be a "veiled motive" for getting therapy: patients did not express their expectations for secondary gain explicitly towards a psychiatrist. This aspect of veiled motives is of particular relevance in regard to the fact that expectations for secondary gain appeared to affect therapy results.

[Spinal epidural fibrosis following lumbar diskectomy and antiadhesion barrier]

Although diskectomy after hemilaminectomy always produces some fibrosis, only few patients develop clinical symptoms. Fibrosis is one of the causes for failed lumbar disc surgery. Identification of fibrosis as the cause of recurring lumbar or sciatic pain requires the existence of a good clinical history and selective physical examination of the patient. MR is the imaging technique of choice although CT and myelography can be useful in some cases. Surgery can correct recurrent hernias, segmentary instability or spinal stenosis, but good results are less likely in patients with epidural fibrosis. When this exists, surgery should be directed to performing an arthrodesis of the vertebral space since the operation itself can destabilize the segment resulting in instability of the affected segment. Application of ADCON-L did not worse and in some cases improved the clinical condition of patients in double blind studies. Our multicentric double blind study showed no clinical differences among 253 patients at six months after surgery. Additionally, since this gel seems to avoid the development of fibrosis, it may prevent one of the main causes of failed disc surgery and, if reoperation is necessary due to disc remains or a lateral stenosis, the absence of fibrosis would facilitate surgery.

Late postoperative results in 1000 work related lumbar spine conditions

BACKGROUND

Poor results after lumbar spinal surgery have been recorded in compensation cases throughout the world medical literature. It seems that psychosocial factors play an important role in the delay in returning to gainful employment but that chronic postoperative lumbar and lower extremity pain is blamed for this state of affairs. The present series of late outcomes is based on actual physical examination by independent neurosurgical and orthopedic experts appointed by the Workman's Compensation Board, providing an impartial opinion as to the discrepancy between objective findings and failure to reintegrate into the work force.

METHODS

One thousand workmen's compensation patients who had undergone lumbar spinal surgery were divided into two groups, one of 600 patients with single operations, evaluated on average 51 months after surgery, and the second of 400 with multiple operations, evaluated on average 38 months postoperatively.

RESULTS

Seventy-one percent of the single operation group had not returned to work more than 4 years after the operation, and 95% of the multiple operations group. In none of these cases was there a neurological deficit that precluded gainful employment, the failure to return to work being blamed on chronic postoperative pain.

CONCLUSIONS

Although motivational (that is, psychosocial) factors undoubtedly play a role in failure to return to work, the role of chronic pain cannot be ignored. Increased attention must be devoted to ascertaining the etiology of this pain and ways to prevent it.

Secondary gain influences the outcome of lumbar but not cervical disc surgery

BACKGROUND

The expectation of monetary compensation has been associated with poor outcomes in lumbar discectomy, fueling a reluctance among surgeons to treat worker's compensation cases. This issue, however, has not been investigated in patients undergoing cervical disc surgery. This study analyzes the relationship between economic forms of secondary gain and surgical outcome in a group of patients with common pay scales, retirement plans, and disability programs.

METHODS

All procedures were performed at the Portsmouth Naval Medical Center between 1993 and 1995; active duty military servicepersons who were treated for cervical radiculopathy were prospectively included. Clinical, demographic, and financial factors were analyzed to determine which were predictive for outcome. Financial data were used to create a compensation incentive (CI) which is proportional to the rank, years of service, potential disability, retirement eligibility, and base pay and reflects the monetary incentive of disability. The results of cervical surgery were compared to a previously reported companion population of patients treated for lumbar disc disease. A good outcome is defined as a return to active duty, whereas a referral for disability is considered a poor surgical result.

RESULTS

One hundred percent follow-up was obtained for 269 patients who were treated with 307 cervical operations. Only 16% (43/269) of cervical patients received disability, whereas 24.7% (86/348) of lumbar patients obtained a poor result (p = 0.0082). Although economic forms of secondary gain were not associated with outcome in cervical disease, both the position (p = 0.002) and duration of an individual's military career were significant factors (p = 0.02). Of the medical variables tested, multilevel surgery (p = 0.03) and revision operations at the same level (p = 0.03) were associated with referral for medical discharge.

CONCLUSIONS

Secondary gain in the form of economic compensation influences outcome in lumbar but not cervical disc surgery; this observation may in part account for the success of cervical surgery relative to lumbar discectomy. Social factors that are independent of the anticipation of economic compensation seem to influence the outcome of cervical disc surgery.