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Ohrt-Nissen S, Heegaard M, Andersen T, Gehrchen M, Dahl B, Tøndevold N. Bracing in severe skeletally immature adolescent idiopathic scoliosis: does a holding strategy change the surgical plan? Eur Spine J 2024:10.1007/s00586-024-08246-1. [PMID: 38607405 DOI: 10.1007/s00586-024-08246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/28/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE The purpose of the study was to assess the changes in flexibility during night-time bracing in skeletally immature adolescent idiopathic scoliosis (AIS) with curves in the surgical range. MATERIALS AND METHODS We included a consecutive cohort of 89 AIS patients with curves ≥ 45° and an estimated growth potential. All patients were eventually treated with fusion surgery, and all patients had side-bending radiographs prior to both bracing and surgery. Curves were classified as structural or non-structural curves according to Lenke at both timepoints. RESULTS The main curve progressed by a mean of 12 ± 10° and the secondary curve by 8 ± 8°. Flexibility of the main curve decreased from 50 ± 19% to 44 ± 19% (p = 0.001) and the underlying curve from 85 ± 21% to 77 ± 22% (p = 0.005). In 69 patients (79%), the Lenke category did not progress during bracing. In 14 patients (15%), the progression in Lenke type occurred in the thoracic region (i.e., Lenke type 1 to type 2), while six patients (7%) progressed in the lumbar region (i.e., type 1 to type 3). In the 69 patients that did not progress, we found that the last touched vertebra moved distally by one or two levels in 26 patients. CONCLUSIONS This is the first study to describe that curve flexibility decreases during bracing in severe AIS. However, this had only a modest impact on the surgical strategy. Bracing as a holding strategy can be applied, but the risk of losing flexibility in the lumbar spine should be outweighed against the risks of premature fusion surgery.
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Affiliation(s)
- Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark.
| | - M Heegaard
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark
| | - Thomas Andersen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark
| | - M Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark
| | - B Dahl
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark
| | - N Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark
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Heegaard M, Tøndevold N, Dahl B, Andersen TB, Gehrchen M, Ohrt-Nissen S. The effect of Providence night-time bracing on the sagittal profile in adolescent idiopathic scoliosis. Eur Spine J 2024; 33:1657-1664. [PMID: 38430401 DOI: 10.1007/s00586-024-08186-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/18/2023] [Accepted: 02/04/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE Adolescent idiopathic scoliosis (AIS) is characterized by coronal scoliosis and often a sagittal hypokyphosis. The effect of bracing on the sagittal profile is not well understood. The aim of this study is to assess the effect of night-time bracing on the sagittal profile in patients with AIS. METHODS We retrospectively included AIS patients with a main curve of 25-45° treated with a night-time brace in our institution between 2005 and 2018. Patients with estimated growth potential based on either Risser stage, hand X-rays, or menarchal status were included. Coronal and sagittal radiographic parameters were recorded at both brace- initiation and -termination. Patients were followed until surgery or one year after brace termination. Results were compared to a published cohort of full-time braced patients. RESULTS One hundred forty-six patients were included. Maximum thoracic kyphosis (TK) increased 2.5° (± 9.7) (p = 0.003), corresponding to a 3.5-fold relative risk increase post bracing in TK compared to a full-time brace cohort. Twenty-seven percent (n = 36) of the patients were hypokyphotic (T4/T12 < 20°) at brace initiation compared with 19% (n = 26) at brace termination (p = 0.134). All other sagittal parameters remained the same at follow-up. We found no association between progression in the coronal plane and change in sagittal parameters. CONCLUSION This is the first study to indicate that night-time bracing of AIS does not induce hypokyphosis. We found a small increase in TK, with a substantially lower risk of developing flat back deformity compared to full-time bracing. The coronal curve progression was not coupled to a change in TK.
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Affiliation(s)
- Martin Heegaard
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark.
| | - Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Thomas B Andersen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
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Heegaard M, Tøndevold N, Dahl B, Andersen TB, Gehrchen M, Ohrt-Nissen S. The influence of night-time bracing on curve progression is not affected by curve magnitude in adolescent idiopathic scoliosis: a study of 299 patients. Acta Orthop 2024; 95:108-113. [PMID: 38347730 PMCID: PMC10863495 DOI: 10.2340/17453674.2024.39965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/06/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND AND PURPOSE The efficacy of bracing larger curves in adolescent idiopathic scoliosis (AIS) patients is uncertain. We aimed to assess the influence of night-time bracing in AIS patients with main curves exceeding 40° Cobb angle at brace initiation. METHODS We reviewed AIS patients treated with nighttime braces between 2005 and 2018. Patients with curves ≥ 25° and estimated growth potential were included. Patients were monitored with radiographs from brace initiation until brace weaning at skeletal maturity. Patients were grouped based on curve magnitude at initial evaluation: a control group (25-39°) and a large-curves group (≥ 40°). Progression was defined as > 5° increase. RESULTS We included 299 patients (control group, n = 125; large-curves group, n = 174). In the control group, 65 (52%) patients progressed compared with 101 (58%) in the large-curves group (P = 0.3). The lower-end vertebra (LEV) shifted distally post-bracing in 41 (23%) patients in the largecurves group. Patients with progressive large curves were younger (age 13.2 [SD 1.5] vs. 13.9 [SD 1.1], P = 0.009) and more premenarchal (n = 36 [42%] vs. n = 6 [9%], P < 0.001) compared with non-progressive large curves. CONCLUSION Progression risk in patients with curves exceeding 40° treated with night-time bracing is similar to smaller curves. The LEV moved distally in almost one-fourth of the larger curves, possibly affecting fusion levels in cases of surgery.
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Affiliation(s)
- Martin Heegaard
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas B Andersen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Schmidt Morgen S, Alfthan Madsen EB, Skive Weiland A, Dahl B, Gehrchen M. Carbon Instrumentation in Patients with Metastatic Spinal Cord Compression. Cancers (Basel) 2024; 16:736. [PMID: 38398127 PMCID: PMC10887085 DOI: 10.3390/cancers16040736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
Recently carbon spinal implants have been introduced in the treatment of patients with metastatic spinal cord compression (MSCC). This is expected to decrease the deflection of radiation and improve diagnostic imaging and radiotherapy when compared to titanium implants. The aim of this study was to determine the safety and effectiveness of spinal carbon instrumentation (CI) in patients with MSCC in a large cohort study. A total of 163 patients received instrumentation between 1 January 2017 and 31 December 2021. A total of 80 were stabilized with CI and 83 with TI. The outcome measures were surgical revision, postsurgical survival, peri-operative bleeding, and surgery time. The peri-operative blood loss in the CI-group was significantly lower than that in the TI-group: 450mL vs. 630mL, (p = 0.02). There were no significant differences between the groups in mean survival (CI 9.9) vs. (TI 12.9) months (p = 0.39), or the number of patients needing a revision (CI 6) vs. (TI 10), (p = 0.39). The median duration of surgery was 121 min, (p = 0.99) with no significant difference between the two groups. Surgical treatment with CI for MSCC is safe and an equally sufficient treatment when compared to TI.
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Affiliation(s)
- Søren Schmidt Morgen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, DK-2100 Copenhagen, Denmark (A.S.W.); (B.D.); (M.G.)
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Schack A, Bari TJ, Gehrchen M, Dahl B, Bech-Azeddine R. Postoperative lordosis distribution index, patient reported outcome measures, and revision surgery following transforaminal lumbar interbody fusion. World Neurosurg X 2024; 21:100251. [PMID: 38173686 PMCID: PMC10762461 DOI: 10.1016/j.wnsx.2023.100251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
Objective Lordosis Distribution Index (LDI) is a new radiographic parameter associated with postoperative residual symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). Recently, it has been applied on patients undergoing instrumented spine surgery, however not correlated to Patient Related Outcome Measures (PROMs). This study investigates whether the obtained the postoperative LDI after TLIF surgery correlates with the clinical outcome measured with PROMs. Methods This study was based on prospectively obtained data in patients undergoing TLIF throughout 2017 at a Danish university hospital. Medical records and the DaneSpine Database were accessed to obtain preoperative, operative and follow-up data. Primary outcome was Oswestry Disability Index (ODI) 12 months postoperatively. Secondary outcomes included revision rate and additional PROMs. Results 126 patients were included. 70 patients were classified with normolordosis (56 %), 42 hypolordosis (33 %) and 14 hyperlordosis (11 %). All groups experienced significant radiological changes undergoing surgery. Average reduction in ODI at 12 months postoperatively was -15.3 (±20.0). Minimally clinical important difference was achieved in 68 patients (54.0 %). No significant difference in PROMs between LDI-groups was observed in unadjusted or adjusted analyses. Revision surgery was performed in 8 patients with normolordosis (11.4 %), 7 hypolordosis (16.7 %) and 4 hyperlordosis (28.6 %). Conclusions We found no significant correlation between postoperative LDI subgroups of normolordotic, hypo- or hyperlordotic patients and the clinical outcome of posterolateral fusion and TLIF surgery. A trend towards lower rate of revision surgery in the normolordotic group compared to the hypo- and hyperlordotic group was observed.
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Affiliation(s)
- Anders Schack
- Copenhagen Spine Research Unit (CSRU), Rigshospitalet, Glostrup, Valdemar Hansens Vej 17, 2600, Glostrup, Denmark
| | - Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Rachid Bech-Azeddine
- Copenhagen Spine Research Unit (CSRU), Rigshospitalet, Glostrup, Valdemar Hansens Vej 17, 2600, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Tkatschenko D, Hansen S, Koch J, Ames C, Fehlings MG, Berven S, Sekhon L, Shaffrey C, Smith JS, Hart R, Kim HJ, Wang J, Ha Y, Kwan K, Hai Y, Valacco M, Falavigna A, Taboada N, Guiroy A, Emmerich J, Meyer B, Kandziora F, Thomé C, Loibl M, Peul W, Gasbarrini A, Obeid I, Gehrchen M, Trampuz A, Vajkoczy P, Onken J. Prevention of Surgical Site Infections in Spine Surgery: An International Survey of Clinical Practices Among Expert Spine Surgeons. Global Spine J 2023; 13:2007-2015. [PMID: 35216540 PMCID: PMC10556889 DOI: 10.1177/21925682211068414] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
STUDY DESIGN Questionnaire-based survey. OBJECTIVES Surgical site infection (SSI) is a common complication in spine surgery but universal guidelines for SSI prevention are lacking. The objectives of this study are to depict a global status quo on implemented prevention strategies in spine surgery, common themes of practice and determine key areas for future research. METHODS An 80-item survey was distributed among spine surgeons worldwide via email. The questionnaire was designed and approved by an International Consensus Group on spine SSI. Consensus was defined as more than 60% of participants agreeing to a specific prevention strategy. RESULTS Four hundred seventy-two surgeons participated in the survey. Screening for Staphylococcus aureus (SA) is not common, whereas preoperative decolonization is performed in almost half of all hospitals. Body mass index (BMI) was not important for surgery planning. In contrast, elevated HbA1c level and hypoalbuminemia were often considered as reasons to postpone surgery. Cefazoline is the common drug for antimicrobial prophylaxis. Alcohol-based chlorhexidine is mainly used for skin disinfection. Double-gloving, wound irrigation, and tissue-conserving surgical techniques are routine in the operating room (OR). Local antibiotic administration is not common. Wound closure techniques and postoperative wound dressing routines vary greatly between the participating institutions. CONCLUSIONS With this study we provide an international overview on the heterogeneity of SSI prevention strategies in spine surgery. We demonstrated a large heterogeneity for pre-, peri- and postoperative measures to prevent SSI. Our data illustrated the need for developing universal guidelines and for testing areas of controversy in prospective clinical trials.
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Affiliation(s)
- Dimitri Tkatschenko
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sonja Hansen
- Department of Hygiene and Environmental Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Koch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sigurd Berven
- Orthopedic Surgery, UCSF Spine Center, San Francisco, CA, USA
| | | | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke Medical Center, Durham, NC, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
| | | | - Yoon Ha
- Department of Neurosurgery, Spine, and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kenny Kwan
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Yong Hai
- Department of Orthopedics, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Marcelo Valacco
- Department of Orthopaedics, Churruca Hospital de Buenos Aires, Buenos Aires, Argentina
| | - Asdrubal Falavigna
- Department of Neurosurgery, University of Caxias do Sul, Caxias do Sul, Brazil
| | | | - Alfredo Guiroy
- Spine Unit, Orthopedic Department, Hospital Español, Mendoza, Argentina
| | - Juan Emmerich
- Department of Neurological Surgery, Children’s Hospital, La Plata, Argentina
| | - Bernhard Meyer
- Department of Neurosurgery, Technische Universität München, Munich, Germany
| | - Frank Kandziora
- Centre for Spinal Surgery and Neurotraumatology, BG Unfallklinik, Frankfurt am Main, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Tyrol, Austria
| | - Markus Loibl
- Department of Spine Surgery, Schulthess Klinik Zürich Switzerland and Department of Trauma Surgery, University Medical Center, Regensburg, Germany
| | - Wilco Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Alessandro Gasbarrini
- Department of Oncologic and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Ibrahim Obeid
- Clinique du Dos, Elsan Jean Villar Private Hospital, Bordeaux, France
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Heegaard M, Tøndevold N, Dahl B, Andersen TB, Gehrchen M, Ohrt-Nissen S. Does Risser stage accurately predict the risk of curve progression in patients with adolescent idiopathic scoliosis treated with night-time bracing? Eur Spine J 2023; 32:3077-3083. [PMID: 37314578 DOI: 10.1007/s00586-023-07808-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 04/03/2023] [Accepted: 06/01/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE Risser stage is widely used as a marker for skeletal maturity (SM) and thereby an indirect measure for the risk of progression of adolescent idiopathic scoliosis (AIS). The Scoliosis Research Society recommends bracing for Risser stages 0-2 as Risser stage 3 or above is considered low risk. Very few studies have assessed the risk of progression during bracing in Risser stages 3-4. The objective of the current study is to determine if Risser stages 3-4 provide a meaningful cutoff in terms of progression risk in patients with AIS treated with night-time bracing. METHODS AIS patients treated with night-time brace from 2005 to 2018 with a Cobb angle between 25 and 40 degrees and Risser stages 0-4 were retrospectively included. Curve progression (> 5 degrees increase) was monitored until surgery or SM. Skeletal maturity was defined as either 2 years postmenarchal, no height development or closed ulnar epiphyseal plates on radiographs. RESULTS One hundred and thirty-five patients were included (Risser stages 0-2: n = 86 and 3-4: n = 49). Overall, radiographic curve progression occurred in 52% while progression beyond 45 degrees was seen in 35%. The progression rate in the Risser 0-2 group was 60% and 37% in the Risser 3-4 group (p = 0.012). In multivariate logistic regression analysis, adjusted for Risser stages and age, only premenarchal status showed a statistically significant association with progression (OR: 2.68, 95%CI 1.08-6.67). CONCLUSION Risser stage does not provide a clinically meaningful differentiation of progression risk in AIS patients treated with a night-time brace. Risk assessment should include other more reliable measures of skeletal growth potential.
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Affiliation(s)
- Martin Heegaard
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark.
| | - Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Thomas B Andersen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
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Tøndevold N, Bari TJ, Andersen TB, Gehrchen M. The Collateral Effect of Enhanced Recovery After Surgery Protocols on Spine Patients With Neuromuscular Scoliosis. J Pediatr Orthop 2023; 43:e476-e480. [PMID: 36922012 DOI: 10.1097/bpo.0000000000002400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) protocols are often specific to a specific type of surgery without assessing the overall effect on the ward. Previous studies have demonstrated reduced length of stay (LOS) with ERAS protocols in patients with adolescent idiopathic scoliosis (AIS), although the patients are often healthy and with few or no comorbidities. In 2018, we used ERAS principles for patients undergoing AIS surgery with a subsequent 40% reduced LOS. The current study aims to assess the potential collateral effect of LOS in patients surgically treated for neuromuscular scoliosis admitted to the same ward and treated by the same staff but without a standardized ERAS protocol. METHODS All patients undergoing neuromuscular surgery 2 years before and after ERAS introduction (AIS patients) with a gross motor function classification score of 4 to 5 were included. LOS, intensive care stay, and postoperative complications were recorded. After discharge, all complications leading to readmission and mortality were noted with a minimum of 2 years of follow-up using a nationwide registry. RESULTS Forty-six patients were included; 20 pre-ERAS and 26 post-ERAS. Cross groups, there were no differences in diagnosis, preoperative curve size, pulmonary or cardiac comorbidities, weight, sex, or age. Postoperative care in the intensive care unit was unchanged between the two groups (1.2 vs 1.1; P = 0.298). When comparing LOS, we found a 41% reduction in the post-ERAS group (11 vs 6.5; P < 0.001) whereas the 90-day readmission rates were without any significant difference (45% vs 34% P = 0.22) We found no difference in the 2-year mortality in either group. CONCLUSION The employment of ERAS principles in a relatively uncomplicated patient group had a positive, collateral effect on more complex patients treated in the same ward. We believe that training involving the caregiving staff is equally important as pharmacological protocols.
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Affiliation(s)
- Niklas Tøndevold
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Heegaard M, Johanning Bari T, Dahl B, Valentin Hansen L, Gehrchen M. Demineralized cortical fibers are associated with a low pseudarthrosis rate in patients undergoing surgery for adult spinal deformity without three-column osteotomy. Brain Spine 2023; 3:101751. [PMID: 37383466 PMCID: PMC10293299 DOI: 10.1016/j.bas.2023.101751] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/05/2023] [Accepted: 05/02/2023] [Indexed: 06/30/2023]
Abstract
Introduction Following surgical treatment for adult spinal deformity (ASD) there is an increased risk of revision surgery due to mechanical failure or pseudarthrosis. Demineralized cortical fibers (DCF) were introduced at our institution aiming to reduce the risk of pseudarthrosis after ASD surgery. Research question We wanted to investigate the effect of DCF on postoperative pseudarthrosis compared with allogenic bone graft in ASD surgery without three-column osteotomies (3CO). Materials & Methods All patients undergoing ASD surgery between January 1, 2010 to June 31, 2020 were included in this interventional study with historical controls. Patients with current or previous 3CO were excluded. Before February 1, 2017, patients undergoing surgery received auto- and allogenic bone graft (non-DCF group) whilst patients after received DCF in addition to autologous bone graft (DCF group). Patients were followed for at least two years. The primary outcome was radiographic or CT-verified postoperative pseudarthrosis requiring revision surgery. Results We included 50 patients in the DCF group and 85 patients in the non-DCF group for final analysis. Pseudarthrosis requiring revision surgery at two-year follow-up occurred in seven (14%) patients in the DCF group compared with 28 (33%) patients in the non-DCF group (p = 0.016). The difference was statistically significant, corresponding to a relative risk of 0.43 (95%CI: 0.21-0.94) in favor of the DCF group. Conclusion We assessed the use of DCF in patients undergoing ASD surgery without 3CO. Our results suggest that the use of DCF was associated with a considerable decreased risk of postoperative pseudarthrosis requiring revision surgery.
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Abstract
AIMS Only a few studies have investigated the long-term health-related quality of life (HRQoL) in patients with an idiopathic scoliosis. The aim of this study was to investigate the overall HRQoL and employment status of patients with an idiopathic scoliosis 40 years after diagnosis, to compare it with that of the normal population, and to identify possible predictors for a better long-term HRQoL. METHODS We reviewed the full medical records and radiological reports of patients referred to our hospital with a scoliosis of childhood between April 1972 and April 1982. Of 129 eligible patients with a juvenile or adolescent idiopathic scoliosis, 91 took part in the study (71%). They were evaluated with full-spine radiographs and HRQoL questionnaires and compared with normative data. We compared the HRQoL between observation (n = 27), bracing (n = 46), and surgical treatment (n = 18), and between thoracic and thoracolumbar/lumbar (TL/L) curves. RESULTS The mean time to follow-up was 40.8 years (SD 2.6) and the mean age of patients was 54.0 years (SD 2.7). Of the 91 patients, 86 were female (95%) and 51 had a main thoracic curve (53%). We found a significantly lower HRQoL measured on all the Scoliosis Research Society 22r instrument (SRS-22r) subdomains (p < 0.001) with the exception of mental health, than in an age-matched normal population. Incapacity to work was more prevalent in scoliosis patients (21%) than in the normal population (11%). The median SRS-22r subscore was 4.0 (interquartile range (IQR) 3.3 to 4.4) for TL/L curves and 4.1 (IQR 3.8 to 4.4) for thoracic curves (p = 0.300). We found a significantly lower self-image score for braced (median 3.6 (IQR 3.0 to 4.0)) and surgically treated patients (median 3.6 (IQR 3.2 to 4.3)) than for those treated by observation (median 4.0 (IQR 4.1 to 4.8); p = 0.010), but no statistically significant differences were found for the remaining subdomains. CONCLUSION In this long-term follow-up study, we found a significantly decreased HRQoL and capacity to work in patients with an idiopathic scoliosis 40 years after diagnosis.Cite this article: Bone Joint J 2023;105-B(2):166-171.
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Affiliation(s)
- Lærke C Ragborg
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Casper Dragsted
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Søren Ohrt-Nissen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Andersen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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11
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Gehrchen ML, Bari TJ, Dahl B, Andersen TB, Gehrchen M. Is preoperative S-albumin associated to postoperative complications and readmission in patients with adult spinal deformity: a prospective analysis of 128 patients using the Spine AdVerse Event Severity (SAVES) system. Spine Deform 2022; 10:893-900. [PMID: 34982418 DOI: 10.1007/s43390-021-00467-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 12/19/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess the association between preoperative S-albumin and postoperative outcome following adult spinal deformity (ASD) surgery. METHODS All patients undergoing ASD surgery from February 1, 2017 and January 31, 2018 at a single quaternary referral center were prospectively included. Adverse events (AE) during admission were assessed using the Spine AdVerse Events Severity (SAVES) system. Based on preoperative S-albumin, patients were categorized as "normal" or "abnormal" and compared regarding postoperative outcome, adverse events (AEs), 30- and 90-day readmission, revision surgery, and mortality. RESULTS A total of 128 patients aged ≥ 18 years were included, and S-albumin was available in 88%. Of these, 73% (n = 93) were classified as "normal", 16% (n = 20) as "abnormal", and 12% (n = 15) as "missing". The "normal" albumin group had less comorbidity burden [ASA score 2 (2, 3) vs 3 (2, 3), p = 0.011], higher hemoglobin levels (8.4 (± 0.9) mmol/L vs 7.4 (± 1.1) mmol/L, p < 0.001), and higher S-albumin (38.9 (± 2.7) g/L vs 31.9 (± 4.4) g/L, < 0.001). The rate of 90-day readmission was significantly increased in the "abnormal" group (65% vs 36%), corresponding to a relative risk increase of 1.25 (95% CI 1.02-1.52, p = 0.029). Similar increased risks were found in subsequent logistic regression analyses, although results were not significant in multivariable analysis (p = 0.102). Comparing remaining outcome parameters, point estimates revealed increased AEs, 30-day readmission, and revision in the "abnormal" albumin group, although effects did not reach statistical significance. CONCLUSIONS In a prospective, consecutive, single-center cohort of 128 patients undergoing ASD surgery, we found a significant association between "abnormal" preoperative S-albumin and increased 90-day readmission. Furthermore, although the findings were not statistically significant, we did find that AEs, 30-day readmission, and revision were numerically more frequent in the "abnormal" group, suggesting an expected tendency that should be further investigated. We conclude that nutritional status prior to ASD surgery could be important to consider and suggest validation in larger prospective cohorts. LEVEL OF EVIDENCE Prognostic II.
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Affiliation(s)
- Mathilde Louise Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin St., Houston, TX, 77030, USA
| | - Thomas Borbjerg Andersen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
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12
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Bari TJ, Hansen LV, Dahl B, Gehrchen M. Use of demineralized cortical fibers is associated with reduced risk of pseudarthrosis after pedicle subtraction osteotomy for adult spinal deformity. Spine Deform 2022; 10:657-667. [PMID: 34807398 DOI: 10.1007/s43390-021-00444-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 11/10/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess the effect of demineralized cortical fibers (DCF) on postoperative pseudarthrosis requiring revision surgery in patients undergoing pedicle subtraction osteotomy (PSO) for adult spinal deformity (ASD). METHODS The use of DCF was introduced across all procedures in 2017 and subsequent patients undergoing PSO surgery were prospectively and consecutively registered. Following sample-size estimation, a retrospective cohort was also registered undergoing the same procedure immediately prior to the implementation of DCF. The non-DCF group underwent surgery with ABG. Minimum follow-up was 2 years in both groups. The main outcome was postoperative pseudarthrosis, either CT-verified or verified intraoperatively during revision surgery due to rod breakage and assessed using Kaplan-Meier survival analyses. RESULTS A total of 48 patients were included in the DCF group and 76 in the non-DCF group. The DCF group had more frequently undergone previous spine surgery (60% vs 36%) and had shorter follow-up (32 ± 2 vs 40 ± 7 months). Pseudarthrosis occurred in 7 (15%) patients in the DCF group and 31 (41%) in the non-DCF group, corresponding to a relative risk increase of 2.6 (95%CI 1.3-2.4, P < 0.01). 1-KM survival analyses, taking time to event into account and thus the difference in follow-up, also showed increased pseudarthrosis in the non-DCF group (log-rank P = 0.022). Similarly, multivariate logistic regression adjusted for age, instrumented levels and sacral fusion was also with significantly increased odds of pseudarthrosis in the non-DCF group (OR: 4.3, 95%CI: 1.7-11.3, P < 0.01). CONCLUSION We found considerable and significant reductions in pseudarthrosis following PSO surgery with DCF compared to non-DCF. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Lars Valentin Hansen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin St, Houston, TX, 77030, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
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13
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Tøndevold N, Dybdal B, Bari TJ, Andersen TB, Gehrchen M. Rapid discharge protocol reduces length of stay and eliminates postoperative nausea and vomiting after surgery for adolescent idiopathic scoliosis. World Neurosurg 2021; 158:e566-e576. [PMID: 34775082 DOI: 10.1016/j.wneu.2021.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Implementing standardized pathways following adolescent idiopathic scoliosis surgery have been shown to reduce length of stay (LOS). However, controversies still exist. This applies especially to the transition to solid foods, postoperative pruritus and postoperative nausea and vomiting (PONV). The aim of this proposed protocol is to present an option to reduce these factors while reducing the LOS. METHODS The protocol was designed with reduction of morphine. One-hundred-eight patients were included in this study, including sixty-six controls prior to intervention. All underwent posterior scoliosis surgery. All patients were scored daily using a Numeric rating scale (NRS) and noted if any nausea, vomiting or pruritus was present. All medications were recorded. For every twenty patients included the steering committee met to identify any implementation issues. RESULTS LOS was reduced from 6.3 to 3.6 days (43% reduction, P=0.003). PONV was reduced from affecting 82% to 9% of patients (P<0.0001). Patients experiencing postoperative pruritus were reduced from 40% to 2%. (P<0.001). Time spent in postoperative recovery was reduced from 278[117-470] mins to 199[128-643], P<0.001. Patient´s pain scores remained unchanged compared to controls (mean 4[3-8]). We found no adverse effects of solid food intake from postoperative day 0 CONCLUSION: We found a significant reduction in length of stay, postoperative nausea and vomiting and pruritus after implementation of the protocol. This allowed for no restrictions in regards to solid food intake postoperatively.
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Affiliation(s)
- Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Bitten Dybdal
- Unit of Acute Pain Management, Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Denmark
| | - Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Borbjerg Andersen
- Spine Unit, Department of Orthopedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
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14
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Bari TJ, Heegaard M, Bech-Azeddine R, Dahl B, Gehrchen M. Lordosis Distribution Index in Short-Segment Lumbar Spine Fusion - Can Ideal Lordosis Reduce Revision Surgery and Iatrogenic Deformity? Neurospine 2021; 18:543-553. [PMID: 34610685 PMCID: PMC8497240 DOI: 10.14245/ns.2040744.372] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/02/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The demand for spinal fusion is increasing, with concurrent reports of iatrogenic adult spinal deformity (flatback deformity) possibly due to inappropriate lordosis distribution. This distribution is assessed using the lordosis distribution index (LDI) which describes the upper and lower arc lordosis ratio. Maldistributed LDI has been associated to adjacent segment disease following interbody fusion, although correlation to later-stage deformity is yet to be assessed. We therefore aimed to investigate if hypolordotic lordosis maldistribution was associated to radiographic deformity-surrogates or revision surgery following instrumented lumbar fusion. METHODS All patients undergoing fusion surgery ( ≤ 4 vertebra) for degenerative lumbar diseases were retrospectively included at a single center. Patients were categorized according to their postoperative LDI as: "normal" (LDI 50-80), "hypolordotic" (LDI < 50), or "hyperlordotic" (LDI > 80). RESULTS We included 149 patients who were followed for 21 ± 14 months. Most attained a normally distributed lordosis (62%). The hypolordotic group had increased postoperative pelvic tilt (PT) (p < 0.001), pelvic incidence minus lumbar lordosis (PI-LL) mismatch (p < 0.001) and decreased global lordosis (p = 0.007) compared to the normal group. Survival analyses revealed a significant difference in revision surgery (p = 0.03), and subsequent multivariable logistic regression showed increased odds of 1-year revision in the hypolordotic group (p = 0.04). There was also a negative, linear correlation between preoperative pelvic incidence (PI) and postoperative LDI (p < 0.001). CONCLUSION In patients undergoing instrumented lumbar fusion surgery, hypolordotic lordosis maldistribution (LDI < 50) was associated to increased risk of revision surgery, increased postoperative PT and PI-LL mismatch. Lordosis distribution should be considered prior to spinal fusion, especially in high PI patients.
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Affiliation(s)
- Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Martin Heegaard
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rachid Bech-Azeddine
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Spine Research Unit (CSRU), Rigshospitalet, Glostrup, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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15
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Federspiel C, Morgen SS, Suppli MH, Kamby C, Kelsen J, Gehrchen M. [Treatment of metastatic spinal cord compression]. Ugeskr Laeger 2021; 183:V10200725. [PMID: 34477101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Metastatic spinal cord compression is an oncologic emergency, and the most frequent initial symptom is radicular backpain. Urgent diagnostics with acute MRI and early treatment is essential to prevent permanent neurologic damage. Treatment is mainly palliative. For patients who have a good prognosis, the treatment of choice is decompressive surgery followed by radiotherapy, but only few patients are candidates to surgery due to significant comorbidities and poor performance status. Optimal therapy is required to maintain high quality of life at an acceptable risk, as argued in this review.
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16
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Bech RD, Zielinski O, Morgen SS, Tøndevold N, Hansen LV, Kelsen J, Gehrchen M. [Spinefractures - diagnosis and treatment]. Ugeskr Laeger 2021; 183:V08200628. [PMID: 34219645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Acute onset back pain is a common reason for referral to primary health care or emergency departments. In this review, the different spine fracture types are highlighted, and a treatment algorithm is proposed. CT is the modality of choice when a spine fracture is suspected. MRI should be performed when disc or ligamentous lesions are suspected or in patients with known ankylosis or diffuse idiopathic skeletal hyperostosis. Treatment is mainly conservative with bracing, but unstable fractures and patients with neurological deficits should be treated surgically.
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17
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Bari TJ, Hallager DW, Hansen LV, Dahl B, Gehrchen M. Reducing revision rates following Pedicle Subtraction Osteotomy surgery: a single-center experience of trends over 7 years in patients with Adult Spinal Deformity. Spine Deform 2021; 9:803-815. [PMID: 33400231 DOI: 10.1007/s43390-020-00256-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/08/2020] [Indexed: 11/30/2022]
Abstract
STUDY DESIGN This is a single-center, retrospective study. OBJECTIVE To assess if implemented changes to clinical practice have reduced mechanical complications following pedicle subtraction osteotomy (PSO) surgery. Adult spinal deformity (ASD) is increasing in prevalence with concurrent increasing demands for surgical treatment. The most extensive technique, PSO, allows for major correction of rigid deformities. However, surgery-related complications have been reported in rates up to 77% and especially mechanical complications occur at unsatisfactory frequencies. METHODS We retrospectively included all patients undergoing PSO for ASD between 2010 and 2016. Changes to clinical practice were introduced continuously in the study period, including rigorous patient selection; inter-disciplinary conferences; implant-material; number of surgeons; surgeon experience; and perioperative standardized protocols for pain, neuromonitoring and blood-loss management. Postoperative complications were recorded in the 2-year follow-up period. Competing risk survival analysis was used to assess cumulative incidence of revision surgery due to mechanical complications. The Mann-Kendall test was used for analysis of trends. RESULTS We included 185 patients undergoing PSO. The level of PSO changed over the study period (P < 0.01) with L3 being the most common level in 2010 compared to L4 in 2016. Both preoperative and surgical corrections of sagittal vertical axis were larger towards the end of the study period. The 2-year revision rate due to mechanical failure steadily declined over the study period from 52% in 2010 to 14% for patients treated in 2016, although without statistically significant trend (P = 0.072). In addition, rates of mechanical complications steadily declined over the study period and significant decreasing trends were observed in time trend analyses of overall complications, major complications and rod breakage. CONCLUSIONS We observed decreased risks of revision surgery due to mechanical complications following PSO in patients with ASD over a 7-year period. We attribute these improvements to advancements in patient selection, surgical planning and techniques, surgeon experience and more standardized perioperative care. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Dennis Winge Hallager
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Lars Valentin Hansen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin St, Houston, TX, 77030, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
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18
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Fruergaard S, Ohrt-Nissen S, Pitter FT, Høy K, Lindberg-Larsen M, Eiskjær S, Dahl B, Gehrchen M. Revision risk after pediatric spinal deformity surgery: a nationwide study with 2-year follow-up. Spine J 2021; 21:642-652. [PMID: 33340758 DOI: 10.1016/j.spinee.2020.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 12/03/2020] [Accepted: 12/10/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Revision risk after pediatric spine surgery is not well established and varies between deformity etiologies. PURPOSE To report the 2-year revision risk following surgery for primary pediatric spinal deformity in a nationwide cohort and to evaluate potential risk factors and reasons for revision surgery. DESIGN Retrospective nationwide cohort study. PATIENT SAMPLE A national registry study of all pediatric spinal deformity patients undergoing surgery during 2006-2015 (n=1310). OUTCOME MEASURES Two-year revision risk. METHODS All patients ≤21 years of age undergoing spinal deformity surgery in Denmark during 2006-2015 were identified by procedure and diagnosis codes in the Danish National Patient Registry (DNPR). Data on revision surgery were retrieved from the DNPR. Patients were categorized in six groups according to etiology. Medical records were reviewed for reason for revision in all patients. Potential risk factors for revision were assessed with multiple logistic regression analyses and included age, etiology, sex, Charlson comorbidity index (CCI), and growth-preserving treatment. RESULTS Patients were categorized according to etiology: idiopathic deformity (53%), neuromuscular deformity (23%), congenital/structural deformity (9%), spondylolisthesis (7%), Scheuermann's kyphosis (5%), and syndromic deformity (3%). Of 1,310 included patients, 9.2% underwent revision surgery within 2 years and 1.5% was revised more than once. Median time to revision was 203 (interquartile range 35-485) days. The multivariable logistic regression found significantly higher odds ratio (OR) for revision in patients with growth-preserving treatment (OR=5.1, 95% confidence interval [CI] 2.6-10.1), congenital deformity (OR=2.7, 95% CI 1.3-5.3), spondylolisthesis (OR=3.5, 95% CI 1.9-6.7), Scheuermann kyphosis (OR=3.9, 95% CI 1.9-8.3), and CCI score ≥3 (OR=2.5 95% CI 1.1-5.6). The most common reason for revision was implant failure (32.5%) followed by residual deformity and/or curve progression (15.8%). CONCLUSIONS In this nationwide study, the 2-year revision risk after primary pediatric spinal deformity surgery is 9.2%. Risk factors for revision are etiology of congenital deformity, spondylolisthesis, Scheuermann kyphosis as well as patients with growth-preserving treatment and higher CCI. The most common reason for revision is implant failure.
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Affiliation(s)
- Sidsel Fruergaard
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Frederik Taylor Pitter
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Kristian Høy
- Spine Unit, Department of Orthopedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
| | - Martin Lindberg-Larsen
- Orthopedic Research Unit, Department of Orthopedic Surgery and Traumatology, Odense University Hospital, J.B. Winsløvsvej 4, 5000, Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, Campusvej 55, 5230, Odense C, Denmark
| | - Søren Eiskjær
- Department of Orthopedic Surgery, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Benny Dahl
- Department of Orthopedic Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
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19
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Solumsmoen S, Bari TJ, Woldu S, Zielinski OB, Gehrchen M, Dahl B, Bech-Azeddine R. A Comparison of Mortality and Morbidity Between Complex and Degenerative Spine Surgery in Prospectively Collected Data From 2280 Procedures. Neurospine 2021; 18:524-532. [PMID: 33745268 PMCID: PMC8497259 DOI: 10.14245/ns.2040628.314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/28/2020] [Indexed: 11/24/2022] Open
Abstract
Objective The reported incidence of complications and/or adverse events (AEs) following spine surgery varies greatly. A validated, systematic, reproducible reporting system to quantify AEs was used in 2 prospective cohorts, from 2 spine surgery centers, conducting either complex or purely degenerative spine surgery; in a comparative fashion. The aim was to highlight the differences between 2 distinctly different prospective cohorts with patients from the same background population.
Methods AEs were registered according to the predefined AE variables in the SAVES (Spine AdVerse Events Severity) system which was used to record all intra- and perioperative AEs. Additional outcomes, including mortality, length of stay, wound infection requiring revision, readmission, and unplanned revision surgery during the index admission, were also registered.
Results A total of 593 complex and 1,687 degenerative procedures were consecutively included with 100% data completion. There was a significant difference in morbidity when comparing the total number of AEs between the 2 groups (p < 0.001): with a mean number of 1.42 AEs per patient (n = 845) in the complex cohort, and 0.97 AEs per patient (n = 1,630) in the degenerative cohort.
Conclusion In this prospective study comparing 2 cohorts, we report the rates of AEs related to spine surgery using a validated reproducible grading system for registration. The rates of morbidity and mortality were significantly higher following complex spine surgery compared to surgery for degenerative spine disease.
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Affiliation(s)
- Stian Solumsmoen
- Copenhagen Spine Research Unit (CSRU), Section of Spine Surgery, Center of Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark.,Department of Epidemiological Research, Statens Serum Institut, Copenhagen, Denmark
| | - Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sarah Woldu
- Copenhagen Spine Research Unit (CSRU), Section of Spine Surgery, Center of Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark
| | - Oliver Bremerskov Zielinski
- Copenhagen Spine Research Unit (CSRU), Section of Spine Surgery, Center of Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedic Surgery & Scoliosis Surgery, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Rachid Bech-Azeddine
- Copenhagen Spine Research Unit (CSRU), Section of Spine Surgery, Center of Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Heegaard M, Bari TJ, Ohrt-nissen S, Gehrchen M. Complications following surgery for scheuermann’s kyphosis: a two-year follow-up of 22 adult patients. Turk Neurosurg 2021; 32:471-480. [DOI: 10.5137/1019-5149.jtn.35974-21.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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21
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Solumsmoen S, Bari TJ, Woldu S, Zielinski OB, Gehrchen M, Dahl B, Bech-Azeddine R. Morbidity and mortality following degenerative spine surgery in a prospective cohort of 1687 consecutive surgical procedures. Acta Neurochir (Wien) 2021; 163:281-287. [PMID: 33230624 DOI: 10.1007/s00701-020-04655-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
STUDY DESIGN Prospective, observational cohort study. OBJECTIVE To determine the true incidence of adverse events (AEs) in European adults undergoing surgery for degenerative spine diseases. The majority of surgeries performed for degenerative spinal diseases are elective, and the need for adequate estimation of risk-benefit of the intended surgery is imperative. A cumbersome obstacle for adequate estimation of surgery-related risks is that the true incidence of complications or adverse events (AEs) remains unclear. METHODS All adult patients (≥ 18 years) undergoing spine surgery at a single center from February 1, 2016, to January 31, 2017, were prospectively and consecutively included. Morbidity and mortality were determined using the Spine AdVerse Events Severity (SAVES) system. Additionally, the correlation between the AEs and length of stay (LOS) and mortality was assessed. RESULTS A total of 1687 procedures were performed in the study period, and all were included for analysis. Of these, 1399 (83%) were lumbar procedures and 288 (17%) were cervical. The overall incidence of AEs was 47.4%, with a minor AE incidence of 43.2% and a major of 14.5%. Female sex (OR 1.5 [95% CI 1.2-1.9), p < 0.001) and age > 65 years (OR 1.5 [95% CI 1.1-1.7], p = 0.012) were significantly associated with increased odds of having an AE. CONCLUSION Based on prospectively registered AEs in this single-center study, we validated the use of the SAVES system in a European population undergoing spine surgery due to degenerative spine disease. We found a higher incidence of AEs than previously reported in retrospective studies. The major AEs registered occurred significantly more often perioperatively and in patients > 65 years.
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Bari TJ, Karstensen S, Sørensen MD, Gehrchen M, Street J, Dahl B. Revision surgery and mortality following complex spine surgery: 2-year follow-up in a prospective cohort of 679 patients using the Spine AdVerse Event Severity (SAVES) system. Spine Deform 2020; 8:1341-1351. [PMID: 32607936 DOI: 10.1007/s43390-020-00164-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 06/19/2020] [Indexed: 12/22/2022]
Abstract
STUDY DESIGN Prospective study. OBJECTIVE To determine the 2-year risk of revision surgery and all-cause mortality after complex spine surgery, and to assess if prospectively registered adverse events (AE) could predict either outcome. Revision surgery and mortality are serious complications to spine surgery. Previous studies of frequency have mainly been retrospective and few studies have employed competing risk survival analyses. In addition, assessment of predictors has focused on preoperative patient characteristics. The effect of perioperative AEs on revision and all-cause mortality risks are not fully understood. METHODS Between January 1 and December 31, 2013, we prospectively included all patients undergoing complex spine surgery at a single, tertiary institution. Complex spine surgery was defined as conditions deemed too complicated for surgery at a secondary institute, or patients with severe comorbidities requiring multidisciplinary observation and treatment. AEs were registered using the Spine Adverse Event Severity system and patients were followed for minimum 2 years regarding revision surgery and all-cause mortality. Incidences were estimated using competing risk survival analyses and correlation between AEs and either outcome was assessed using proportional odds models. RESULTS We included a complete and consecutive cohort of 679 adult and pediatric patients. Demographics, surgical data, AEs, and events of revision or all-cause mortality were registered. The cumulative incidence of 2-year all-cause revision was 19% (16-22%) and all-cause mortality was 15% (12-18%). Deformity surgery was the surgical category with highest incidence of revision and the highest incidence of all-cause mortality was seen in the tumor group. Across surgical categories, cumulative incidences of 2-year revision ranged between 11% (tumor) and 33% (deformity), whilst 2-year all-cause mortality ranged between 3% (deformity) and 33% (tumor). We found that major intraoperative AEs were associated to increased odds of revision. Deep wound infection was associated to increased odds of all-cause mortality. CONCLUSIONS We report the cumulative incidences of revision surgery and all-cause mortality following complex spine surgery. We found higher incidences of revision compared to previous retrospective studies. Prospectively registered AEs were correlated to increased odds of revision surgery and all-cause mortality. These results may serve as reference for future interventional studies and aid in identifying at-risk patients. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Sven Karstensen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Mathias Dahl Sørensen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - John Street
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, Floor 6, Blusson Spinal Cord Center, 818 West 10th Ave., Vancouver, BC, V5Z 1M9, Canada
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin St, Houston, TX, 77030, USA
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Morgen SØS, Hansen LV, Karbo T, Svardal-Stelmer R, Gehrchen M, Dahl B. Minimal Access vs. Open Spine Surgery in Patients With Metastatic Spinal Cord Compression - A One-Center Randomized Controlled Trial. Anticancer Res 2020; 40:5673-5678. [PMID: 32988892 DOI: 10.21873/anticanres.114581] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/15/2020] [Accepted: 07/23/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM We conducted a randomized controlled trial to investigate whether minimally access spine surgery (MASS) is less morbid than open surgery (OS) in patients with metastatic spinal cord compression (MSCC). PATIENTS AND METHODS A total of 49 MSCC patients were included in the trial. The outcome measures were bleeding (L), operation time (min), re-operations and prolonged wound healing. RESULTS The median age was 67 years (range=42-85 years) and 40% were men. The peri-operative blood loss in the MASS-group was significantly lower than that in the OS-group; 0.175L vs. 0.500L, (p=0.002). The median operation time for MASS was 142 min (range=72-203 min) vs. 103 (range=59-435 min) for OS (p=0.001). There was no significant difference between the two groups concerning revision surgery or delayed wound healing. CONCLUSION The MASS technique in MSCC patients is associated with less blood loss, but a longer operation time when compared to the OS technique.
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Affiliation(s)
- SØren Schmidt Morgen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Valentin Hansen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ture Karbo
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Robert Svardal-Stelmer
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Division of Orthopedic Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, U.S.A
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Ohrt-Nissen S, Lastikka M, Andersen TB, Helenius I, Gehrchen M. Conservative treatment of main thoracic adolescent idiopathic scoliosis: Full-time or nighttime bracing? J Orthop Surg (Hong Kong) 2020; 27:2309499019860017. [PMID: 31284817 DOI: 10.1177/2309499019860017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To compare treatment efficacy between the Boston full-time brace and the Providence part-time brace in main thoracic adolescent idiopathic scoliosis (AIS). METHODS Patients were treated with either the Boston brace (n = 37) or the Providence brace (n = 40). Inclusion criteria were Risser grade ≤2, major curve between 25° and 40° with the apex of the curve between T7 and T11 vertebrae. Two-year follow-up was available in all patients unless brace treatment had reached endpoint. The primary outcome measure was main curve progression to ≥45°. RESULTS Median age was 12.6 years and median treatment length at follow-up was 25 months (interquartile range (IQR): 18-32)) with no difference between the groups (p ≥ 0.116). Initial median main Cobb angle was 29° (IQR: 27-33) and 36° (IQR: 33-38) in the Boston and Providence groups, respectively (p < 0.001). At follow-up, 13 patients (35%) had progressed to ≥45° in the Boston group versus 16 patients (40%) in the Providence group (p = 0.838). Twenty-three patients (62%) had progressed by more than 5° in the Boston group versus 22 patients (55%) in the Providence group (p = 0.685). The secondary thoracolumbar/lumbar curve progressed by more than 5° in 14 (38%) and 18 (45%) in the Boston and Providence groups, respectively (p = 0.548). CONCLUSIONS Despite a larger initial curve size in the Providence group, progression of more than 5° or to surgical indication area was similar in the Boston group. Our results indicate that nighttime bracing is a viable alternative to full-time bracing also in main thoracic AIS.
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Affiliation(s)
- Søren Ohrt-Nissen
- 1 Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Markus Lastikka
- 2 Department of Pediatric Orthopedic Surgery, Turku University Hospital, Turku, Finland
| | - Thomas Borbjerg Andersen
- 1 Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ilkka Helenius
- 2 Department of Pediatric Orthopedic Surgery, Turku University Hospital, Turku, Finland
| | - Martin Gehrchen
- 1 Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Dragsted C, Ohrt-Nissen S, Hallager DW, Tøndevold N, Andersen T, Dahl B, Gehrchen M. Reproducibility of the classification of early onset scoliosis (C-EOS). Spine Deform 2020; 8:285-293. [PMID: 32030643 DOI: 10.1007/s43390-019-00006-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/07/2019] [Indexed: 12/01/2022]
Abstract
STUDY DESIGN Reproducibility study. OBJECTIVES Assess the agreement and reliability of the classification of early onset scoliosis (C-EOS). C-EOS is a promising tool for patients with early onset scoliosis (EOS). However, the reliability has only been examined without measuring radiographs and not including the annual progression rate (APR) modifier. METHODS We included a single-center consecutive cohort of patients diagnosed with EOS seen in our outpatient clinic. Patients had no previous spine surgery. Four raters rated 60 cases. Two anterior-posterior full-spine radiographs, taken minimum 6 months apart, and one sagittal radiograph were measured twice by all raters in a blinded test-retest setup. Results were assessed using crude frequency of overall agreement (OA), intra- and inter-rater Fleiss kappa (κ) statistics, and intraclass correlation coefficient (ICC). We calculated the 95% limits of agreement (LOA) for major curve angle (MCA), kyphosis, and APR using a linear mixed-effects model. Inter- and intra-rater LOA were analyzed for each etiology separately. RESULTS Mean age was 8.7 ± 3.4 years and the etiology were congenital/structural (n = 20), idiopathic (n = 19), neuromuscular (n = 13), or syndromic (n = 8). For etiology, OA was 75.8% and κ = 0.80. For major curve angle, OA was 84.2%, κ = 0.86, ICC = 0.97, and LOA = 12.8°. For kyphosis, OA was 55.8%, κ = 0.52, ICC = 0.87, and LOA = 20.6°. For APR, OA was 76.7%, κ = 0.61, ICC = 0.77, and LOA = 17.4°/year. Inter- and intra-rater LOA were generally largest for neuromuscular and smallest for idiopathic patients. CONCLUSIONS We found substantial agreement for etiology, however, with disagreement in certain cases. The reliability of MCA was excellent; however, somewhat lower for kyphosis and APR with less accuracy. The measurement errors of MCA, kyphosis, and APR depended largely on the etiology. Regarding APR, LOA exceeded the 10°/year increments proposed in the C-EOS, suggesting a revision of this optional modifier. LEVEL OF EVIDENCE Diagnostic study level 1.
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Affiliation(s)
- Casper Dragsted
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Søren Ohrt-Nissen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Dennis Winge Hallager
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Niklas Tøndevold
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Thomas Andersen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Karimi D, Morgen SS, Fruergaard S, Gehrchen M, Dahl B. Long-term Survival After Surgical Treatment of Spinal Metastasis - The Predictive Role of Sex. Anticancer Res 2020; 40:1475-1479. [PMID: 32132046 DOI: 10.21873/anticanres.14091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 01/26/2020] [Accepted: 02/03/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM An increasing number of patients undergo surgical treatment for metastatic spinal cord compression (MSCC). However, the possible role of sex as an independent predictor of long-term survival has not been studied. This study aimed to examine whether sex is associated with long-term survival after surgical treatment in patients with MSCC. PATIENTS AND METHODS A total of 110 patients were operated on for MSCC from 2005 through 2006. The relation between sex and overall survival was investigated. The follow-up period was 10 years. RESULTS Survival time was significantly longer for women compared to men (mean±SD: 29±5.2 vs. 14±3.6 month (p=0.01). With adjusted analysis, this difference remained statistically significant. After adjusting for specific primary tumor type and time since surgery, the hazard-ratio of 10-year survival for men compared to women was 1.47 (95% confidence intervaI=1.01-2.18, p=0.048). CONCLUSION These findings indicate that sex is associated with long-term survival in patients treated for MSCC.
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Affiliation(s)
- Dennis Karimi
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren S Morgen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sidsel Fruergaard
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Benny Dahl
- Division of Orthopedic Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, U.S.A
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Tøndevold N, Lastikka M, Andersen T, Gehrchen M, Helenius I. Should instrumented spinal fusion in nonambulatory children with neuromuscular scoliosis be extended to L5 or the pelvis? Bone Joint J 2020; 102-B:261-267. [DOI: 10.1302/0301-620x.102b2.bjj-2019-0772.r2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aims It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis. Methods In all, 91 nonambulatory patients with neuromuscular scoliosis were included. All underwent surgery using bilateral, segmental, pedicle screw instrumentation. A total of 40 patients underwent fusion to L5 and 51 had their fixation extended to the pelvis. The two groups were assessed for differences in terms of clinical and radiological findings, as well as complications. Results The main curve (MC) was a mean of 90° (40° to 141°) preoperatively and 46° (15° to 82°) at two-year follow-up in the L5 group, and 82° (33° to 116°) and 19° (1° to 60°) in the pelvic group (p < 0.001 at follow-up). Correction of MC and pelvic obliquity (POB) were statistically greater in the pelvic group (p < 0.001). There was no statistically significant difference in the operating time, blood loss, or complications. Loss of MC correction (> 10°) was more common in patients fixated to the pelvis (23% vs 3%; p = 0.032), while loss of pelvic obliquity correction was more frequent in the L5 group (25% vs 0%; p = 0.007). Risk factors for loss of correction (either POB or MC) included preoperative coronal imbalance (> 50 mm, odds ratio (OR) 11.5, 95%confidence interval (CI) 2.0 to 65; p = 0.006) and postoperative sagittal imbalance (> 25 mm, OR 11.0, 95% CI1.9 to 65; p = 0.008). Conclusion We found that patients undergoing pelvic fixation had a greater correction of MC and POB. The rate of complications was not different. Preoperative coronal and postoperative sagittal imbalance were associated with increased risks of loss of correction, regardless of extent of fixation. Therefore, we recommend pelvic fixation in all nonambulatory children with neuromuscular scoliosis where coronal or sagittal imbalance are present preoperatively. Cite this article: Bone Joint J 2020;102-B(2):261–267.
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Affiliation(s)
- Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Markus Lastikka
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - Thomas Andersen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ilkka Helenius
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
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Fruergaard S, Jain MJ, Deveza L, Liu D, Heydemann J, Ohrt-Nissen S, Dragsted C, Gehrchen M, Dahl B. Evaluation of a new sagittal classification system in adolescent idiopathic scoliosis. Eur Spine J 2019; 29:744-753. [PMID: 31802239 DOI: 10.1007/s00586-019-06241-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/21/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of the present study was to validate a new spinal sagittal classification. METHODS We retrospectively included 105 consecutive AIS patients who underwent posterior spinal fusion. Preoperative long-standing EOS radiographs were available on all patients. Patients were classified according to the four suggested sagittal patterns: type 1, 2a, 2b or 3. Several predetermined sagittal parameters were compared between the groups. RESULTS The mean preoperative Cobb angle was 64° ± 12°, and 73% of the patients were female. Of 105 patients, 51 were type 1, 14 were type 2a, one was type 2b and 39 were type 3. The distribution of the four sagittal patterns was significantly different compared with the original publication (p < 0.05). However, the two study populations were comparable in terms of Lenke and Roussouly types (p = 0.49 and 0.47, respectively). In our study population, the sagittal groups differed significantly in terms of thoracic kyphosis, length of thoracic and lumbar curves, lumbar lordosis, thoracic slope, C7 slope, pelvic incidence and sacral slope (p < 0.05). CONCLUSION The distribution of the four sagittal patterns varies between AIS cohorts. Type 2b was rare, which limits the clinical applicability. Contrary to the original publication, we found that the spinopelvic parameters lumbar lordosis, pelvic incidence and sacral slope were significantly different between the Abelin-Genevois types. Hence, the corrective surgical strategy may need to incorporate these spinopelvic parameters to achieve a balanced spine requiring a minimum of energy expenditure. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Sidsel Fruergaard
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA. .,Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Mohit J Jain
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Lorenzo Deveza
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - David Liu
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - John Heydemann
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Casper Dragsted
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.,Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
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Andersen MØ, Fritzell P, Eiskjaer SP, Lagerbäck T, Hägg O, Nordvall D, Lönne G, Solberg T, Jacobs W, van Hooff M, Gerdhem P, Gehrchen M. Surgical Treatment of Degenerative Disk Disease in Three Scandinavian Countries: An International Register Study Based on Three Merged National Spine Registers. Global Spine J 2019; 9:850-858. [PMID: 31819851 PMCID: PMC6882087 DOI: 10.1177/2192568219838535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Observational study of prospectively collected data. OBJECTIVES Patients with chronic low back pain resistant to nonoperative treatment often face a poor prognosis for recovery. The aim of the current study was to compare the variation and outcome of surgical treatment of degenerative disc disease in the Scandinavian countries based on The International Consortium for Health Outcomes Measurement core spine data sets. METHODS Anonymized individual level data from 3 national registers were pooled into 1 database. At the time of surgery, the patient reports data on demographics, lifestyle topics, comorbidity, and data on health-related quality of life such as Oswestry Disability Index, Euro-Qol-5D, and back and leg pain scores. The surgeon records diagnosis, type of surgery performed, and complications. One-year follow-ups are obtained with questionnaires. Baseline and 1-year follow-up data were analyzed to expose any differences between the countries. RESULTS A total of 1893 patients were included. At 1-year follow-up, 1315 (72%) patients responded. There were statistically significant baseline differences in age, smoking, comorbidity, frequency of previous surgery and intensity of back and leg pain. Isolated fusion was the primary procedure in all the countries ranging from 84% in Denmark to 76% in Sweden. There was clinically relevant improvement in all outcome measures except leg pain. CONCLUSIONS In homogenous populations with similar health care systems the treatment traditions can vary considerably. Despite variations in preoperative variables, patient reported outcomes improve significantly and clinically relevant with surgical treatment.
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Affiliation(s)
- Mikkel Østerheden Andersen
- Center for Spine Surgery & Research, Region of Southern Denmark, Middelfart, Denmark
- University of Southern Denmark, Odense, Denmark
| | - Peter Fritzell
- Capio St Göran Hospital, Stockholm, Sweden
- Uppsala University, Uppsala, Sweden
- Qulturum Center for Learning and Innovation in Healthcare, Jönköping, Sweden
| | | | - Tobias Lagerbäck
- Karolinska University Hospital and Karolinska Institutet, Huddinge, Sweden
| | - Olle Hägg
- Spine Center Göteborg, Göteborg, Sweden
| | - Dennis Nordvall
- Qulturum Center for Learning and Innovation in Healthcare, Jönköping, Sweden
| | - Greger Lönne
- Innlandet Hospital Trust, Lillehammer, Norway
- St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tore Solberg
- University Hospital of Northern Norway, Tromsø, Norway
- The Arctic University of Norway, Tromsø, Norway
| | - Wilco Jacobs
- The Health Scientist, The Hague, the Netherlands
| | - Miranda van Hooff
- Sint Maartenskliniek, Nijmegen, the Netherlands
- Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul Gerdhem
- Karolinska University Hospital and Karolinska Institutet, Huddinge, Sweden
| | - Martin Gehrchen
- Rigshospitalet University of Copenhagen, Copenhagen, Denmark
- Martin Gehrchen, Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark.
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Dahl B, Dragsted C, Ohrt-Nissen S, Andersen T, Gehrchen M. Use of a distraction-to-stall lengthening procedure in magnetically controlled growing rods: A single-center cohort study. J Orthop Surg (Hong Kong) 2019; 26:2309499018779833. [PMID: 29871534 DOI: 10.1177/2309499018779833] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The objective of this study was to assess the outcome of patients treated with magnetically controlled growing rods (MCGRs) using a standardized distraction procedure with intended distraction-to-stall and to compare the outcomes between idiopathic and nonidiopathic patients. METHODS This was a retrospective single-center cohort study. Conversion cases were excluded. Distractions were performed with 2- to 3-month intervals with the intention of distraction-to-stall on both rods. Distraction length was measured on X-rays every 6 months. Spinal height was assessed using T1-T12 and T1-S1 annual increase. RESULTS 19 patients (eight idiopathic and 11 nonidiopathic) were included. Mean age at surgery was 9.7 ± 1.9 years, and median follow-up was 1.9 years (interquartile range (IQR): 1.3-2.2). Major curve improved from median 76° (IQR: 64-83) preoperatively to 42° (IQR: 32-51) postoperatively ( p < 0.001) corresponding to a curve correction of 43% (IQR: 33-51). Correction was maintained at 1- and 2-year follow-up. Median annual T1-T12 and T1-S1 height increase were 10 mm (IQR: 6-16) and 11 mm (IQR: 7-33), respectively. A total of 159 distraction procedures were performed; 83.5% of these were distracted-to-stall, and 16.5% were stopped due to discomfort. Median rod distraction per procedure was 2.0 mm (IQR: 1.6-2.7) for the concave side and 1.7 mm (IQR: 1.4-2.5) for the convex side. Five patients had implant-related complications. Patients with nonidiopathic etiology were significantly younger and had lower flexibility compared with idiopathic patients ( p ≤ 0.040). However, we found no statistically significant difference in curve correction, spinal height increase, distraction length, or complications between the two groups ( p ≥ 0.109). CONCLUSION MCGR effectively corrected the deformity and increased spinal height using a distraction procedure with intended distraction-to-stall. Five of 19 patients had implant-related complications, and we found no difference in the outcomes between idiopathic and nonidiopathic patients.
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Affiliation(s)
- Benny Dahl
- 1 Department of Orthopedic Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Casper Dragsted
- 2 Spine Unit, Orthopedic Surgery Department, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Søren Ohrt-Nissen
- 2 Spine Unit, Orthopedic Surgery Department, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Andersen
- 2 Spine Unit, Orthopedic Surgery Department, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Gehrchen
- 2 Spine Unit, Orthopedic Surgery Department, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Bari TJ, Hallager DW, Tøndevold N, Karbo T, Hansen LV, Dahl B, Gehrchen M. Spinopelvic Parameters Depending on the Angulation of the Sacral End Plate Are Less Reproducible Than Other Spinopelvic Parameters in Adult Spinal Deformity Patients. Spine Deform 2019; 7:771-778. [PMID: 31495478 DOI: 10.1016/j.jspd.2018.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/27/2018] [Accepted: 12/03/2018] [Indexed: 11/18/2022]
Abstract
STUDY DESIGN Reproducibility study. OBJECTIVES To report the agreement and reliability for commonly used sagittal plane measurements. SUMMARY OF BACKGROUND DATA Spinopelvic parameters and sagittal vertical axis (SVA) are commonly used parameters for preoperative planning and postoperative evaluation of patients with adult spinal deformity (ASD). Previous reproducibility studies have focused on describing the reliability using intraclass correlation coefficients (ICCs), thus quantifying the methods' ability to distinguish between individuals. To our knowledge, no previous study in patients with ASD has reported the measurement error in terms of limits of agreement. The current study aimed to report the agreement and reliability for measurements of pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and SVA in ASD patients. METHODS In a consecutive, one-center cohort of 64 patients referred for ASD evaluation, a blinded test-retest study was performed. Reliability was assessed using ICCs, whereas 95% limits of agreement (LOAs) were used to quantify agreement. RESULTS We found "excellent" (ICC > 0.9) results in all analyses of reliability except for interrater PI, which was classified as "good" (ICC = 0.89). However, considerable interrater measurement error was observed for parameters depending on the angulation of the sacral end plate (95% LOA of ±11° and ±14° for SS and PI, respectively) compared with ±5° for PT and ±7 mm for SVA, which depends on the location of the sacral end plate. Intrarater agreement was only slightly better. CONCLUSION These are to our knowledge the first estimates of measurement error for sagittal spinopelvic parameters in ASD patients. Despite near excellent ICCs, we found considerable measurement error for parameters depending on the angulation rather than the location of the sacral end plate. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark.
| | - Dennis Winge Hallager
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ture Karbo
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Lars Valentin Hansen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
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Pitter FT, Sikora M, Lindberg-Larsen M, Pedersen AB, Dahl B, Gehrchen M. Use of Opioids and Other Analgesics Before and After Primary Surgery for Adult Spinal Deformity: A 10-Year Nationwide Study. Neurospine 2019; 17:237-245. [PMID: 31345014 PMCID: PMC7136115 DOI: 10.14245/ns.1938106.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/15/2019] [Indexed: 12/31/2022] Open
Abstract
Objective To report the 1-year pre and postoperative analgesic use in patients undergoing primary surgery for adult spinal deformity (ASD) and assess risk factors for chronic postoperative opioid use.
Methods Patients > 18 years undergoing primary instrumented surgery for ASD in Denmark between 2006 and 2016 were identified in the Danish National Patient Registry. Information on analgesic use were obtained from the Danish National Health Service Prescription Database. Use of analgesics was calculated one year before and after surgery for each patient, per quarter (-Q4 to -Q1 before and Q1 to Q4 after). Users were defined as patient with one or more prescriptions in the given quarter.
Results We identified 892 patients. Preoperatively, 28% (n = 246) of patients were opioid users in -Q4 and 33% (n = 295) in -Q1. Postoperatively, 85% (n = 756) of patients were opioid users in Q1 and 31% (n = 280) in Q4. Proportions of users of other analgesics (paracetamol, antidepressants, and anticonvulsants) were stable before and after surgery. Use of nonsteroidal anti-inflammatory drug decreased postoperatively by 40% (-Q1 vs. Q4). 26% of patients had chronic preoperative opioid use (one or more prescriptions in each -Q2 and -Q1) and 24% had chronic postoperative use (prescription each of Q1–Q4). Multivariate logistic regression analysis showed age increment per 10 years and preoperative chronic opioid use as risk factors for chronic postoperative opioid use.
Conclusion One year after ASD surgery, opioid use was not reduced compared to preoperative usage.
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Affiliation(s)
- Frederik Taylor Pitter
- Spine Unit, Department of Orthopedic Surgery, University Hospital of Copenhagen Rigshospitalet, Copenhagen, Denmark
| | - Matt Sikora
- Neuroscience Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | | | - Alma Becic Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Benny Dahl
- Department of Orthopedic Surgery, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, University Hospital of Copenhagen Rigshospitalet, Copenhagen, Denmark
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Pitter FT, Lindberg-Larsen M, Pedersen AB, Dahl B, Gehrchen M. Revision Risk After Primary Adult Spinal Deformity Surgery: A Nationwide Study With Two-Year Follow-up. Spine Deform 2019; 7:619-626.e2. [PMID: 31202380 DOI: 10.1016/j.jspd.2018.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/06/2018] [Accepted: 10/21/2018] [Indexed: 11/15/2022]
Abstract
STUDY DESIGN Cohort study. OBJECTIVES To report the two-year revision risk following primary adult spinal deformity (ASD) surgery, describe reasons for revisions, and assess risk factors for revision surgery. SUMMARY OF BACKGROUND DATA Revision risk following primary ASD surgery has been reported to vary between 7% and 26%, but with loss to follow-up as a considerable challenge. METHODS Patients ≥18 years of age undergoing primary instrumented surgery for ASD in Denmark during 2006-2014 were identified by procedure and diagnosis codes in the Danish National Patient Registry (DNPR). Complete two-year follow-up on revision surgery for each patient was achieved. Medical records were reviewed to determine reasons for revisions. Overall comorbidity was summarized using the Charlson Comorbidity Index (CCI) based on DNPR data; low comorbidity (CCI 0); medium comorbidity (CCI 1-2); and high comorbidity (CCI ≥3). Risk factors for revision were assessed in a Cox regression model. RESULTS A total of 553 patients were identified. Of these, 19.9% were revised within the two-year follow-up and 7.2% of patients were revised more than once. Median time to revision was 308 days (interquartile range 105-508). The most common reason for revision was implant failure (38.2%) followed by infection (11.8%). Increased age (hazard ratio [HR] = 1.13, 95% confidence interval [CI] 1.01-1.26, per 10 years increment) and high comorbidity burden (HR = 2.10, 95% CI 1.16-3.79) were associated with increased revision risk. Risk of revision increased from 2006 to 2014; hence, year of primary surgery (with 2006 as reference) was associated with increased revision risk (HR = 1.09, 95% CI 1.01-1.18). CONCLUSIONS The revision risk within 2 years after primary ASD surgery was 19.9% nationwide in Denmark, and implant failure was the most common reason for revision. Increased comorbidity and age were separately associated with increased risk of revision. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Frederik T Pitter
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9-2100, København Ø, Denmark.
| | - Martin Lindberg-Larsen
- Department of Orthopedic Surgery and Traumatology, Odense University Hospital, J.B. Winsløvsvej 4-5000, Odense C, Denmark
| | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45-8200, Aarhus N, Denmark
| | - Benny Dahl
- Department of Orthopedic Surgery, Texas Children's Hospital & Baylor College of Medicine, Houston, TX 77030, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9-2100, København Ø, Denmark
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Bari TJ, Ohrt-Nissen S, Hansen LV, Dahl B, Gehrchen M. Ability of the Global Alignment and Proportion Score to Predict Mechanical Failure Following Adult Spinal Deformity Surgery-Validation in 149 Patients With Two-Year Follow-up. Spine Deform 2019; 7:331-337. [PMID: 30660230 DOI: 10.1016/j.jspd.2018.08.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/27/2018] [Accepted: 08/04/2018] [Indexed: 11/16/2022]
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVES To validate the Global Alignment and Proportion (GAP) score in a single-center cohort of adult spinal deformity (ASD) patients. SUMMARY OF BACKGROUND DATA Surgical treatment for ASD is associated with a high risk of mechanical failure and consequent revision surgery. To improve prediction of mechanical complications, the GAP score was developed with promising results. Development was based on the assumption that not all patients would benefit from the same fixed radiographic targets as pelvic incidence is an individual, morphological parameter that greatly influences the sagittal curves of the spine. METHODS In a validation study of the GAP score, patients undergoing ASD surgery with four or more levels of instrumentation were consecutively included at a tertiary spine unit. Patients were followed for a minimum of two years. Pre- and postoperative GAP score and categories were calculated for all patients, and the association with mechanical failure and revision surgery was analyzed. RESULTS A total of 149 patients with a mean age of 57.4 years were included. Overall, the rates of mechanical failure and revision surgery were 51% and 35% respectively. The area under the curve (AUC) using receiver operating characteristic was classified as "no or low discriminatory power" for the GAP score in predicting either outcome (AUC = 0.50 and 0.49, respectively). Similarly, there were no significant associations between GAP categories and the occurrence of mechanical failure or revision surgery when using Cochran-Armitage test of trend (p = .28 for mechanical failure and p = .58 for revision surgery). CONCLUSIONS In a consecutive series of surgically treated ASD patients, we found no significant association between postoperative GAP score and mechanical failure or revision surgery. Despite minor limitations in similarities to the original study cohort, further validation studies or adjustments to the original scoring system are proposed. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, University Hospital of Copenhagen, Copenhagen 2100, Denmark.
| | - Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, University Hospital of Copenhagen, Copenhagen 2100, Denmark
| | - Lars Valentin Hansen
- Spine Unit, Department of Orthopedic Surgery, University Hospital of Copenhagen, Copenhagen 2100, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, University Hospital of Copenhagen, Copenhagen 2100, Denmark
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Bari TJ, Hallager DW, Tøndevold N, Karbo T, Hansen LV, Dahl B, Gehrchen M. Moderate Interrater and Substantial Intrarater Reproducibility of the Roussouly Classification System in Patients With Adult Spinal Deformity. Spine Deform 2019; 7:312-318. [PMID: 30660227 DOI: 10.1016/j.jspd.2018.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 05/05/2018] [Accepted: 08/18/2018] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Reproducibility study of a classification system. OBJECTIVES To provide the inter- and intrarater reproducibility of the Roussouly Classification System in a single-center prospective cohort of patients referred for Adult Spinal Deformity. SUMMARY OF BACKGROUND DATA The Roussouly Classification System was developed to describe the variation in sagittal spine shape in normal individuals. A recent study suggests that patients' spine types could influence the outcome following spinal surgery. The utility of a classification system depends largely on its reproducibility. METHODS Sixty-four consecutive patients were included in a blinded test-retest setting using digital radiographs. All ratings were performed by four spine surgeons with different levels of experience. There was a 14-day interval between the two reading sessions. Inter- and intrarater reproducibility was calculated using Fleiss Kappa and crude agreement percentages. RESULTS We found moderate interrater (κ = 0.60) and substantial intrarater (κ = 0.68) reproducibility. All 4 raters agreed on the Roussouly type in 47% of the cases. The most experienced rater had significantly higher intrarater reliability compared to the least experienced rater (κ = 0.57 vs 0.78). The two most experienced raters also had the highest crude agreement percentage (75%); however, they also had a significant difference in distribution of spine types. CONCLUSION The current study presents moderate interrater and substantial intrarater reliability of the Roussouly Classification System. These findings are acceptable and comparable to previous results of reproducibility for a classification system in patients with Adult Spinal Deformity. Additional studies are requested to validate these findings as well as to further investigate the impact of the classification system on outcome following surgery.
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Affiliation(s)
- Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Dennis Winge Hallager
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Ture Karbo
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lars Valentin Hansen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Ohrt-Nissen S, Bari T, Dahl B, Gehrchen M. Sagittal Alignment After Surgical Treatment of Adolescent Idiopathic Scoliosis-Application of the Roussouly Classification. Spine Deform 2019; 6:537-544. [PMID: 30122389 DOI: 10.1016/j.jspd.2018.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/18/2017] [Accepted: 02/02/2018] [Indexed: 10/28/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To investigate spinopelvic alignment and spine shape in patients surgically treated for adolescent idiopathic scoliosis (AIS) and to assess the distribution and clinical applicability of the Roussouly classification. SUMMARY OF BACKGROUND DATA How spinopelvic alignment is affected in AIS patients is not well established. Roussouly et al. proposed a classification based on the sagittal spinal profile and spinopelvic alignment that may have clinical utility in these patients. METHODS A consecutive cohort of 134 surgically treated AIS patients were included. Whole-spine standing lateral radiographs were analyzed preoperatively, one-week postoperatively and at two-year follow-up. Patients were categorized using the modified Roussouly classification and analyzed for sagittal alignment. RESULTS Postoperatively, global thoracic kyphosis (TK) decreased by 2.6° and lumbar lordosis (LL) decreased by 6.2°(p ≤ .012) while Pelvic tilt (PT) increased 1.4° (p = .024). At two-year follow-up, TK and LL had returned to preoperative values (p ≥ .346) while PT had decreased from preoperative 9.7 ± 7.6° to 7.0 ± 7.5° (p > .001). Proximal junctional angle increased from 8.4 ± 5.0° preoperatively to 12.8 ± 8.9 (p < .001). Preoperatively, Roussouly curve types were distributed equally apart from a lower rate of type 1 (12%). At final follow-up, 30% were categorised as type 3 with pelvic anteversion which is considerably higher than the normal adolescent population. Only three patients were type 1 at the final follow-up. Overall, we found a high rate of proximal junctional kyphosis (16%), PI-LL mismatch (60%) and pelvic anteversion (38%). In preoperative type 1 patients, the rate was 50%, 82% and 64%, respectively. CONCLUSION We found that immediate postoperative changes in lordosis and kyphosis were reversed at final follow-up and found evidence of proximal junctional kyphosation and pelvic anteversion as the main compensatory mechanisms. Poor sagittal alignment was frequent in type 1 curves, and surgical treatment may need to be individualized according to the sagittal profile. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Søren Ohrt-Nissen
- Department of Orthopedic Surgery, Spine Unit, University Hospital of Copenhagen, Blegdamsvej 9, 2100 København, Denmark.
| | - Tanvir Bari
- Department of Orthopedic Surgery, Spine Unit, University Hospital of Copenhagen, Blegdamsvej 9, 2100 København, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital, 6621 Fannin St, Houston, TX 77030, USA
| | - Martin Gehrchen
- Department of Orthopedic Surgery, Spine Unit, University Hospital of Copenhagen, Blegdamsvej 9, 2100 København, Denmark
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Lønne G, Fritzell P, Hägg O, Nordvall D, Gerdhem P, Lagerbäck T, Andersen M, Eiskjaer S, Gehrchen M, Jacobs W, van Hooff ML, Solberg TK. Lumbar spinal stenosis: comparison of surgical practice variation and clinical outcome in three national spine registries. Spine J 2019; 19:41-49. [PMID: 29792994 DOI: 10.1016/j.spinee.2018.05.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Decompression surgery for lumbar spinal stenosis (LSS) is the most common spinal procedure in the elderly. To avoid persisting low back pain, adding arthrodesis has been recommended, especially if there is a coexisting degenerative spondylolisthesis. However, this strategy remains controversial, resulting in practice-based variation. PURPOSE The present study aimed to evaluate in a pragmatic study if surgical selection criteria and variation in use of arthrodesis in three Scandinavian countries can be linked to variation in treatment effectiveness. STUDY DESIGN This is an observational study based on a combined cohort from the national spine registries of Norway, Sweden, and Denmark. PATIENT SAMPLE Patients aged 50 and older operated during 2011-2013 for LSS were included. OUTCOME MEASURES Patient-Reported Outcome Measures (PROMs): Oswestry Disability Index (ODI) (primary outcome), Numeric Rating Scale (NRS) for leg pain and back pain, and health-related quality of life (Euro-Qol-5D) were reported. Analysis included case-mix adjustment. In addition, we report differences in hospital stay. METHODS Analyses of baseline data were done by analysis of variance (ANOVA), chi-square, or logistic regression tests. The comparisons of the mean changes of PROMs at 1-year follow-up between the countries were done by ANOVA (crude) and analysis of covariance (case-mix adjustment). RESULTS Out of 14,223 included patients, 10,890 (77%) responded at 1-year follow-up. Apart from fewer smokers in Sweden and higher comorbidity rate in Norway, baseline characteristics were similar. The rate of additional fusion surgery (patients without or with spondylolisthesis) was 11% (4%, 47%) in Norway, 21% (9%, 56%) in Sweden, and 28% (15%, 88%) in Denmark. At 1-year follow-up, the mean improvement for ODI (95% confidence interval) was 18 (17-18) in Norway, 17 (17-18) in Sweden, and 18 (17-19) in Denmark. Patients operated with arthrodesis had prolonged hospital stay. CONCLUSIONS Real-life data from three national spine registers showed similar indications for decompression surgery but significant differences in the use of concomitant arthrodesis in Scandinavia. Additional arthrodesis was not associated with better treatment effectiveness.
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Affiliation(s)
- Greger Lønne
- Department of Orthopaedics, Innlandet Hospital Trust, Anders Sandvigs gt. 17, 2629 Lillehammer, Norway; National Advisory Unit on Spinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Olav Kyrres gate 17, 7006 Trondheim, Norway; The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Helse Nord RHF, Postboks 1445, 8038 Bodø, Norway.
| | - Peter Fritzell
- Department of Orthopaedics, Capio St Göran Hospital, Sankt Göransplan 1, 112 81 Stockholm, Sweden; Department of Surgical Sciences, Division of Orthopaedics, Uppsala University, Akademiska sjukhuset entrence 70, 1 tr, 751 85 Uppsala, Sweden; Strömstad akademi, Norra Bergsgatan 23, 45280 Strömstad, Sweden; Qulturum Center for Learning and Innovation in Healthcare, Hus B4 Länssjukhuset Ryhov, 553 05 Jönköping, Sweden
| | - Olle Hägg
- Spine Center Göteborg, Gruvgatan 8, 421 30, Västra Frölunda, Göteborg, Sweden; Swespine Steering Group, Swedish National Spine Register, Sveriges Kommuner och Landsting, SE-118 82 Stockholm, Sweden
| | - Dennis Nordvall
- Qulturum Center for Learning and Innovation in Healthcare, Hus B4 Länssjukhuset Ryhov, 553 05 Jönköping, Sweden
| | - Paul Gerdhem
- Department of Orthopaedics, Karolinska University Hospital Huddinge, K54, SE-14186 Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Karolinska Institutet, K54, SE-14186, Stockholm, Sweden
| | - Tobias Lagerbäck
- Department of Orthopaedics, Karolinska University Hospital Huddinge, K54, SE-14186 Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Karolinska Institutet, K54, SE-14186, Stockholm, Sweden
| | - Mikkel Andersen
- Sector for Spine Surgery and Research, Lillebaelt Hospital, Østre Hougvej 55, 5500 Middelfart, Denmark
| | - Søren Eiskjaer
- Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Wilco Jacobs
- The Health Scientist, Fraeylemastraat 13, 2532 TX, The Hague, The Netherlands
| | - Miranda L van Hooff
- Department Research, Sint Maartenskliniek, Nijmegen, Hengstdal 3, 6574 NA Ubbergen, The Netherlands; Department of Orthopedics, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Tore K Solberg
- The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Helse Nord RHF, Postboks 1445, 8038 Bodø, Norway; Department of Neurosurgery, University Hospital of Northern Norway, Breivika, 9038, Tromsø, Norway; Institute of Clinical Medicine, University of Tromsø The Arctic University of Norway, Hansine Hansens veg 18, 9037, Tromsø, Norway
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Fruergaard S, Ohrt-Nissen S, Dahl B, Kaltoft N, Gehrchen M. Neural Axis Abnormalities in Patients With Adolescent Idiopathic Scoliosis: Is Routine Magnetic Resonance Imaging Indicated Irrespective of Curve Severity? Neurospine 2018; 16:339-346. [PMID: 30653908 PMCID: PMC6603845 DOI: 10.14245/ns.1836154.077] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/06/2018] [Indexed: 12/05/2022] Open
Abstract
Objective Magnetic resonance imaging (MRI)-verified neural axis abnormalities (NAAs) have been described in adolescent idiopathic scoliosis (AIS), and several risk factors have been associated with the presence of NAAs in AIS patients. However, the clinical significance of these findings is unclear. The purpose of the present study was to determine the prevalence of NAAs in a large consecutive cohort of AIS patients and to evaluate the clinical significance of previously proposed risk factors.
Methods We prospectively included AIS patients referred to a tertiary facility for evaluation. Full-spine MRI scans were performed on all included patients irrespective of curve magnitude or proposed treatment modality. MRI scans were prospectively analyzed by a neuroradiologist and the pathologic findings were confirmed by a second independent radiologist.
Results NAA was observed in 34 of the 381 patients (8.9%): 32 patients had a syrinx, 1 patient had an arachnoid cyst, and 1 patient had a Chiari malformation. Four patients were referred for a neurosurgical evaluation but none received any neurosurgical treatment. No statistically significant difference was observed between the NAA and non-NAA groups in terms of sex, major curve size, thoracic kyphosis, left thoracic curve, curve convexity, curve progression, or level of pain (p>0.05).
Conclusion In this prospective study examining the risk factors for NAA in AIS patients, we found that previously proposed risk factors could not predict the MRI outcomes. The finding of an NAA had no clinical implications and we do not support MRI scans as a routine diagnostic modality in all AIS patients.
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Affiliation(s)
- Sidsel Fruergaard
- Department of Orthopedic Surgery, Spine Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Søren Ohrt-Nissen
- Department of Orthopedic Surgery, Spine Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopaedic Surgery, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Nicolai Kaltoft
- Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Gehrchen
- Department of Orthopedic Surgery, Spine Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Ohrt-Nissen S, Dahl B, Gehrchen M. Choice of Rods in Surgical Treatment of Adolescent Idiopathic Scoliosis: What Are the Clinical Implications of Biomechanical Properties? - A Review of the Literature. Neurospine 2018; 15:123-130. [PMID: 29991241 PMCID: PMC6104735 DOI: 10.14245/ns.1836050.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/01/2018] [Indexed: 11/23/2022] Open
Abstract
The surgical treatment of adolescent idiopathic scoliosis (AIS) involves 3-dimensional curve correction with multisegmental pedicle screws attached to contoured bilateral rods. The substantial corrective forces exert a high level of stress on the rods, and the ability of the rod to withstand these forces without undergoing permanent deformation relies on its biomechanical properties. These properties, in turn, are dependent on the material, diameter, and shape of the rod. The surgical treatment of AIS is characterized by the requirement for a special biomechanical profile that may differ substantially from what is needed for adult deformity surgery. This overview summarizes the current knowledge of rod biomechanics in frequently used rod constructs, with a particular focus on translational research between biomechanical studies and clinical applicability in AIS patients.
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Affiliation(s)
- Søren Ohrt-Nissen
- Department of Orthopedic Surgery, Spine Unit, Copenhagen University Hospital, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Martin Gehrchen
- Department of Orthopedic Surgery, Spine Unit, Copenhagen University Hospital, Copenhagen, Denmark
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Faundez A, Le Huec JC, Hansen LV, Poh Ling F, Gehrchen M. Optimizing Pedicle Subtraction Osteotomy Techniques: A New Reduction Plier to Increase Technical Safety and Angular Reduction Efficiency. Oper Neurosurg (Hagerstown) 2018; 16:383-388. [DOI: 10.1093/ons/opy086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 05/23/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Pedicle subtraction osteotomy (PSO) is a technically demanding surgery. There is room for development of osteotomy reduction instruments like the one we present in this study, to better guide angular correction and closure of the osteotomy line.
OBJECTIVE
To present a new surgical instrument that optimizes PSOs of the thoracolumbar spine.
METHODS
Seventeen consecutive patients have been treated at 3 different European University Hospitals. All underwent a PSO of the lumbar spine to treat major sagittal imbalance. The amount of vertebral angular correction needed was calculated using the full balance integrated (FBI) method. A special plier, which allows to safely control the angular correction, was used intraoperatively. Preoperative and early postoperative global sagittal balance parameters were compared.
RESULTS
The mean preoperative calculated correction angle (FBI) was 33.8°; the mean postoperative correction obtained was 32.1°. Lumbar lordosis was statistically greater than preoperatively (55.8° vs 19.4°, P < .0001). The global sagittal balance was improved, as shown by the increase of the spino-sacral angle from 122° preoperatively to 128° postoperatively (P = .0547). None of the patients had an intraoperative or early postoperative neurologic complication. There were no mechanical intraoperative complications during correction nor at the first postoperative follow-up.
CONCLUSION
The advantages of the instrument are safe, precise, and efficient reduction, by a rotation of the pedicle screws close to the osteotomy line, thus avoiding collapse and lack of correction, complications usually seen with the conventional technique. Further prospective studies are needed to confirm these results.
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Affiliation(s)
- Antonio Faundez
- Division of Orthopaedic Surgery, Geneva University Hospitals, Geneva, Switzerland
| | | | - Lars V Hansen
- Spine Unit, Department of Orthopaedic Surgery U-2162, Rigshospitalet, The National University Hospital Copenhagen, Copenhagen, Denmark
| | - Fong Poh Ling
- Spine Unit, Department of Orthopedic Surgery, Singapore General Hospital, Singapore
| | - Martin Gehrchen
- Spine Unit, Department of Orthopaedic Surgery U-2162, Rigshospitalet, The National University Hospital Copenhagen, Copenhagen, Denmark
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Ohrt-Nissen S, Dragsted C, Dahl B, Ferguson JAI, Gehrchen M. Improved restoration of thoracic kyphosis using a rod construct with differentiated rigidity in the surgical treatment of adolescent idiopathic scoliosis. Neurosurg Focus 2018; 43:E6. [PMID: 28965450 DOI: 10.3171/2017.7.focus17351] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to compare postoperative sagittal alignment among 3 rod constructs with different rigidity profiles. METHODS This was a dual-center retrospective cohort study involving 2 consecutive cohorts in which patients were surgically treated for adolescent idiopathic scoliosis. Lenke Type 5 curves were excluded. Patients were operated on with all-pedicle screw instrumentation using 3 different rod constructs. The first group was operated on using a hybrid construct (HC) consisting of a normal circular rod on the convex side and a beam-like rod (BR) on the concave side. The second group was operated on with a standard construct (SC) using bilateral BRs in the full length of the fusion. The third group was operated on with a modified construct (MC). The modified rods have a beam-like shape in the caudal portion, but in the cranial 2 or 3 fusion levels the rod transitions to a circular shape with a smaller anteroposterior diameter. Radiographs were analyzed preoperatively and at the first postoperative follow-up (range 1-8 weeks). The primary outcome was pre- to postoperative change in thoracic kyphosis (TK), and the secondary outcome was the ability to achieve postoperative TK within the normal range. RESULTS The HC, SC, and MC groups included 23, 70, and 46 patients, respectively. The 3 groups did not differ significantly in preoperative demographic or radiographic parameters. The mean ± standard deviation of the preoperative main curve was 60.7° ± 12.6°, and the mean of curve correction was 62.9% ± 10.4% with no significant difference among groups (p ≥ 0.680). The groups did not differ significantly in coronal balance or proximal or thoracolumbar curve correction (p ≥ 0.189). Mean postoperative TK was 23.1° ± 6.3°, 19.6° ± 7.6°, and 23.4° ± 6.9° in the HC, SC and MC groups, respectively (p = 0.013), and the mean change in TK was -3.5° ± 11.3°, -7.1° ± 11.6°, and 0.1° ± 10.9°, respectively (p = 0.005). The MC group had significantly higher postoperative TK and less loss of TK compared with the SC group (p ≤ 0.018). Postoperative TK ≤ 10° was found in 12 patients (17%) in the SC group, 1 patient (5%) in the HC group, and 1 patient (2%) in the MC group (p = 0.021). There were no differences in proximal alignment, thoracolumbar alignment, or sagittal vertical axis (p ≥ 0.249). Lumbar lordosis was 58.9° ± 11.2° in the HC group versus 52.0° ± 1.3° and 55.0° ± 11.0° and the SC and MC groups, respectively (p = 0.040). CONCLUSIONS In the 3 rod constructs with different rigidity profiles, significantly better restoration of kyphosis was achieved with the use of bilateral modified rods compared with bilateral standard rods. In the MC and HC groups, the rate of severe postoperative hypokyphosis was significantly lower than in the SC group. This is the first study to describe the clinical use of a rod with a reduced proximal diameter and show marked radiographic improvement in sagittal alignment.
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Affiliation(s)
- Søren Ohrt-Nissen
- Department of Orthopaedic Surgery, Spine Unit, University Hospital of Copenhagen, Denmark
| | - Casper Dragsted
- Department of Orthopaedic Surgery, Spine Unit, University Hospital of Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital, Houston, Texas; and
| | | | - Martin Gehrchen
- Department of Orthopaedic Surgery, Spine Unit, University Hospital of Copenhagen, Denmark
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Dragsted C, Aagaard T, Ohrt-Nissen S, Gehrchen M, Dahl B. Mortality and health-related quality of life in patients surgically treated for spondylodiscitis. J Orthop Surg (Hong Kong) 2018. [PMID: 28639530 DOI: 10.1177/2309499017716068] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To assess mortality, disability, and health-related quality of life (HRQL) in patients surgically treated for spondylodiscitis. METHODS A retrospective longitudinal study was conducted on all patients surgically treated for spondylodiscitis over a 6-year period at a single tertiary spine center. Indications for surgery, pre- and postoperative neurological impairment, comorbidities, and mortality were recorded. A survey was conducted on all eligible patients with the EuroQol 5-dimension (EQ-5D) questionnaire and Oswestry Disability Index (ODI). RESULTS Sixty-five patients were diagnosed with spondylodiscitis not related to recent spine surgery. One-year mortality rate was 6%. In all, 36% and 27% had pre- and postoperative neurological impairment, respectively, with only one patient experiencing deterioration postoperatively. At final follow-up (median 2 years), mean ODI was 31% (SD = 22) and mean EQ-5D time trade-off score was 0.639 (SD = 0.262); this was significantly lower than that in the normal population ( p < 0.001). Patients with neurological impairment prior to index surgery had lower EQ-5D scores ( p = 0.005) and higher ODI ( p = 0.02) at final follow-up compared with patients without neurological impairment. CONCLUSIONS Several years after surgery, patients surgically treated for spondylodiscitis have significantly lower HRQL and more disability than the background population. Neurological impairment prior to index surgery predicts adverse outcome in terms of disability and lower HRQL.
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Affiliation(s)
- Casper Dragsted
- 1 Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Theis Aagaard
- 2 Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Ohrt-Nissen
- 1 Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Gehrchen
- 1 Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Benny Dahl
- 1 Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Ohrt-Nissen S, Hallager DW, Karbo T, Gehrchen M, Dahl B. Radiographic and Functional Outcome in Adolescent Idiopathic Scoliosis Operated With Hook/Hybrid Versus All-Pedicle Screw Instrumentation-A Retrospective Study in 149 Patients. Spine Deform 2017; 5:401-408. [PMID: 29050717 DOI: 10.1016/j.jspd.2017.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 05/02/2017] [Accepted: 05/09/2017] [Indexed: 11/30/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To compare radiographic outcome and health-related quality of life in patients with adolescent idiopathic scoliosis (AIS) treated with hook/hybrid (H/H) or all-pedicle screw (PS) instrumentation. SUMMARY OF BACKGROUND DATA PS instrumentation has largely replaced H/H in the surgical treatment of AIS but whether a normalized sagittal profile can be obtained with the PS construct is still debated. Additionally, comparative studies assessing HRQL and surgical complications are needed. METHODS Two consecutive series of surgically treated AIS patients were included. Surgical treatment consisted of H/H or low-profile all-PS instrumentation. Radiographic and clinical follow-up, including SRS-22r questionnaires, was performed a minimum of two years postoperatively. RESULTS There were 85 and 64 patients in the H/H and PS group, respectively. The groups did not differ on baseline parameters apart from a lower flexibility in the H/H group (34% ± 14% vs. 39% ± 14% in the PS group, p = .026). Mean curve correction at final follow-up was 31% ± 13% versus 49% ± 12% in the H/H and PS group, respectively (p < .001), and mean loss of correction was 7° versus 4° (p < .001). The Cincinnati correction index was significantly higher in the PS group at final follow-up (p < .001). Postoperative thoracic kyphosis was significantly higher in the H/H group (27° ± 11° vs. 22° ± 11° in the PS group) with a mean change in kyphosis of 3° ± 9° versus -3° ± 12° in the H/H and PS group, respectively. SRS-22 scores did not differ between the two groups (p > .090), and the reoperation rate at final follow-up was 9% in the H/H group and 6% in the PS group (p = .556). CONCLUSIONS In a large consecutive cohort of AIS patients followed for a minimum of two years, we found a significantly better curve correction and less loss of correction with PS instrumentation compared to H/H. There was no significant difference in SRS-22r scores at final follow-up. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Søren Ohrt-Nissen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Nørregade 10, 1165 København, Denmark.
| | - Dennis W Hallager
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Nørregade 10, 1165 København, Denmark
| | - Ture Karbo
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Nørregade 10, 1165 København, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Nørregade 10, 1165 København, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital, TX, USA
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Ohrt-Nissen S, Bukhari N, Dragsted C, Gehrchen M, Johansson PI, Dirks J, Stensballe J, Dahl B. Blood transfusion in the surgical treatment of adolescent idiopathic scoliosis-a single-center experience of patient blood management in 210 cases. Transfusion 2017; 57:1808-1817. [PMID: 28500653 DOI: 10.1111/trf.14137] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/04/2017] [Accepted: 03/04/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND The surgical treatment of adolescent idiopathic scoliosis can be associated with substantial blood loss, requiring allogeneic red blood cell (RBC) transfusion. This study describes the use of RBC and the effect of a standardized perioperative patient blood management program. STUDY DESIGN AND METHODS Patients treated with posterior instrumented fusion were consecutively enrolled over a 6-year period. Patient blood management strategies were implemented in 2011, including prophylactic tranexamic acid, intraoperative permissive hypotension, restrictive fluid therapy (including avoidance of synthetic colloids), restrictive RBC trigger according to institutional standardized protocol, the use of cell savage, and goal-directed therapy according to thrombelastography. RESULTS In total, 210 patients were included. 64 patients (31%) received RBC transfusions. A decline in the intraoperative rate of RBC transfusion was observed, from 77% in 2011 to 13% in 2016 (p < 0.001). Patients in the transfusion group had a significantly larger major curve, lower preoperative hemoglobin, higher estimated blood loss, and an increased use of crystalloid volume resuscitation. Multiple logistic regression showed that significant predictors for RBC transfusion were preoperative hemoglobin level (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.27-0.57), estimated blood loss (OR, 1.26; 95% CI, 1.15-1.42), and year of surgery (indicating the effect of patient blood management) (OR per year, 0.76; 95% CI, 0.58-0.99). CONCLUSION A perioperative patient blood management program substantially reduced the need for RBC transfusion. A preoperative evaluation of anemia is essential to further minimize transfusion rates.
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Affiliation(s)
- Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Naeem Bukhari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Casper Dragsted
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pär I Johansson
- Section for Transfusion Medicine, Rigshospitalet, Capitol Region Blood Bank, Copenhagen, Denmark
| | - Jesper Dirks
- Department of Anesthesiology, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Stensballe
- Department of Anesthesiology, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Section for Transfusion Medicine, Rigshospitalet, Capitol Region Blood Bank, Copenhagen, Denmark
| | - Benny Dahl
- Division of Orthopedic Surgery, Texas Children's Hospital, Houston, Texas
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Laouissat F, Sebaaly A, Gehrchen M, Roussouly P. Classification of normal sagittal spine alignment: refounding the Roussouly classification. Eur Spine J 2017; 27:2002-2011. [DOI: 10.1007/s00586-017-5111-x] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 03/14/2017] [Accepted: 04/23/2017] [Indexed: 11/30/2022]
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Ohrt-Nissen S, Hallager DW, Henriksen JL, Gehrchen M, Dahl B. Curve Magnitude in Patients Referred for Evaluation of Adolescent Idiopathic Scoliosis: Five Years' Experience From a System Without School Screening. Spine Deform 2016; 4:120-124. [PMID: 27927543 DOI: 10.1016/j.jspd.2015.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 08/14/2015] [Accepted: 10/10/2015] [Indexed: 11/19/2022]
Abstract
STUDY DESIGN Retrospective cross-sectional study. OBJECTIVES To analyze the referral pattern of patients with adolescent idiopathic scoliosis (AIS) in a tertiary hospital in a nationalized health care system without school screening and to compare curve magnitude on referral with results reported in the literature. SUMMARY OF BACKGROUND DATA In Denmark, school screening for AIS has not been in effect for more than two decades, and there is limited knowledge of curve magnitude and pattern of referral to specialized treatment in our country. Other studies, however, have assessed the effectiveness of school scoliosis screening. Our tertiary institution receives referrals for evaluation of AIS from general practitioners (GPs) and other hospitals or private specialists. METHOD A review was conducted on all patients diagnosed with AIS between 2010 and 2015. Data collection included age, gender, menarchal status, recommended treatment, and major curve Cobb angle for all patients aged 10-19 years referred for evaluation of AIS. Major curve magnitude was categorized as 10-19, 20-39, or ≥40 degrees, and the distribution of categories was compared to a screened population reported in the litterature. RESULTS A total of 166 of 460 newly referred AIS patients were referred from GP. Mean age was 15 years (standard deviation = 2) and median Cobb angle was 35 degrees. Overall, 33% were initially recommended treatment with a brace. This group had a median curve size of 41 degrees, and 28% presented more than 1 year past menarche. We found a significantly larger curve magnitude at the time of referral in our GP cohort compared to a screened population (p < .001), and 22% versus 8% had a Cobb angle >40 degrees (p < .001). CONCLUSION The present study confirms that in a health care system without school screening, patients with AIS referred for evaluation by GPs have larger curve sizes compared to systems with school screening. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Søren Ohrt-Nissen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen East, Denmark.
| | - Dennis W Hallager
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen East, Denmark
| | - Jeppe L Henriksen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen East, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen East, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen East, Denmark
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Karstensen S, Bari T, Gehrchen M, Street J, Dahl B. Morbidity and mortality of complex spine surgery: a prospective cohort study in 679 patients validating the Spine AdVerse Event Severity (SAVES) system in a European population. Spine J 2016; 16:146-53. [PMID: 26456809 DOI: 10.1016/j.spinee.2015.09.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 08/20/2015] [Accepted: 09/28/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Most literature on complications in spine surgery has been retrospective or based on national databases with few variables. The Spine AdVerse Events Severity (SAVES) system has been found reliable and valid in two Canadian centers, providing precise information regarding all adverse events (AEs). PURPOSE This study aimed to determine the mortality and examine the incidence of morbidity in patients undergoing complex spinal surgery, including pediatric patients, and to validate the SAVES system in a European population. STUDY DESIGN A prospective, consecutive cohort study was conducted using the SAVES version 2010 in the period from January 1, 2013 until December 31, 2013. A retrospective analysis was performed on all patients operated from November 1, 2011 until October 31, 2012 for comparison. PATIENT SAMPLE Patients undergoing spinal surgery at a tertiary referral center comprised the patient sample. OUTCOME MEASURES Morbidity and mortality were determined according to the newest version of the SAVES system and compared with the Canadian cohort. Other outcomes were length of stay, readmission, unplanned second surgery during index admission, as well as wound infections requiring revision. METHODS All patients undergoing spinal surgery at an academic tertiary referral center in the study period were prospectively included. The newest version of SAVES system was used, and a research coordinator collected all intraoperative and perioperative data prospectively. Once a week all patients were reviewed for additional events, validation of the data, and clarification of any questions. Patients were grouped according to the type of admission (elective of emergency) and age, and subgrouped according to a major diagnostic group. The survival status was registered on January 31, 2014 to obtain 30-day survival. RESULTS A total of 679 consecutive cases were included with 100% data completion. The in-hospital mortality was 1.3% and the 30-day mortality was 2.7%; all occurring after emergency procedures. The number of intraoperative AEs was 162 (overall incidence 20%), and the number of postoperative AEs was 1,415 (overall incidence 77%). Of the patients, 2.2% had postoperative infections requiring surgical revision. CONCLUSIONS A prospective registration improves AE recognition, and our data confirm the generalizability of the SAVES system to pediatric and non-Canadian populations.
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Affiliation(s)
- Sven Karstensen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen, Denmark.
| | - Tanvir Bari
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen, Denmark
| | - John Street
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, Floor 6, Blusson Spinal Cord Center, 818 West 10th Ave., Vancouver, British Columbia V5Z 1M9, Canada
| | - Benny Dahl
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen, Denmark
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Clement RC, Welander A, Stowell C, Cha TD, Chen JL, Davies M, Fairbank JC, Foley KT, Gehrchen M, Hagg O, Jacobs WC, Kahler R, Khan SN, Lieberman IH, Morisson B, Ohnmeiss DD, Peul WC, Shonnard NH, Smuck MW, Solberg TK, Stromqvist BH, Hooff MLV, Wasan AD, Willems PC, Yeo W, Fritzell P. A proposed set of metrics for standardized outcome reporting in the management of low back pain. Acta Orthop 2015; 86:523-33. [PMID: 25828191 PMCID: PMC4564773 DOI: 10.3109/17453674.2015.1036696] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Outcome measurement has been shown to improve performance in several fields of healthcare. This understanding has driven a growing interest in value-based healthcare, where value is defined as outcomes achieved per money spent. While low back pain (LBP) constitutes an enormous burden of disease, no universal set of metrics has yet been accepted to measure and compare outcomes. Here, we aim to define such a set. PATIENTS AND METHODS An international group of 22 specialists in several disciplines of spine care was assembled to review literature and select LBP outcome metrics through a 6-round modified Delphi process. The scope of the outcome set was degenerative lumbar conditions. RESULTS Patient-reported metrics include numerical pain scales, lumbar-related function using the Oswestry disability index, health-related quality of life using the EQ-5D-3L questionnaire, and questions assessing work status and analgesic use. Specific common and serious complications are included. Recommended follow-up intervals include 6, 12, and 24 months after initiating treatment, with optional follow-up at 3 months and 5 years. Metrics for risk stratification are selected based on pre-existing tools. INTERPRETATION The outcome measures recommended here are structured around specific etiologies of LBP, span a patient's entire cycle of care, and allow for risk adjustment. Thus, when implemented, this set can be expected to facilitate meaningful comparisons and ultimately provide a continuous feedback loop, enabling ongoing improvements in quality of care. Much work lies ahead in implementation, revision, and validation of this set, but it is an essential first step toward establishing a community of LBP providers focused on maximizing the value of the care we deliver.
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Affiliation(s)
- R Carter Clement
- Department of Orthopaedic Surgery, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | | | - Caleb Stowell
- International Consortium for Health Outcomes Measurement, Boston, MA, USA
| | - Thomas D Cha
- Department of Orthopaedics, Massachusetts General Hospital, Boston, MA, USA
| | - John L Chen
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | | | - Kevin T Foley
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Martin Gehrchen
- Department of Orthopaedic Surgery, Spine Section, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Olle Hagg
- Spine Center Göteborg, Gothenburg, Sweden
| | - Wilco C Jacobs
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Safdar N Khan
- Department of Orthopaedics, Division of Spine, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | | | | | | | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center and Medical Center Haaglanden, Leiden and The Hague, the Netherlands
| | - Neal H Shonnard
- Director, Spine SCOAP Collaborative, Rainier Orthopedic Institute, Puyallup, WA, US
| | - Matthew W Smuck
- Department of Orthopaedic Surgery, PM&R Section, Stanford University, Palo Alto, CA, USA
| | - Tore K Solberg
- Department of Ophthalmology and Neurosurgery, University Hospital of Northern Norway, Tromsø, Norway,The Norwegian Registry for Spine Surgery (NORspine), Northern Norway Regional Health Authority, Tromsø, Norway
| | - Bjorn H Stromqvist
- Department of Orthopedics, Clinical Sciences Lund, Lund University Hospital, Lund, Sweden
| | | | - Ajay D Wasan
- Department of Anesthesiology, University of Pittsburgh Medical Center Pittsburgh, PA, USA
| | - Paul C Willems
- Maastricht University Medical Center, Maastricht, the Netherlands
| | - William Yeo
- Orthopaedic Diagnostic Centre, Singapore General Hospital, Singapore
| | - Peter Fritzell
- Department of Orthopaedic Surgery, Ryhov Hospital, Jönköping, Sweden,Registry Manager, Swespine
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Nielsen DH, Gehrchen M, Hansen LV, Walbom J, Dahl B. Inter- and Intra-rater Agreement in Assessment of Adult Spinal Deformity Using the Scoliosis Research Society-Schwab Classification. Spine Deform 2014; 2:40-47. [PMID: 27927441 DOI: 10.1016/j.jspd.2013.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 09/01/2013] [Accepted: 09/05/2013] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Cross-sectional assessment of inter- and intra-rater agreement. OBJECTIVES To assess inter- and intra-rater agreement between spine surgeons with different levels of experience in a large consecutive series of adult patients referred to a tertiary institution for evaluation of a spinal deformity using the Scoliosis Research Society (SRS)-Schwab classification. BACKGROUND The development of the SRS-Schwab classification of adult spinal deformity is based on current knowledge about relevant radiographic variables related to health-related quality of life. Clinical implementation of the classification requires satisfactory reliability. Two recent reports on agreement were based on a small selected case sample using pre-marked radiographs and a large cohort of only surgical patients, including congenital deformity. METHODS Scoliosis Research Society-Schwab classification of 67 consecutive adult patients referred for surgical evaluation of a spinal deformity was done in a blinded fashion without pre-marking by 2 senior spine surgeons, 1 attending, and 1 spine fellow. After 2 weeks, the classification was repeated on recoded radiographs. Inter- and intra-rater agreement was analyzed using Fleiss kappa statistics. Rater bias was assessed using Bhapkar test for marginal homogeneity. RESULTS According to Landis and Koch, the observed agreements were considered substantial to almost perfect for curve type and sagittal modifiers and moderate for entire grade, with no consistent differences between surgeons with different levels of experience. CONCLUSIONS The results for each individual radiographic parameter correspond to previous findings and support use of the SRS-Schwab classification in adult spinal deformity. The results for entire grade were considered only moderate. The authors recommend that it is not used as an individual parameter.
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Affiliation(s)
- Dennis H Nielsen
- Spine Unit, Department of Orthopaedic Surgery 2161, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Martin Gehrchen
- Spine Unit, Department of Orthopaedic Surgery 2161, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lars V Hansen
- Spine Unit, Department of Orthopaedic Surgery 2161, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jonas Walbom
- Spine Unit, Department of Orthopaedic Surgery 2161, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopaedic Surgery 2161, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
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50
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Kiaer T, Gehrchen M. Transpedicular closed wedge osteotomy in ankylosing spondylitis: results of surgical treatment and prospective outcome analysis. Eur Spine J 2010; 19:57-64. [PMID: 19662442 PMCID: PMC2899742 DOI: 10.1007/s00586-009-1104-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 02/12/2009] [Accepted: 07/17/2009] [Indexed: 10/20/2022]
Abstract
Surgery in late stage ankylosing spondylitis (AS) most often tends to correct the sagittal balance with an extension osteotomy of the spine. In the literature, extension osteotomy was first described as an open wedge osteotomy but recently closed wedge osteotomy resecting the pedicles and posterior elements have become more popular. Only a limited number of cases have been reported in the literature and with limited focus on outcome of this major surgery. In this study, we reported the results of a large series of extension osteotomy in a population of patients with AS focusing on the technical aspects, complication rates, correction obtained and outcome evaluation using newer spine outcome measuring instruments. In the period from 1995 to 2005, 36 consecutive patients fulfilled the criteria where the files, radiographs and patients were available for further studies. The following data were recorded: Age, sex, comorbidity, indication, operation time and blood loss, level of osteotomy and estimated Correction. Furthermore, perioperative complications and all late complications were registered. The average follow-up was 50 months (3-128). Twenty-one patients also filled out questionnaires (SF36 and Oswestry Disability Index) preoperatively. At the end of the period all patients were contacted and filled out the same questionnaires. Fifteen of the patients had two pedicular resection osteotomies performed, 21 had one, and two had polysegmental osteotomies. Mean operation time was 180 min, bleeding was mean 2,450 ml, stay at the hospital was 13 days. One patient had partial paresis of the lower extremities all other complications were minor. The median correction was 45 degrees . The median Oswestry score improved significantly from 54 (range 20-94) preoperatively to 38 (range 2-94) postoperatively. The SF-36 score significantly increased, when evaluated on the major components Physical Component Summary (PCS) and Mental Component Summary (MCS). The thoracolumbar closed wedge pedicular resection osteotomy used in this series was a safe method for correction of incapacitating kyphosis in AS. There was an acceptable rate of perioperative complications and no mortality. The correction obtained was in average 45 degrees . All of the patients except one maintained their good correction and restored function. Outcome analysis showed a significant improvement in SF-36 and Oswestry Disability Index, and the mental component of the SF-36 showed improvement to values near the normative population. It is concluded that corrective osteotomy of the thoracolumbar spine in AS is an effective and safe treatment with improvements in quality of life.
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Affiliation(s)
- Thomas Kiaer
- Department of Orthopaedic Surgery, Spine Section, Rigshospitalet, National University Hospital, Copenhagen, Denmark
| | - Martin Gehrchen
- Department of Orthopaedic Surgery, Spine Section, Rigshospitalet, National University Hospital, Copenhagen, Denmark
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