Prospective, multicenter clinical trial comparing the M6-C compressible cervical disc with anterior cervical discectomy and fusion for the treatment of single-level degenerative cervical radiculopathy: 5-year results of an FDA investigational device exemption study

BACKGROUND CONTEXT

Various total disc replacement (TDR) designs have been compared to anterior cervical discectomy and fusion (ACDF) with favorable short and long-term outcomes in FDA-approved investigational device exemption (IDE) trials. The unique design of M6-C, with a compressible viscoelastic nuclear core and an annular structure, has previously demonstrated favorable clinical outcomes through 24 months.

PURPOSE

To evaluate the long-term safety and effectiveness of the M6-C compressible artificial cervical disc and compare to ACDF at 5 years.

STUDY DESIGN

Prospective, multicenter, concurrently and historically controlled, FDA-approved IDE clinical trial.

PATIENT SAMPLE

Subjects with one-level symptomatic degenerative cervical radiculopathy were enrolled and received M6-C (n=160) or ACDF (n=189) treatment as part of the IDE study. Safety outcomes were evaluated at 5 years for all subjects. The primary effectiveness endpoint was available at 5 years for 113 M6-C subjects and 106 ACDF controls.

OUTCOME MEASURES

The primary endpoint of this analysis was composite clinical success (CCS) at 60 months. Secondary endpoints were function and pain (neck disability index, VAS), physical quality of life (SF-36, SF-12), safety, neurologic, and radiographic assessments.

METHODS

Propensity score subclassification was used to control for selection bias and match baseline covariates of the control group to the M6-C subjects. Sixty-month CCS rates were estimated for each treatment group using a generalized linear model controlling for propensity score.

RESULTS

At 5 years postoperatively, the M6-C treatment resulted in 82.3% CCS while the ACDF group showed 67.0% CCS (superiority p=.013). Secondary endpoints indicated that significantly more M6-C subjects achieved VAS neck and arm pain improvements and showed maintained or improved physical functioning on quality-of-life measures compared to baseline assessments. The M6-C group-maintained flexion-extension motion, with significantly greater increases from baseline disc height and disc angle than observed in the control group. The rates of M6-C subsequent surgical interventions (SSI; 3.1%) and definitely device- or procedure-related serious adverse events (SAE failure; 3.1%) were similar to ACDF rates (SSI=5.3%, SAE failure=4.8%; p>.05 for both).

CONCLUSIONS

Subjects treated with the M6-C artificial disc demonstrated superior 5-year achievement of clinical success when compared to ACDF controls. In addition, significantly more subjects in the M6-C group showed improved pain and physical functioning scores than observed in ACDF subjects, with no difference in reoperation rates or safety outcomes.

Longitudinal Assessment of Modern Spine Surgery Training: 10-Year Follow-up of a Nationwide Survey of Residency and Spine Fellowship Program Directors

Spine surgeons complete training through residency in orthopaedic surgery (ORTH) or neurosurgery (NSGY). A survey was conducted in 2013 to evaluate spine surgery training. Over the past decade, advances in surgical techniques and the changing dynamics in fellowship training may have affected training and program director (PD) perceptions may have shifted.

Methods

This study is a cross-sectional survey distributed to all PDs of ORTH and NSGY residencies and spine fellowships in the United States. Participants were queried regarding characteristics of their program, ideal characteristics of residency training, and opinions regarding the current training environment. χ2 tests were used to compare answers over the years.

Results

In total, 241 PDs completed the survey. From 2013 to 2023, NSGY increased the proportion of residents with >300 spine cases (86%-100%) while ORTH remained with >90% of residents with < 225 cases (p < 0.05). A greater number of NSGY PDs encouraged spine fellowship even for community spine surgery practice (0% in 2013 vs. 14% in 2023, p < 0.05), which continued to be significantly different from ORTH PDs (∼88% agreed, p > 0.05). 100% of NSGY PDs remained confident in their residents performing spine surgery, whereas ORTH confidence significantly decreased from 43% in 2013 to 25% in 2023 (p < 0.05). For spinal deformity, orthopaedic PDs (92%), NSGY PDs (96%), and fellowship directors (95%), all agreed that a spine fellowship should be pursued (p = 0.99). In both 2013 and 2023, approximately 44% were satisfied with the spine training model in the United States. In 2013, 24% of all PDs believed we should have a dedicated spine residency, which increased to 39% in 2023 (fellowship: 57%, ORTH: 38%, NSGY: 21%) (p < 0.05).

Conclusion

Spine surgery training continues to evolve, yet ORTH and neurological surgery training remains significantly different in case volumes and educational strengths. In both 2013 and 2023, less than 50% of PDs were satisfied with the current spine surgery training model, and a growing minority believe that spine surgery should have its own residency training pathway.

Level of Evidence

IV.

Bridging the Cervicothoracic Junction During Multi-Level Posterior Cervical Decompression and Fusion: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and Meta-analysis.

OBJECTIVE

This systematic review seeks to compare fusion, reoperation and complication rates, estimated blood loss (EBL), and surgical time between multi-level instrumented fusions with LIVs (lowest instrumented vertebra) in the cervical spine and those that extend into the thoracic spine.

SUMMARY OF BACKGROUND DATA

Several studies address the question of whether to extend a long-segment, posterior cervical fusions, performed for degenerative disease, into the upper thoracic spine. Recommendations for appropriate LIV continue to vary.

METHODS

A comprehensive computerized literature search through multiple electronic databases without date limits up until April 3rd, 2020 using combinations of key search terms and sets of inclusion/exclusion criteria was performed.

RESULTS

Our comprehensive literature search yielded 3852 studies. Of these, 8 articles consisting of 1162 patients were included in the meta-analysis. In 61.2% of the patients, the fusion did not cross the cervicothoracic junction (CTJ) (cervical LIV, CLV). In the remaining 38.8%, the fusion extended into the upper thoracic spine (thoracic LIV, TLV). Overall, mean patient age was 62.5 years (range: 58.8-66.1 years). Our direct analysis showed that odds of fusion were not statistically different between the CLV and TLV groups (OR: .648, 95% CI: .336-1.252, P = .197). Similarly, odds of reoperation (OR: 0.726, 95% CI: 0.493-1.068, P = .104) and complication rates were similar between the 2 groups (OR: 1.214, 95% CI: 0.0.750-1.965, P = .430). Standardized mean difference (SMD) for the blood loss (SMD: .728, 95% CI: 0.554-.901, P = .000) and operative (SMD: 0.653, 95% CI: .479-.826, P = .000) differed significantly between the 2 groups. The indirect analysis showed similar fusion (Effect Size (ES)_TLV: .892, 95% CI: .840-.928 vs ES_CLV:0.894, 95% CI:0.849-.926); reoperation rate (ES_TLV:0.112, 95% CI: 0.075-.164 vs ES_CLV: .125, 95% CI: .071-.211) and complication rates (ES_TLV: .108, 95% CI: .074-.154 vs ES_CLV:0.081, 95% CI: .040-.156).

CONCLUSIONS

Our meta-analysis showed that fusion, complication, and reoperation rates did not differ significantly between patients in whom multi-level posterior fusions ended in the cervical spine vs those of which was extended into the thoracic spine. The mean blood loss, operative time and length of stay were significantly lower in patients with CLV at C6 or C7, compared to their counterparts. These data suggest that, absent focal, C7-T1 pathology, extension of long, posterior cervical fusions into the thoracic spine may not be necessary.

The Reliability of CT Scan Measurements of Pelvic Incidence in the Evaluation of Adult Spondylolisthesis

Background: Pelvic incidence (PI) has been described as a parameter that may be a risk factor for lumbar spondylolisthesis (SPL). Studies have reported PI measurement is more precise in CT scans. Very limited studies have measured PI using CT scans to evaluate SPL. We analyzed the reliability of CT scans to measure PI to evaluate SPL and compared it to patients without SPL.

Methods: A retrospective, cross-sectional study of PI in a consecutive cohort of patients’ pelvic/abdominal CT scans from an emergency room visit at a Level 1 trauma center between 2013 and 2016. Inclusion criteria was >18 years and had no lumbar or pelvis fracture. A total of 361 patients met the criteria for our study. We documented age, average PI, and SPL (type, grading, and location). Sagittal CT scans were used to measure PI (between hip axis to an orthogonal line originating at the center of superior end plate axis of first sacral vertebra). Patients were categorized: with SPL (n=45) and without SPL (n=316). Subgroups were comprised based on the location of SPL (L4/L5 and L5/S1) and type of SPL. Analysis of variance (ANOVA) and chi-square tests used; p≤0.05 considered statistically significant.

Results: Patients with SPL were significantly older versus patients without SPL, p=0.006. There were no statistical differences in PI between patients with and without SPL (p=0.29); between subgroups of patients with SPL at L4/L5 and without SPL (p=0.52); between subgroups with type of SPL at L4/L5 and without SPL (p=0.47); and between SPL patients at L5/S1 and without SPL (p=0.40). Patients with isthmic SPL at L5/S1 had nearly significant higher PIs (p=0.06) compared to those without SPL or with degenerative SPL at L5/S1. There was a trend towards higher PI in Grade 2 SPL patients at L5/S1, p=0.18.

Conclusions: Patients with SPL were significantly older than patients without SPL. The two trends observed were that PI was higher in patients with isthmic SPL at L5/S1 and an increased PI with Grade 2 isthmic SPL at L5/S1. Our reported CT PI measurements correlated with reported PI measured using standard radiographs in patients with SPL. CT scans may be a reliable modality to evaluate adult SPL.

Harmonized outcome measures for use in degenerative lumbar spondylolisthesis patient registries and clinical practice

OBJECTIVE

The development of new treatment approaches for degenerative lumbar spondylolisthesis (DLS) has introduced many questions about comparative effectiveness and long-term outcomes. Patient registries collect robust, longitudinal data that could be combined or aggregated to form a national and potentially international research data infrastructure to address these and other research questions. However, linking data across registries is challenging because registries typically define and capture different outcome measures. Variation in outcome measures occurs in clinical practice and other types of research studies as well, limiting the utility of existing data sources for addressing new research questions. The purpose of this project was to develop a minimum set of patient- and clinician-relevant standardized outcome measures that are feasible for collection in DLS registries and clinical practice.

METHODS

Nineteen DLS registries, observational studies, and quality improvement efforts were invited to participate and submit outcome measures. A stakeholder panel was organized that included representatives from medical specialty societies, health systems, government agencies, payers, industries, health information technology organizations, and patient advocacy groups. The panel categorized the measures using the Agency for Healthcare Research and Quality's Outcome Measures Framework (OMF), identified a minimum set of outcome measures, and developed standardized definitions through a consensus-based process.

RESULTS

The panel identified and harmonized 57 outcome measures into a minimum set of 10 core outcome measure areas and 6 supplemental outcome measure areas. The measures are organized into the OMF categories of survival, clinical response, events of interest, patient-reported outcomes, and resource utilization.

CONCLUSIONS

This effort identified a minimum set of standardized measures that are relevant to patients and clinicians and appropriate for use in DLS registries, other research efforts, and clinical practice. Collection of these measures across registries and clinical practice is an important step for building research data infrastructure, creating learning healthcare systems, and improving patient management and outcomes in DLS.

Prospective, multicenter clinical trial comparing M6-C compressible six degrees of freedom cervical disc with anterior cervical discectomy and fusion for the treatment of single-level degenerative cervical radiculopathy: 2-year results of an FDA investigational device exemption study

BACKGROUND CONTEXT

Various designs of total disc replacement (TDR) devices have been compared to anterior cervical discectomy and fusion (ACDF) with favorable outcomes in FDA-approved investigational device exemption trials. The design of M6-C with a compressible viscoelastic nuclear core and an annular structure is substantially different than prior designs and has previously demonstrated favorable kinematics and clinical outcomes in small case series.

PURPOSE

To evaluate the safety and effectiveness of the novel M6-C compressible artificial cervical disc compared with ACDF for subjects with single-level degenerative cervical radiculopathy.

STUDY DESIGN/SETTING

Prospective, multicenter, concurrently and historically controlled, FDA-approved investigational device exemption clinical trial.

PATIENT SAMPLE

Subjects with one-level symptomatic degenerative cervical radiculopathy were enrolled and assigned to receive M6-C or ACDF.

OUTCOME MEASURES

Pain and function (Neck Disability Index, VAS), quality of life (SF-36), safety, neurologic, and radiographic assessments of motion (both flexion extension and lateral bending) were performed. The primary clinical endpoint was composite clinical success (CCS) at 24 months.

METHODS

Using propensity score subclassification to control for selection bias, 160 M6-C subjects were compared to a matched subset of 189 ACDF controls (46 concurrent and 143 historical controls).

RESULTS

Both ACDF and M6-C subjects reported significant improvements in patient-reported outcomes at all time points over baseline. Overall SF-36 Physical Component Score and neck and arm pain scores were significantly improved for M6-C as compared to ACDF treatment. CCS and mean Neck Disability Index improvements were similar between M6-C and ACDF. Correspondingly, there were significantly fewer subjects that utilized pain medication or opioids following M6-C treatment at 24 months relative to baseline. Range of motion was maintained in subjects treated with M6-C. Subsequent surgical interventions, dysphagia rates, and serious adverse events were comparable between groups.

CONCLUSIONS

M6-C treatment demonstrated both safety and effectiveness for the treatment of degenerative cervical radiculopathy. Treatment with M6-C demonstrated noninferiority for the primary endpoint, indicating a similar ability to achieve CCS at 24 months. However, for the secondary endpoints, M6-C subjects demonstrated significantly improved pain and function compared to ACDF subjects, while maintaining range of motion, improving quality of life, and decreasing analgesic and opioid usage at 2 years postoperatively relative to baseline.

Is it safe to stop at C7 during multilevel posterior cervical decompression and fusion? - multicenter analysis

BACKGROUND CONTEXT

Despite a number of studies addressing the anatomical and biomechanical challenges of long segment, posterior cervical fusion surgery, recommendations for appropriate caudal "end level" vary widely.

PURPOSE

Compare revision rates, patient reported outcomes and radiographic outcomes in patients in whom 3+ level posterior fusions ended in the cervical spine versus those in whom the fusion was extended into the thoracic spine.

STUDY DESIGN

Multicenter retrospective analysis.

OUTCOME MEASURES

Visual analog scale (VAS), Oswestry disability index (ODI), cervical lordosis, C2-C7 sagittal plumbline, T1 slope, and revision rate.

METHODS

We assembled a radiographic and clinical database of patients that had undergone three or more level posterior cervical fusions for degenerative disease from January 2013 to May 2015 at one of four busy spine centers. Only those patients with at least 2 years of postoperative (postop) follow-up were included. Patients were divided into two groups: group I (fusion ending at C6 or C7) and group II (fusion extending into the thoracic spine). All radiographic measurements (cervical lordosis, T1 slope, and C2-C7 sagittal plumbline) were performed by an independent experienced clinical researcher.

RESULTS

Two hundred and sixty-four patient cases were reviewed and sorted into the two outlined groups, Group I (n=168) and Group II (n=96). Demographically, mean age, percentage of females, non-smokers and anterior support were greater in Group II than in Groups I (p<.05). Mean estimated blood loss (EBL), operative time (OR) and length of hospital stay (LOS) were significantly higher in Group II (p<.05). Rate of revision was not clinically or statistically significantly different (p>.05) between Group I (11.1%) and Group II (9.4%). The majority of the revision surgeries occurred between 2 to 5 years postop. A greater number of subjacent degeneration/spondylolisthesis events were noted in Group I compared with Group II (3.6% vs. 1.2%). There were significant improvements in mean clinical outcomes (ie, VAS and ODI) at two years postop in both groups, but there were no statistically significant differences between the groups (p>.05). Mean cervical lordosis at 2 years postop improved in all groups (12.8° vs. 14.1°); however, there was no significant statistical difference in change for mean cervical lordosis (2 weeks vs. 2 year postop) between the two groups. Similary, there were no significant statistical differences in change for mean C2-C7 sagittal plumbline and T1 slope (2 weeks vs. 2 year postop) between the two groups(p>.05).

CONCLUSIONS

Caudal end level did not significantly affect revision rates, patient reported outcomes or radiographic outcomes. Higher EBL, OR, and LOS in group II suggest that, absent focal C7-T1 pathology, extension of posterior cervical fusions into the thoracic spine may not be necessary. Extension of posterior cervical fusions into the thoracic spine may be recommended for higher risk patients with limitations to strong C7 bone anchorage. In others, it is safe to stop at C7.

Nerve Root Sedimentation Sign: Can It Predict the Success for Surgical Intervention in Patients With Symptomatic Lumbar Spinal Stenosis?

INTRODUCTION

 The use of interspinous process devices are less invasive surgical methods designed to manage mild to moderate lumbar spinal stenosis symptoms. Symptomatic relief may not be seen in all patients undergoing this procedure. Magnetic resonance imaging (MRI) parameters have been used to predict the success of clinical outcomes in patients with symptomatic lumbar spinal stenosis for decompressive surgeries. The purpose of this study was to determine the feasibility of using nerve root sedimentation sign to predict mid- to long-term clinical outcomes of patients treated with interspinous spacers for lumbar spinal stenosis.

METHODS

This was a retrospective study using prospective multicenter Food and Drug Administration Investigational Device Exemption (FDA IDE) trial (Superion™ and X-STOP®) data. Inclusion criteria were patients treated with interspinous spacers, aged 45 or older with lumbar spinal stenosis at one or more contiguous levels from L1 to L5 and symptoms of neurogenic claudication. Preoperative axial T2 weighted MRI images were used to determine nerve root sedimentation sign. Preoperative, six-week, one- and two-year postoperative clinical outcomes were measured using Oswestry Disability Index (ODI) scores. Clinical outcomes were compared between positive and negative nerve root sedimentation sign groups; p ≤0.05 was considered significant.

RESULTS

This study included n=374 patients; 40 excluded; 334 included (113=positive nerve root sedimentation sign (NRSS) (34%) and 221=negative NRSS (66%)). At six weeks, significant postoperative ODI correction was noted in both groups (p<0.001). No significant differences in ODI scores were identified between groups. A subgroup analysis with MRI image quality grade 3 and certainty determination grade 5, six-week postoperative ODI correction was significant in both groups. Six-week, one- and two-year postoperative ODI scores were greater by 6 points in the positive nerve root sedimentation sign group compared to the negative nerve root sedimentation sign group.

CONCLUSIONS

 Although satisfactory postoperative improvement occurred in both groups, there were statistically significant differences noted in certain sub-categories. The subgroup analysis indicated MRI image quality and nerve root sedimentation sign certainty of determination may be factors that may aid with planning the surgical management of lumbar spinal stenosis.

Clinical Outcomes of Idiopathic Scoliosis Surgery: Is There a Difference Between Young Adult Patients and Adolescent Patients?

Background

Surgical outcomes of adolescent idiopathic scoliosis (AIS) patients have been well studied. However, few studies have examined the surgical outcomes of young adult idiopathic scoliosis (YAdIS) patients. This study analyzed and compared the surgical outcomes of young adult (19-30 years) and adolescent (10-18 years) idiopathic scoliosis patients.

Methods

This is a retrospective, comparative two-center study. Reviewed data of consecutive AIS and YAdIS patients who had undergone posterior spinal deformity surgery (n=56) by two spine surgeons from 2010 to 2014. Inclusion criteria were age between 10 to 30 years and preoperative coronal Cobb angle >40^o. We excluded patients with previous correction surgery. Demographic data (age at time of surgery, gender, body mass index (BMI)), surgical data (preoperative diagnosis, number of levels fused, blood loss, duration of surgery, peri- and postoperative complications, duration of surgery, length of stay, revision surgery, and final follow-up) and radiographic data collected, reviewed, and analyzed. The groups were divided as AIS (n=29) and YAdIS (n=27).

Results

Patients’ gender, BMI, average preoperative main coronal curve (YAdIS 53^o vs. AIS 57⁰), and follow-up intervals were not statistically different between groups. Statistically significant for YAdIS patients were more levels fused (10.6 vs. 8.9, p=0.02) and more intraoperative blood loss (872 ml vs. 564 ml, p=0.02) were statistically significant. Not significant between the groups were duration of surgery (p>0.05), perioperative complications (p=0.14), and length of stay (p=0.11). At mean 21 months follow-up, patients in both groups had a significant correction of their main coronal curve (YAdIS 21^o vs. 53^o, p<0.001, and AIS, 19^o vs. 57^o, p<0.01). YAdIS had a lower percentage correction of their curves (61% vs. 68%, p=0.03). Three YAdIS (11.1%) and no AIS (0%) patients had additional surgery, p=0.07. YAdIS had more distal fusion levels at L4 or below.

Conclusions

YAdIS patients had a greater number of levels fused, higher blood losses, and lower major Cobb correction versus AIS patients.

DuraSeal Exact Is a Safe Adjunctive Treatment for Durotomy in Spine: Postapproval Study

STUDY DESIGN

A nonrandomized, two-armed prospective study.

OBJECTIVE

Water-tight dural closure is paramount to the prevention of cerebrospinal fluid (CSF) leakage and associated complications. Synthetic polyethylene glycol (PEG) hydrogel has been used as an adjunct to sutured dural repair; however, its expansion postoperatively is a concern for neurological complications. A low-swell formulation of PEG sealant was introduced as DuraSeal Exact Spine Sealant System (DESS). A Post-Approval Study was performed primarily to evaluate the safety and efficacy of DESS for spinal dural repair compared to current alternatives, in a large patient population, reflecting a real-world practice.

METHODS

A total of 36 sites in the United States enrolled 429 patients treated with DESS as an adjunct to dural repair in the spinal sealant group and 406 patients treated with all other modalities in the control arm, from October 2011 to June 2016. The primary endpoint was the incidence of CSF leak within 90 days of operation. The secondary endpoints evaluated were deep surgical site infection and neurological serious adverse events.

RESULTS

The CSF leakage in the DESS group (6.6%) was not significantly different from the control group (6.5%) (p = .83), and there was no significant difference in the time to first leak. The two groups had no significant differences in deep surgical site infection (1.6% versus control 2.1%, p = .61) or proportion of subjects with neurological serious adverse events (2.9% versus control 1.6%, p = .516).

CONCLUSIONS

DuraSeal Exact Spinal Sealant is safe when compared to current alternatives for spinal dural repair.

Fifth Lumbar L5 Perineural Cyst with Unusual Radiculopathy: Traction Plexopathy

Perineural cysts are cystic dilations and are frequently seen in relation to the lumbosacral spine. We describe a case of a fifth lumbar (L5) perineural cyst with unusual radicular symptoms and discuss the possible role of traction plexopathy caused by the cyst. A 38-year-old male presented with a longstanding history of back pain and right side thigh pain. This pain radiated from the buttocks to the lateral and anterior aspect of the thigh. He described the pain as pins and needles/burning with no significant relief with medications or rest. Imaging of the lumbar spine revealed a cystic lesion on the right side involving the L5 nerve root in the foraminal region. He failed conservative treatment and elected to have the cyst removed even with a guarded prognosis. A wide L5 laminectomy was performed. Due to the size of the cyst which was causing traction on the exiting L5 nerve root, the L5 pedicle was excised in order to delineate the cyst and to prevent any iatrogenic injury to the root. The patient had the dramatic improvement in his radicular pain immediately after the surgery and continues to be pain-free at his latest three-year follow-up. This case highlights the unusual pain pattern distribution from a perineural cyst possibly secondary to traction effect of the tumor.

Safety and Efficacy of the Use of Intrathecal Morphine for Spinal Three Column Osteotomy

Introduction

The use of intrathecal morphine has the potential to help alleviate the pain that patients experience undergoing spinal surgeries. Complications can cause immobilization, which can lead to vascular thrombosis and ileus. Studies have shown epidural analgesia significantly lowered postoperative pain scores in scoliosis surgeries. Intrathecal anesthesia has been shown to have good pain control over the initial 24-hour postoperative period.

Purpose

Determine if intrathecal morphine would reduce postoperative pain with minimal side effects.

Methods

The surgical case logs from three spinal deformity surgeons from a single academic medical center were reviewed retrospectively. This included cases where more than five levels of fusion occurred and surgery involved an osteotomy. The records of 17 patients were queried, and patient and surgical data were collected. The patients were divided into two groups: eight patients were administered intrathecal morphine and nine patients received no morphine. Postoperative pain scores were obtained hourly over the initial 24 hours postoperatively by nurses trained to obtain pain scores from the Numeric Pain Rating Scale. In addition, the rates of any noted side effects were recorded. Analysis of variance (ANOVA) and Fisher’s exact tests were used to calculate any statistical significance with p < 0.05 considered to be significant.

Results

The maximum and total 24-hour postoperative pain scores had a mean of 5.6 (standard deviation = 4.2; p = 0.4266) and 69.3 (standard deviation = 57.8; p = 0.9189), respectively, for patients administered intrathecal morphine. The patients who did not receive intrathecal morphine had total pain scores of 3.9 (standard deviation = 4.5) and 65.7 (standard deviation = 79.7), respectively. Though the results were not statistically significant, there was a potential trend toward decreased in pain mean scores in the first 10 hours for the intrathecal morphine group. There was no statistical difference in the rate of side effects between patients.

Conclusions

The use of intrathecal morphine did not significantly appear to reduce postoperative pain in patients when compared to intravenous or oral narcotics. There was a potential trend in a reduction in postoperative pain during the first 10 hours postoperatively, but this did not reach a statistically significant value and did not hold up after the first 10 hours postoperatively. However, it was noted that intrathecal morphine was safe to use in postoperative spinal deformity surgery as no statistical significance in side effects was noted.

Paper #19: Utilization and Reliability of Intraoperative Neuromonitoring in Vertebral Column Resections for Severe Early-Onset Scoliosis

Use of IOM in treating EOS with a VCR was found to be effective in 100% of the patients; despite 7/33 having a preop neuro deficit. 12/33 with an IOM change, with 42% having a post-op deficit.

Paper #20: Vertebral Column Resection for Early-Onset Scoliosis: Indications, Utilization and Outcomes

EOS treated with VCR were predominantly congenital or myelomeningocele with 84% performed at index surgery and 70% definitive fusion. Correction of major curve was 69% and increases in spinal and thoracic height. Complication rate was 33% with 57% being IONM/neuro related.

Guillain-Barré Syndrome After Revision Lumbar Surgery: A Case Report

Guillain-Barré syndrome (GBS) is a term that is used to describe a group of immune-mediated peripheral neuropathies, with the most common feature being rapid polyradiculoneuropathy. The exact etiology of this syndrome is unknown. In the field of orthopedics, GBS has been reported to occur after total hip arthroplasty, orthopedic trauma, and spine surgery. We report a unique case of GBS after elective revision lumbar spine surgery. A 62-year-old female presented with persistent low back pain and radiculopathy and elected to have revision lumbar spine surgery. Approximately 24 to 36 hours after hospital discharge, she returned to the hospital with weakness in her legs. After an electromyography (EMG), the patient was diagnosed with GBS and placed on intravenous immunoglobulin (IVIG). She developed respiratory failure, which required intubation and eventually converted to a tracheostomy and was finally decannulated. Over the course of 12 months, she improved to her pre-surgical baseline, gaining 5/5 strength in her upper and lower extremities and was able to ambulate independently without any aids. This was a case of GBS that occurred in a patient approximately two weeks after revision lumbar surgery. GBS is a poorly understood and rare complication of lumbar spine surgery that needs to be recognized quickly to be effectively treated.

Lumbar Spinal Candida Glabrata Treated Without Surgical Intervention: A Case Report

Candida glabrata is a low virulent commensal fungal organism that, rarely, can cause osteomyelitis. Diagnosis of such an infection is often difficult as the case typically presents with an insidious onset of back pain and minimally elevated biomarkers of inflammation. Furthermore, it is difficult to eradicate and often resistant to common antifungals. 

A 61-year-old man presented with an eight-month history of persistent low back pain which had unsuccessfully been managed by his primary care physician. He had a past surgical history of gastric by-pass complicated by adhesions, ulceration, and perforation with an infection of Candida glabrata that had been treated with intravenous micafungin. Radiological examination showed degenerative changes with suspicion of osteomyelitis and a computerized tomography (CT)-guided biopsy provided tissue samples with subsequent positive cultures for Candida glabrata. The patient was admitted for fungal osteomyelitis with Candida glabrata, treated with intravenous micafungin, and his infection was resolved after six months. At two-year follow-up his back pain has been resolved and no infection was present. In a patient with osteoarticular pain and a previous history of candidal infection with possible candidemia, one should maintain suspicion for fungal osteomyelitis.

Purely Ligamentous Flexion-Distraction Injury in a Five-Year-Old Child Treated with Surgical Management

Chance fractures by definition are a type of flexion-distraction injury with concomitant vertebral body fracture. Although uncommon in the pediatric population, they are associated with motor vehicle accidents and typically involve the thoraco-lumbar spine. Injury occurs when the spine rotates about a fixed axis, such as a lap belt. Our case reports the management of a five-year-old girl involved in a head-on collision who suffered a purely ligamentous flexion-distraction injury (Chance-type injury, without bone involvement) at the L2-L3 vertebral level. Previously these injuries were managed conservatively with serial casting; however, we present a case in which surgical management was used. A five-year-old girl sustained multiple injuries after being involved in a high-speed motor vehicle accident. At presentation, there was obvious abdominal bruising with a seat-belt sign and marked kyphosis of the spine with severe tenderness at the L2-L3 level. She required immediate exploratory laparotomy for her intraabdominal injuries. After stabilization, an orthopedic consult was deemed necessary. She was found to have occipital-cervical injury with mild anterolisthesis of C2 on C3 and disruption of the apical ligament. There was evidence of bilateral dislocation of the L2-L3 facet joints with marked disruption of the posterior ligaments and a hematoma sack. She required open reduction and internal fixation with an L2-L3 laminectomy, pedicle screw and rod placement. The kyphotic deformity was reduced using a compression device and stable alignment was achieved intraoperatively.

This was a rare and difficult case with limited evidence on the appropriate management of such an injury. Due to the severe instability of her injury, a surgical approach was taken. At two years postoperative, the patient is neurologically intact and pain free. Imaging revealed stable alignment of her lumbar hardware. Ultimately, this has resulted in an excellent outcome at the current follow-up.

Osteoblastomas of the spine: a comprehensive review

Osteoblastomas are primary bone tumors with an affinity for the spine. They typically involve the posterior elements, although extension through the pedicles into the vertebral body is not uncommon. Histologically, they are usually indistinguishable from osteoid osteomas. However, there are different variants of osteoblastomas, with the more aggressive type causing more pronounced bone destruction, soft-tissue infiltration, and epidural extension. A bone scan is the most sensitive radiographic examination used to evaluate osteoblastomas. These osseous neoplasms usually present in the 2nd decade of life with dull aching pain, which is difficult to localize. At times, they can present with a painful scoliosis, which usually resolves if the osteoblastoma is resected in a timely fashion. Neurological manifestations such as radiculopathy or myelopathy do occur as well, most commonly when there is mass effect on nerve roots or the spinal cord itself. The mainstay of treatment involves surgical intervention. Curettage has been a surgical option, although marginal excision or wide en bloc resection are preferred options. Adjuvant radiotherapy and chemotherapy are generally not undertaken, although some have advocated their use after less aggressive surgical maneuvers or with residual tumor. In this manuscript, the authors have aimed to systematically review the literature and to put forth an extensive, comprehensive overview of this rare osseous tumor.

Prospective randomized controlled trial of The Stabilis Stand Alone Cage (SAC) versus Bagby and Kuslich (BAK) implants for anterior lumbar interbody fusion

Background

Degenerative disc disease is common and debilitating for many patients. If conservative extensive care fails, anterior lumbar interbody fusion has proven to be an alternative form of surgical management. The Stabilis Stand Alone Cage(SAC) was introduced as a method to obtain stability and fusion. The purpose of this study was to determine whether the Stabilis Stand Alone Cage (SAC) is comparable in safety and efficacy to the Bagby and Kuslich (BAK) device.

Methods

As part of a prospective, randomized, controlled FDA trial, 73 patients underwent anterior interbody fusion using either the SAC(56%) or the BAK device (44%).

Results

Background characteristics were similar between the two groups. There was no significant difference between the SAC and BAK groups in mean operative time or mean blood loss during surgery. Adverse event rates did not differ between the groups. Assessment of plain radiographs could not confirm solid fusion in 63% of control and 71% of study patients. Functional scores from Owestry and SF-36 improved in both groups by the two-year follow-up. There were no significant differences between the SAC and BAK patients with respect to outcome.

Conclusions

Both the Stabilis Stand Alone Cage and the BAK Cage provided satisfactory improvement in function and pain relief, despite less than expected radiographic fusion rates. The apparent incongruency between fusion rates and functional outcomes suggests that either radiographs underestimate the true incidence of fusion, or that patients are obtaining good pain relief and improved function despite a lower rate of fusion than previously reported. This was a Level III study.

Unilateral cervical facet dislocation: a biomechanical study of several constructs including unilateral lateral mass fixation supplemented by an interspinous cable

Object

Both ventral and dorsal operative approaches have been used to treat unilateral cervical facet injuries. The gold standard ventral approach is anterior cervical discectomy and fusion. There is, however, no clear gold standard dorsal operation. In this study, the authors tested the stability of multiple posterior constructs, including unilateral lateral mass fixation supplemented by an interspinous cable.

Methods

Six fresh human cervical spine specimens (C3–T1) were tested by applying pure moments to the C-3 vertebral body in increments of 0.5 Nm from 0 Nm to 2.0 Nm. Each specimen was tested in the following 8 conditions (in the order shown): 1) intact; 2) after destabilization via injury to the C5–6 facet; 3) with bilateral C5–6 lateral mass screws and rods; 4) after further destabilization by creating a right unilateral lateral mass fracture of C-5 (which rendered secure screw placement into the right C-5 lateral mass impossible); 5) with unilateral left C5–6 lateral mass screws and rod; 6) with unilateral C5–6 lateral mass screws and rod supplemented with an interspinous cable; 7) with a bilateral multilevel dorsal construct C4–6; and 8) after a C5–6 anterior cervical discectomy and fusion (ACDF) procedure with a polyetheretherketone graft and plate.

Results

The bilateral C5–6 lateral mass construct reduced the range of C5–6 motion to 33.6% of normal. The unilateral C5–6 lateral mass construct resulted in an increased range of motion to 110.1% of normal. The unilateral lateral mass construct supplemented by an interspinous cable reduced the C5–6 range of motion to 89.4% of normal. The bilateral C4–6 lateral mass construct reduced the C5–6 range of motion to 44.2% of normal. The C5–6 ACDF construct reduced the C5–6 range of motion to 62.6% of normal.

Conclusions

The unilateral lateral mass construct supplemented by an interspinous cable does reduce range of motion compared with an intact specimen, but is significantly inferior to a C4–6 bilateral lateral mass construct. When using a dorsal approach, the unilateral construct with a cable should only be considered in selected instances.

Myofascial trigger points

Painful conditions of the musculoskeletal system, including myofascial pain syndrome, constitute some of the most important chronic problems encountered in a clinical practice. A myofascial trigger point is a hyperirritable spot, usually within a taut band of skeletal muscle, which is painful on compression and can give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena. Trigger points may be relieved through noninvasive measures, such as spray and stretch, transcutaneous electrical stimulation, physical therapy, and massage. Invasive treatments for myofascial trigger points include injections with local anesthetics, corticosteroids, or botulism toxin or dry needling. The etiology, pathophysiology, and treatment of myofascial trigger points are addressed in this article.

Vertebroplasty and kyphoplasty

Vertebral compression fractures occur more frequently than hip and ankle fractures combined. These fragility fractures frequently result in both acute and chronic pain, but more importantly are a source of increased morbidity and possibly mortality. Percutaneous veretebral augmentation offers a minimally invasive approach for the treatment of vertebral compression fractures. The history, technique, and results of vertebroplasty and kyphoplasty are reviewed. Both methods allow for the introduction of bone cement into the fracture site with clinical results indicating substantial pain relief in approximately 90% of patients.

Invasive and minimally invasive surgical techniques for back pain conditions

This article summarizes current issues related to invasive and minimally invasive surgical techniques for back pain conditions. It describes pain generators and explains theories about how discs fail. The article discusses techniques for treating painful sciatica, painful motion segments, and spinal stenosis. Problems related to current imaging are also presented. The article concludes with a discussion about physical therapy.

Intra-articular injections

Intra-articular injections are one method that physicians may use to treat joint pain. This method offers direct access to the source of pain for the troubled patient. Substances ranging from steroids to hyaluronic acid have been injected successfully into the various joints of the body in an attempt to provide relief for chronic joint pain. Anesthesiologists and orthopedic surgeons have begun to use intra-articular injections of local anesthetics for postoperative analgesia. This history, agents, and methods of intra-articular injections are reviewed.

Invasive and minimally invasive surgical techniques for back pain conditions

Back pain is a ubiquitous problem for developed countries. It is a source of disability for society and is a financial drain through lost wages and productivity. The treatment of spine-related pain has changed over the years: minimally invasive approaches are now favored. Despite this trend, surgeons still rely on decompressions of compressed neurological structures and the fusion of painful motion segments. The history of treatments of spine-related pain as well as modern and minimally invasive techniques are reviewed.

Vertebroplasty and kyphoplasty

Vertebral compression fractures occur more frequently than hip and ankle fractures combined. These fragility fractures frequently result in both acute and chronic pain, but more importantly are a source of increased morbidity and possibly mortality. Percutaneous vertebral augmentation offers a minimally invasive approach for the treatment of vertebral compression fractures. The history, technique, and results of vertebroplasty and kyphoplasty are reviewed. Both methods allow for the introduction of bone cement into the fracture site with clinical results indicating substantial pain relief in approximately 90% of patients.

Myofascial trigger points

Painful conditions of the musculoskeletal system, including myofascial pain syndrome, constitute some of the most important chronic problems encountered in a clinical practice. A myofascial trigger points is a hyperirritable spot, usually within a taut band of skeletal muscle, which is painful on compression and can give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena. Trigger points may be relieved through noninvasive measures, such as spray and stretch, transcutaneous electrical stimulation, physical therapy, and massage. Invasive treatments for myofascial trigger points include injections with local anesthetics, corticosteroids, or botulism toxin or dry needling. The etiology, pathophysiology, and treatment of myofascial trigger points are addressed in this article.