Effects of fusion and conservative treatment on disc degeneration and rates of subsequent surgery after thoracolumbar fracture

OBJECT

The objective of this study was to compare the incidence of degeneration and need for subsequent fusion surgery between patients who were treated nonsurgically and patients treated with fusion after a diagnosis of thoracic-or lumbar-level fracture without degenerative disease.

METHODS

The authors performed a retrospective study of Orthopedic United Healthcare patients diagnosed with thoracic or lumbar fracture. Patients were filtered into thoracic and lumbar fracture groups using diagnostic codes and then assigned to one of 2 treatment subgroups (fusion surgery or no surgery) on the basis of procedural codes. Disc degeneration and follow-up surgery were recorded. Chi-square statistical analysis was used.

RESULTS

Of 3699 patients diagnosed with a thoracic fracture, 117 (3.2%) underwent thoracic fusion and 3215 (86.9%) were treated nonsurgically. Within 3 years, 147 (4.6%) patients from the nonsurgical subgroup and fewer than 11 (0.9%-8.5%) from the fusion subgroup were diagnosed with thoracic disc degeneration. From the nonsurgical subgroup, 11 (0.3%) patients underwent a thoracic surgery related to disc degeneration compared with zero from the fusion group (p > 0.05). Of 5016 patients diagnosed with lumbar fracture, 150 (3.0%) underwent fusion and 4371 (87.1%) had no surgery. Within 3 years, 503 patients (11.5%) from the nonsurgical subgroup and 35 (23.3%) from the fusion subgroup were diagnosed with lumbar disc degeneration (p < 0.05). From the nonsurgical subgroup, 42 (1.0%) went on to have surgery related to disc degeneration, compared with fewer than 11 (0.7%-6.7%) from the fusion subgroup (values not precise due to privacy limitations).

CONCLUSIONS

Fusion surgery for thoracic fracture does not appear to increase the likelihood of undergoing future surgery. In the lumbar region, initial fusion surgery appears to increase the incidence of disc degeneration and could potentially necessitate future surgeries.

Use of the Rosenberger brace in the treatment of progressive adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To evaluate the efficacy of the Rosenberger thoracic lumbar sacral orthosis in preventing curve progression in adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Radiographic outcomes of patients using the Rosenberger thoracic lumbar sacral orthosis have never been reported in the literature, but reports of other thoracic lumbar sacral orthoses conflict concerning the ability braces to improve on the natural history of adolescent idiopathic scoliosis.

METHODS

Seventy-one patients with progressive adolescent idiopathic scoliosis treated with the Rosenberger were evaluated at an average of 2.3 years following brace discontinuation. Initial curves averaged 29 degrees. Braces were prescribed for 16 to 20 hours per day and worn for an average of 3.2 years. Patients were between 9 and 16 years of age, and all were skeletally immature at the time of bracing.

RESULTS

Twenty-one patients (30%) underwent instrumentation and arthrodesis despite bracing. Forty (56%) had more than 5 degrees of progression. Overall, 43 (61%) had surgery and/or progressed by the time of follow-up. The average curve correction was 33% in patients who did not have surgery and 21% in those patients who did (P < 0.04). Other significant factors associated with brace failure included absence of menarche before treatment, younger age at presentation and initial bracing, increased apical rotation of the primary curve at presentation, and a thoracic curve pattern.

CONCLUSIONS

The Rosenberger brace demonstrated an overall failure rate similar to untreated rates from published natural history studies, although subgroups of patients had lower failure rates. These findings suggest the need for further refinement of the indications for the Rosenberger brace.

Nerve monitoring changes related to iliac artery compression during anterior lumbar spine surgery

BACKGROUND CONTEXT

There are no studies in the literature that correlate compression of the iliac vessels resulting in obstruction of blood flow with changes in nerve monitoring parameters during anterior lumbar surgery.

PURPOSE

To determine whether there is significant compression of the iliac vessels that can cause temporary nerve root ischemia or limb ischemia that could be responsible for loss of somatosensory evoked potentials (SSEP) while retractors are in place for exposure during anterior lumbar interbody fusion (ALIF).

SETTING

Patients coming to the operating room for ALIF from levels L2-L3 to L5-S1 would be studied for nerve monitoring changes during the procedure with particular attention to the intervals just before placement of a retractor, while the retractor was in place and immediately after removal of the retractor.

PATIENT SAMPLE

Forty-five consecutive patients were studied for changes in SSEP and oxygen saturation (SaO(2)) while undergoing ALIF.

OUTCOME MEASURES

Patients were considered to have lost saturation if the SaO(2) decreased to below 90%. Patients were considered to have abnormal SSEP with any increase in latency and decrease in amplitude.

METHODS

SSEP and SaO(2) were monitored continuously and simultaneously before exposure of the disc spaces, during exposure with retractors in place and after removal of the retractors.

RESULTS

Thirteen of 23 patients with exposure at L4-L5 had both loss of SSEP signals and loss of SaO(2) with exposure. All 13 patients had return to normal saturation and recovery of the SSEP signals within 15 minutes of removal of the retractors. Both of these are significant correlations (p<.001).

CONCLUSION

This study showed that the majority (57%) of patients undergoing ALIF at the L4-L5 level are subject to compression of the left iliac vessels enough to cause desaturation distally as measured by pulse oxymetry. This vascular compromise, as well as the return to normal saturation, correlates with changes noted in SSEP soon after both deployment and removal of the retractors used for exposure. The mechanism appears to be a transient ischemic response. Failure of the SSEP signals to recover may be diagnostic of left iliac artery thrombosis.

Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study

CONTEXT

Previous long-term studies of idiopathic scoliosis have included patients with other etiologies, leading to the erroneous conclusion that all types of idiopathic scoliosis inevitably end in disability. Late-onset idiopathic scoliosis (LIS) is a distinct entity with a unique natural history.

OBJECTIVE

To present the outcomes related to health and function in untreated patients with LIS.

DESIGN, SETTING, AND PATIENTS

Prospective natural history study performed at a midwestern university with outpatient evaluation of patients who presented between 1932 and 1948. At 50-year follow-up, which began in 1992, 117 untreated patients were compared with 62 age- and sex-matched volunteers. The patients' mean age was 66 years (range, 54-80 years).

MAIN OUTCOME MEASURES

Mortality, back pain, pulmonary symptoms, general function, depression, and body image.

RESULTS

The estimated probability of survival was approximately 0.55 (95% confidence interval [CI], 0.47-0.63) compared with 0.57 expected for the general population. There was no significant difference in the demographic characteristics of the 2 groups. Twenty-two (22%) of 98 patients complained of shortness of breath during everyday activities compared with 8 (15%) of 53 controls. An increased risk of shortness of breath was also associated with the combination of a Cobb angle greater than 80 degrees and a thoracic apex (adjusted odds ratio, 9.75; 95% CI, 1.15-82.98). Sixty-six (61%) of 109 patients reported chronic back pain compared with 22 (35%) of 62 controls (P =.003). However, of those with pain, 48 (68%) of 71 patients and 12 (71%) of 17 controls reported only little or moderate back pain.

CONCLUSIONS

Untreated adults with LIS are productive and functional at a high level at 50-year follow-up. Untreated LIS causes little physical impairment other than back pain and cosmetic concerns.