The Spine Journal

Five-year trends in spine care: the impact of health care reform

Gregory J. Przybylski — 2012-01-03

I am both honored and humbled to stand before you today and describe the privilege I have had in helping with the stewardship of North American Spine Society (NASS) over the past year. Many fantastic people have come before me, and I believe the NASS stewardship will continue to influence both our practices and health policy nationally over the coming years.

Injection of AAV2-BMP2 and AAV2-TIMP1 into the nucleus pulposus slows the course of intervertebral disc degeneration in an in vivo rabbit model

2011-10-24

Abstract: Background context: Intervertebral disc degeneration (IDD) is a common cause of back pain. Patients who fail conservative management may face the morbidity of surgery. Alternative treatment modalities could have a significant impact on disease progression and patients’ quality of life.Purpose: To determine if the injection of a virus vector carrying a therapeutic gene directly into the nucleus pulposus improves the course of IDD.Study design: Prospective randomized controlled animal study.Methods: Thirty-four skeletally mature New Zealand white rabbits were used. In the treatment group, L2–L3, L3–L4, and L4–L5 discs were punctured in accordance with a previously validated rabbit annulotomy model for IDD and then subsequently treated with adeno-associated virus serotype 2 (AAV2) vector carrying genes for either bone morphogenetic protein 2 (BMP2) or tissue inhibitor of metalloproteinase 1 (TIMP1). A nonoperative control group, nonpunctured sham surgical group, and punctured control group were also evaluated. Serial magnetic resonance imaging (MRI) studies at 0, 6, and 12 weeks were obtained, and a validated MRI analysis program was used to quantify degeneration. The rabbits were sacrificed at 12 weeks, and L4–L5 discs were analyzed histologically. Viscoelastic properties of the L3–L4 discs were analyzed using uniaxial load-normalized displacement testing. Creep curves were mathematically modeled according to a previously validated two-phase exponential model. Serum samples obtained at 0, 6, and 12 weeks were assayed for biochemical evidence of degeneration.Results: The punctured group demonstrated MRI and histologic evidence of degeneration as expected. The treatment groups demonstrated less MRI and histologic evidence of degeneration than the punctured group. The serum biochemical marker C-telopeptide of collagen type II increased rapidly in the punctured group, but the treated groups returned to control values by 12 weeks. The treatment groups demonstrated several viscoelastic properties that were distinct from control and punctured values.Conclusions: Treatment of punctured rabbit intervertebral discs with AAV2-BMP2 or AAV2-TIMP1 helps delay degenerative changes, as seen on MRI, histologic sampling, serum biochemical analysis, and biomechanical testing. Although data from animal models should be extrapolated to the human condition with caution, this study supports the potential use of gene therapy for the treatment of IDD.

Commentary: A promising gene therapy approach to treat disc degeneration

S. Timothy Yoon — 2012-01-01

COMMENTARY ON: Leckie SK, Bechara BP, Hartman RA, et al. Injection of AAV2-BMP-2 and AAV2-TIMP-1 into the nucleus pulposus slows the course of intervertebral disc degeneration in an in vivo rabbit model. Spine J 2012;12:7–20 (in this issue).

Morbidity and mortality of major adult spinal surgery. A prospective cohort analysis of 942 consecutive patients

2012-01-03

Abstract: Background context: To date, most reports on the incidence of adverse events (AEs) in spine surgery have been retrospective and dependent on data abstraction from hospital-based administrative databases. To our knowledge, there have been no previous rigorously performed prospective analysis of all AEs occurring in the entire population of patients presenting to an academic quaternary referral center.Purpose: To determine the mortality and true incidence and severity of morbidity (major and minor, medical and surgical) in adults undergoing complex spinal surgery, both trauma and elective, in a quaternary referral center. To examine the influence of the introduction of a dedicated weekly multidisciplinary rounds, and a formal abstraction tool, on the recording of this prospective perioperative morbidity data. To examine the validity and inter- and intraobserver reliability of a dedicated Spine AdVerse Events Severity system, version 2 (SAVES V2) AE abstraction tool.Study design: Ours is an academic quaternary referral center serving a population of 4.5 million people. Beginning in April 2008, a spine-specific AE-recording instrument, entitled SAVES V2, was introduced at our center for reporting, categorization, and classification of AEs. The use of this system remains an ongoing prospective study.Patient sample: All adult patients admitted to the spine service of a quaternary referral center for a 12-month period.Outcome measures: A validity and an inter- and intraobserver reliability examination of the SAVES V2 system, as used at our institution. Morbidity and inhospital deaths, unplanned second surgeries during index admission, wound infections requiring reoperation, and readmissions during the same calendar year. We also examined in detail all intraoperative and nonsurgical postoperative AEs, as well as hospital length of stay (LOS).Methods: Data on all patients undergoing surgery over a 12-month period were prospectively collected using a perioperative morbidity abstraction tool at weekly dedicated mortality and morbidity rounds. This tool allows identification of each specific AE and grades the severity. Before the introduction of this system, and using the hospital inpatient database, our documented perioperative morbidity rate (major and minor, medical and surgical) was 23%. Diagnosis, operative data, hospital data, major and minor complications both medical and surgical, and deaths were recorded.Results: One hundred percent of all patients discharged from the unit had complete data available for analysis. Nine hundred forty-two patients with an age range of 16 to 90 years (mean, 54 years; mode, 38 years) were identified. There were 552 males and 390 females. Around 58.5% of patients had undergone elective surgery. Thirty percent of patients were American Spinal Injury Association class D or worse on admission. The average LOS was 13.5 days (range, 1–221 days). Eight hundred twenty-two (87%) patients had at least one documented complication. Thirty-nine percent of these adversely affected hospital LOS. There were 14 mortalities during the study period. The rate of intraoperative surgical complication was 10.5% (4.5% incidental durotomy and 1.9% hardware malposition requiring revision and 2.2% blood loss >2 L). The incidence of postoperative complication was 73.5% (wound complications, 13.5%; delerium, 8%; pneumonia, 7%; neuropathic pain, 5%; dysphagia, 4.5%; and neurological deterioration, 3%).Conclusions: Major spinal surgery in the adult is associated with a high incidence of intra- and postoperative complications. We identified a very high rate of previously unrecognized postoperative complications, which adversely affect LOS. Without strict adherence to a prospective data collection system, the true complexity of this surgery may be greatly underestimated.

Utilization characteristics of spinal interventions

Zach I. Abbott, Kavita V. Nair, Richard R. Allen, Venu R. Akuthota — 2011-12-05

Abstract: Background context: Several investigators have identified an explosive increase in spinal injection rates in the Veterans Administration and Medicare populations. Furthermore, utilization of spinal injection procedures appears to vary by geographic location, subspecialty, and practice setting. Medicare claims analysis has shown that a small percentage of physicians perform a disproportionately large number of injections. Although Medicare utilization has been well characterized, the utilization patterns for privately insured individuals are not clearly known.Purpose: The primary purpose of this article was to investigate whether relatively few providers are responsible for a disproportionately high percentage of interventional spine procedures in privately insured plans and to quantify any such findings. The secondary purpose was to determine if provider specialty is a relevant variable in any identified patterns of disproportionate utilization.Study design: A descriptive analysis of utilization patterns using the Medstat MarketScan database was conducted between 2003 and 2007. The database contains deidentified medical, pharmacy, and enrollment claims representing 12 to 14 million individuals.Patient sample: A data set was generated based on the following inclusion criteria: all patients aged between 18 and 99 years receiving at least one spinal interventional procedure between 2003 and 2007: epidural steroid injections, intra-articular facet or medial branch blocks, medial branch radio frequency neurotomy, sacroiliac joint injections, and discography. Our inclusion criteria yielded data on nearly 200,000 patients treated by over 20,000 providers.Outcome measures: Not applicable.Methods: The number of procedures was tallied for a 12-month period beginning with a patient’s first procedure claim. The total number of procedures per patient and the mean number of procedures per patient were calculated for the study sample. Within each specialty, all spinal procedures were summed for each individual provider within each procedure category and as an overall total. The overall mean number of therapeutic procedures per patient for all physicians within a specialty was calculated. Within each specialty, the total number of procedures performed by each physician was analyzed in percentiles to highlight any disparity between high- and low-using providers.Results: The final therapeutic procedure data set contained 196,332 patients who received 875,627 procedures. The principal nine specialties performing these procedures were anesthesiology (49.2% of the total number of procedures in the final data set), physiatry (12.5%), pain management (12.0%), family practice (10.2%), orthopedics (5.5%), radiology (3.0%), neurology (2.8%), internal medicine (2.8%), and neurosurgery (1.9%). The overall mean number of procedures across all categories performed per patient during the 12-month inclusion period was 4.46±6.44. Neurologists and pain management specialists were the only provider groups in which the mean number of procedures per patient exceeded the overall mean. The highest 10% of providers, which encompasses those providers performing a mean greater than or equal to 5.08 procedures per patient per year, perform 36.6% of the total spinal procedures performed. The highest 20% of providers, which encompasses those providers with a mean greater than or equal to 3.75, account for 57.6% of all spinal procedures. The highest 10% of providers perform nine times more procedures per patient compared with the lowest 10% and 4.5 times more procedures than the median. This same pattern of high utilization by disproportionately few providers was observed across all nine specialties.Conclusions: These findings demonstrate that relatively few providers are responsible for a disproportionately high percentage of interventional spine procedures. This pattern of marked overutilization by a minority of providers is the dominant characteristic of utilization within all specialties.

Cost-utility of lumbar decompression with or without fusion for patients with symptomatic degenerative lumbar spondylolisthesis

Salin Kim, Soroush Mortaz Hedjri, Peter C. Coyte, Y. Raja Rampersaud — 2011-12-12

Abstract: Background context: The most common surgical treatment of symptomatic degenerative lumbar spondylolisthesis (DLS) is decompression and instrumented fusion. However, contemporary, midline-sparing, microdecompressive techniques have shown good results for selected patients with stable Grade 1 DLS. Growing concerns over the rising cost and rates of spinal fusion warrant both clinical and economic comparative effectiveness research in this common spinal diagnosis.Purpose: To determine the relative cost-utility of decompression with and without concomitant instrumented fusion for selected patients with DLS.Study design/setting: Comparative cost-effectiveness study.Patient sample: Probabilities and utilities were estimated from an observational cohort study and the current literature. Costing information was obtained from our institution (microcase costing data/patient) and the literature. Probabilities considered were perioperative and general mortality, probability of clinical improvement and clinical worsening, and reoperation.Outcome measures: The primary outcome was the incremental cost/utility ratio (ICUR) expressed as the differential cost per relative gain in quality-adjusted life-year (QALY).Methods: A Markov model with 10-year follow-up was developed. The analyses were carried out from the hospital’s perspective. Sensitivity analysis was used to test the robustness of the model.Results: The cost-utility of decompression with fusion and decompression alone at 10 years postintervention was $3,281/QALY and $1,040/QALY, respectively. Compared with decompression alone, decompression plus instrumented fusion was associated with an improvement in quality of life at a cost of $185,878 per QALY in the base-case analysis. The ICUR was invariant to changes in clinical effectiveness of decompression alone, percentage of inpatient decompressions, and varying cost or QALY discounting rates. The ICUR was sensitive to change in QALY and cost structure changes.Conclusions: For a select subgroup of patients with DLS (leg-dominant pain with a stable Grade 1 spondylolisthesis), decompression without fusion is significantly more cost effective than instrumented fusion and provides an opportunity for increased service delivery and/or cost savings for this growing population.

The development of a model for translation of the Neck Disability Index to utility scores for cost-utility analysis in cervical disorders

Shawn S. Richardson, Sigurd Berven — 2012-01-03

Abstract: Background context: The Neck Disability Index (NDI) is a commonly used disease-specific instrument for cervical spine disorders with good responsiveness and psychometric properties compared with general health status measures. However, NDI scores are unitless and do not have an intrinsic value that is comparable to other health status measures, and these scores have limited value in cost-utility analysis. The translation of disease-specific measures to Short Form-6 Dimensions (SF-6D) utility scores may be useful in cost-utility analysis.Purpose: The purpose of this study is to present a model for translating the NDI to SF-6D utility scores, permitting the use of NDI scores in the cost-utility analysis of cervical disorders.Study design/setting: A secondary analysis of a multicenter prospective clinical trial of the Synthes ProDisc-C (Synthes, West Chester, PA, USA) was performed.Patient sample: Patients included were randomized to receive either a total disc arthroplasty or anterior cervical discectomy and fusion for treatment of symptomatic cervical disc disease involving one vertebral level between C3 and C7. All subjects completed NDI and 36-Item Short Form Health Survey (SF-36) self-assessments at preoperative and postoperative follow-ups of 6 weeks, 3, 6, 12, 18, and 24 months.Outcome measures: The NDI is a validated and widely used self-reported questionnaire designed to assess patient-determined disability resulting from neck pain, including pain level and effects on activities of daily living. The SF-6D is a preference-based health state classification system derived from six health dimensions of the SF-36 self-reported questionnaire, including the domains of physical functioning, role limitation, social functioning, bodily pain, mental health, and vitality.Methods: The collected data points were divided into two cohorts: one for model formation and one for the assessment of model validity. SF-36 scores were converted to SF-6D utilities via three previously published methods. Correlation analyses and linear regression modeling between SF-6D and NDI created the models for translating scores. For validation, Spearman and Pearson correlations were calculated between the observed and predicted SF-6D utilities, and prediction errors were calculated.Results: Four hundred thirty patients with 2,137 time points were used for creation and validation of the model. Pearson and Spearman correlation coefficients between the NDI and the SF-6D derived from each conversion method were found to be between −0.8255 and −0.8504 (p<.01). R2 values ranged from 0.68 to 0.71 and root mean squared error (RMSE) from 0.092 to 0.084. Correlations between estimated and observed SF-6D scores ranged from 0.8325 to 0.8372 (p<.01). The mean prediction error was less than 0.006, with standard deviation (SD) between 0.082 and 0.093.Discussion: Correlations between NDI and SF-6D utility scores are strong and statistically significant. The model has a large R2 and small RMSE. The prediction models produce a small mean prediction error, but the SD of the prediction errors is large. High correlations between NDI and SF-6D permit these models to be used to calculate overall utilities, changes in utilities, and quality-adjusted life-years for large data samples. However, the relatively large observed prediction error SDs may limit the accuracy of translation of individual data points or small sample sizes.

Low back pain in the United States: incidence and risk factors for presentation in the emergency setting

Brian R. Waterman, Philip J. Belmont, Andrew J. Schoenfeld — 2011-10-07

Abstract: Background context: Low back pain is prevalent in the United States. At the present time, no large longitudinal study is available characterizing the incidence of this condition in the US population or identifying potential risk factors for its development.Purpose: To characterize the incidence of acute low back pain requiring medical evaluation in the emergency department and establish risk factors for its development.Study design: Cross-sectional study.Patient sample: United States population estimates.Outcome measures: Incidence rate ratios were calculated to determine the influence of age, sex, and race on the development of low back pain requiring emergent medical evaluation.Methods: The National Electronic Injury Surveillance System was queried for all cases of low back pain presenting to emergency departments between 2004 and 2008. Incidence rate ratios were then calculated with respect to age, sex, and race. The chi-square statistic was used to identify statistically significant differences in the incidence of low back pain requiring emergent medical evaluation between subgroups.Results: An estimated 2.06 million episodes of low back pain occurred among a population at risk of over 1.48 billion person-years for an incidence rate of 1.39 per 1,000 person-years in the United States. Low back pain accounted for 3.15% of all emergency visits. Injuries sustained at home (65%) accounted for most patients presenting with low back pain. Low back pain demonstrates a bimodal distribution with peaks between 25 and 29 years of age (2.58/1,000 person-years) and 95 to 99 years of age (1.47/1,000) without differentiation by underlying etiology. When compared with females, males showed no significant differences in the rates of low back pain. However, when analyzed by 5-year age group, males aged 10 to 49 years and females aged 65 to 94 years had increased risk of low back pain than their opposite sex counterparts. When compared with Asian race, patients of black and white race were found to have significantly higher rates of low back pain. Older patients were found to be at a greater risk of hospital admission for low back pain.Conclusion: Age, sex, and race are significant risk factors for the development of low back pain necessitating treatment in an emergency department.

Commentary: Back pain epidemiology—the challenge of case definition and developing new ideas

Tapio Videman, Michele C. Battié — 2012-01-01

COMMENTARY ON: Waterman BR, Belmont PJ Jr, Schoenfeld AJ. Lower back pain in the United States: incidence and risk factors for presentation in the emergency setting. Spine J 2012;12:63–70 (in this issue).

Postoperative spinal alignment remodeling in Lenke 1C scoliosis treated with selective thoracic fusion

Yu Wang, Cody E. Bünger, Yanqun Zhang, Chunsen Wu, Ebbe S. Hansen — 2011-12-05

Abstract: Background context: Selective thoracic fusion may cause spinal imbalance in certain patients; how the spinal alignment changes over time after surgery is highly correlated with the final spinal balance.Purpose: To investigate how spinal alignment changes over time after selective thoracic fusion and how spinal alignment remodeling affects spinal balance.Methods: All adolescent idiopathic scoliosis (AIS) cases surgically treated in our institution between 2002 and 2008 were reviewed. Inclusion criteria were as follows: Lenke 1C scoliosis patients treated with posterior pedicle screw–only constructs; the lowest instrumented vertebra (LIV) ended at L1 level or above; and 2-year radiographic follow-up. Standing anteroposterior and lateral digital radiographs from four different time points (preoperatively, immediately, 3 months, and 2 years postoperatively) were reviewed. In each standing anteroposterior radiograph, the center sacral vertical line (CSVL, the vertical line that bisects the proximal sacrum) was first drawn, and the translation (deviation from the CSVL) of some key vertebrae was measured, such as the LIV, LIV+1 (the first vertebra below LIV), LIV+2 (the second vertebra below LIV), LIV+3 (the third vertebra below LIV), lumbar apical vertebra (AV), thoracic AV, and T1. Additionally, the Cobb angles of the major thoracic and lumbar curves were measured at different time points, and the correction rates were calculated. Furthermore, clinical photographs of the patients from the back were taken preoperatively and postoperatively.Results: Of 278 AIS patients reviewed, 29 met the inclusion criteria. The continuous follow-up of our present study revealed an interesting phenomenon: postoperative spinal alignment remodeling. A hypothetical criterion was established to determine the onset of the phenomenon. By means of a series of analyses, the criterion was validated. The results of our present study showed that selective thoracic fusion tended to cause leftward spinal imbalance in these Lenke 1C AIS patients. Twenty of the 29 patients had leftward spinal imbalance immediately after surgery. Although some patients regained spinal balance through postoperative spinal alignment remodeling, 11 patients remained imbalanced at 2-year follow-up.Conclusions: Selective thoracic fusion is prone to cause leftward spinal imbalance in Lenke 1C scoliosis patients. Postoperative spinal alignment remodeling can facilitate recovery of spinal balance in some patients. Postoperative spinal imbalance in Lenke 1C scoliosis patients could be prevented by selecting stable vertebra or the vertebrae above as LIV, checking the balance condition during surgery, or considering ratio criteria when selecting candidates for selective thoracic fusion.

Commentary: Postoperative spinal alignment remodeling in Lenke 1C scoliosis treated with selective thoracic fusion

Lawrence G. Lenke — 2012-01-01

COMMENTARY ON: Wang Y, Bünger CE, Zhang Y, et al. Postoperative spinal alignment remodeling in Lenke 1C scoliosis treated with selective thoracic fusion. Spine J 2012;12:73–80 (in this issue).

A rare case of life-threatening giant plexiform schwannoma

2012-01-03

A 28-year-old woman with idiopathic scoliosis presented with a cervical mass and progressive gait disturbance over the course of 2 years. Examination demonstrated mild spastic paraplegia, hypoesthesia with upper level at T5 and severe respiratory failure requiring assisted ventilation. Magnetic resonance imaging showed multiple thoracic masses compressing left lung, trachea, and spinal cord (). Surgical resection was performed. Through C5–T1 laminectomy, the intradural part of the neoplasia was completely removed, and the extradural part was enucleated as much as possible. After surgery, the respiratory function improved. Histologic pattern and S100 protein diffuse reactivity were consistent with plexiform schwannoma, a rare benign cutaneous variation of schwannoma . Although deep-seated plexiform schwannomas involving spinal cord are occasionally described , this case is undoubtedly impressive because of the life-threatening tumor size ().

Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care. Kroenke K, Wu J, Bair MJ, Krebs EE, Damush TM, Tu W. Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care. J Pain 2011;12(9):964–73. Epub 2011 Jun 16

2012-01-01

Pain and depression are the most prevalent physical and psychological symptom-based disorders, respectively, and co-occur 30 to 50% of the time. However, their reciprocal relationship and potentially causative effects on one another have been inadequately studied. Longitudinal data analysis involving 500 primary care patients with persistent back, hip, or knee pain were enrolled in the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study. Half of the participants had comorbid depression and were randomized to a stepped care intervention (n=123) or treatment as usual (n=127). Another 250 nondepressed patients with similar pain were followed in a parallel cohort. Outcomes were assessed at baseline, 3, 6, and 12 months. Mixed effects model repeated measures (MMRM) multivariable analyses were conducted to determine if change in pain severity predicted subsequent depression severity, and vice versa. Change in pain was a strong predictor of subsequent depression severity (t-value=6.63, p<.0001). Likewise, change in depression severity was an equally strong predictor of subsequent pain severity (t-value=7.28, p<.0001). Results from the full cohort were similar in the clinical trial subgroup. In summary, pain and depression have strong and similar effects on one another when assessed longitudinally over 12 months.

Risk factors for immediate postoperative complications and mortality following spine surgery: a study of 3475 patients from the National Surgical Quality Improvement Program. Schoenfeld AJ, Ochoa LM, Bader JO, Belmont PJ Jr. J Bone Joint Surg Am 2011;93(17):1577–82

2012-01-01

This investigation sought to identify risk factors for immediate postoperative morbidity and mortality among a large series of patients undergoing spine surgery who were prospectively entered into a national registry.

The effect of lumbosacral manipulation on corticospinal and spinal reflex excitability on asymptomatic participants. Fryer G, Pearce AJ. J Manipulative Physiol Ther 2011 Oct 28. [Epub ahead of print]

2012-01-01

The aim of the study was to examine the effects of a high-velocity, low-amplitude (HVLA) manipulation to the lumbosacral joint on corticospinal excitability, as measured by motor evoked potentials (MEPs) using transcranial magnetic stimulation, and spinal reflex excitability, as measured by the Hoffman reflex (H-reflex).

Heritability of scoliosis. Grauers A, Rahman I, Gerdhem P. Eur Spine J 2011 Nov 18. [Epub ahead of print]

2012-01-01

To estimate the heritability of scoliosis in the Swedish Twin Registry. Self-reported data on scoliosis from 64,578 twins in the Swedish Twin Registry were analysed. Prevalence, pair- and probandwise concordances and tetrachoric correlations in mono- and dizygotic same-sex twins were calculated. The relative importance of genetic variance, i.e. the heritability, and unique and shared environmental variance was estimated using structural equation modelling in Mx software. In addition, all twins in the twin registry were matched against the Swedish Inpatient Register on the primary diagnosis idiopathic scoliosis.

Lumbar plexus anatomy within the psoas muscle: implications for the transpsoas lateral approach to the L4-L5 disc. Davis TT, Bae HW, Mok JM, Rasouli A, Delamarter RB. J Bone Joint Surg Am 2011;93(16):1482-7.

2012-01-01

The transpsoas lateral surgical approach has been advocated as an alternative to direct anterior approaches for less invasive or minimally invasive access to the spine. Postoperative thigh pain, paresthesia, and/or weakness have been described after the use of this surgical approach. The purpose of this cadaveric anatomic study is to provide a description of the lumbar plexus as it relates to the transpsoas lateral surgical approach.

Executive function in chronic pain patients and healthy controls: different cortical activation during response inhibition in fibromyalgia. Glass JM, Williams DA, Fernandez-Sanchez ML, et al. J Pain 2011;12(12):1219–29. Epub 2011 Sep 25

2012-01-01

The primary symptom of fibromyalgia (FM) is chronic, widespread pain; however, patients report additional symptoms including decreased concentration and memory. Performance-based deficits are seen mainly in tests of working memory and executive function. Neural correlates of executive function were investigated in 18 FM patients and 14 age-matched healthy controls during a simple Go/No-Go task (response inhibition) while they underwent functional magnetic resonance imaging (fMRI). Performance was not different between FM and healthy control, in either reaction time or accuracy. However, fMRI revealed that FM patients had lower activation in the right premotor cortex, supplementary motor area, midcingulate cortex, putamen and, after controlling for anxiety, in the right insular cortex and right inferior frontal gyrus. A hyperactivation in FM patients was seen in the right inferior temporal gyrus/fusiform gyrus. Despite the same reaction times and accuracy, FM patients show less brain activation in cortical structures in the inhibition network (specifically in areas involved in response selection/motor preparation) and the attention network along with increased activation in brain areas not normally part of the inhibition network. We hypothesize that response inhibition and pain perception may rely on partially overlapping networks, and that in chronic pain patients, resources taken up by pain processing may not be available for executive functioning tasks such as response inhibition. Compensatory cortical plasticity may be required to achieve performance on a par with control groups.

The maturation of grafted bone after posterior lumbar interbody fusion with an interbody carbon cage: a prospective five-year study. Kanemura T, Ishikawa Y, Mstsumoto A, et al. J Bone Joint Surg Br 2011;93(12):1638–45.

2012-01-01

We evaluated the maturation of grafted bone in cases of successful fusion after a one- or two-level posterior lumbar interbody fusion (PLIF) using interbody carbon cages. We carried out a five-year prospective longitudinal radiological evaluation of patients using plain radiographs and CT scans. One year after surgery, 117 patients with an early successful fusion were selected for inclusion in the study. Radiological evaluation of interbody bone fusion was graded on a 4-point scale. The mean grades of all radiological and CT assessments increased in the five years after surgery, and differences compared to the previous time interval were statistically significant for three or four years after surgery. Because the grafted bone continues to mature for three years after surgery, the success of a fusion should not be assessed until at least three years have elapsed. There were no significant differences in the longitudinal patterns of grafted bone maturity between iliac bone and local bone. However, iliac bone grafting may remodel faster than local bone.

Malpractice claims associated with medication management for chronic pain. Fitzgibbon DR, Rathmell JP, Michna E, Stephens LS, Posner KL, Domino KB. Anesthesiology 2010;112(4):948–56.

2012-01-01

Medication management is an integral part of chronic pain management. Prompted by an increase in the role of medication management in anesthesia chronic pain liability, we investigated the characteristics of malpractice claims collected from 2005 to 2008.

Prevalence of heterotopic ossification after cervical total disc arthroplasty: a meta-analysis. Chen J, Wang X, Bai W, Shen X, Yuan W. Eur Spine J 2011 Dec 2. [Epub ahead of print]

2012-01-01

Heterotopic ossification (HO) is a well-known complication after total hip and knee arthroplasty. But limited studies have focused on prevalence of HO following cervical total disc arthroplasty (CTDA) and the published data show controversial results.

Exploring the care experience of patients undergoing spinal surgery: a qualitative study. Davis RE, Vincent C, Henley A, McGregor A. J Eval Clin Pract 2011 Oct 26. [Epub ahead of print]

2012-01-01

This exploratory study sought to explore the patient experience of the surgical journey from decision to operate, to hospitalization, discharge and subsequent recovery. Patients attended one of two focus group discussions.

Meetings Calendar

2012-01-01

Spinal glioblastoma multiforme of the conus medullaris with holocordal and intracranial spread in a child: a case report and review of the literature

2011-12-26

Abstract: Background context: Spinal glioblastoma multiforme (GBM) is a rare clinical entity. According to our review of the literature, only 15 cases of spinal GBM originating from the conus medullaris (CM) have been reported. Furthermore, there has been no case of spinal GBM originating from the CM with holocordal and intracranial involvements, which were already present at the time of initial diagnosis. Despite a variety of treatments, the previous studies have uniformly reported poor results of this lethal condition.Purpose: The present report illustrates a 10-year-old girl with spinal GBM with rare involvement pattern, that is, the tumor originating from the CM with the holocordal and intracranial involvements, undergoing a novel chemotherapy regimen.Study design: A case report and review of literature.Methods: Magnetic resonance (MR) imaging with gadolinium enhancement clearly revealed holocordal and intracranial lesions, which were otherwise unidentifiable by plane MR imaging. Open biopsy was performed. After histologic diagnosis, novel chemotherapy regimen, that is, simultaneous high-dose chemotherapy (cyclophosphamide, cisplatin, vincristine, and etoposide) combined with autologous peripheral blood stem cell transplantation (auto-PBSCT), intrathecal injections of both methotrexate and dexamethasone, and radiotherapy, which respected the tolerance threshold of the spinal cord, were performed.Results: Novel chemotherapy regimen achieved marked tumor regression until the 12th month of treatment. The patient became ambulatory with T-shaped canes and has returned to the school life. Unfortunately, the patient died because of the relapse of the tumor 14 months after the initial diagnosis; however, this strategy has achieved longer survival than previously reported mean survival (12 months).Conclusions: The authors advocate enhanced MR imaging of the whole central nervous system for the potential spreading of this disease. This is the first report of simultaneous high-dose chemotherapy combined with auto-PBSCT, intrathecal injections of antineoplastic agents, and radiotherapy for the treatment of spinal GBM, which achieved marked tumor regression. We believe that accumulated experiences in the treatment of this lethal condition might contribute well to improve its therapeutic outcome.

Metastatic gastrointestinal stromal tumor to the thoracic and lumbar spine: first reported case and surgical treatment

2012-01-09

Abstract: Background context: Metastatic epidural spinal cord compression from gastrointestinal stromal tumors (GISTs) is a rarely reported phenomenon.Purpose: To describe the surgical management of metastatic GIST to two noncontiguous regions of the spinal column.Study design: Case report.Methods: Review of the medical chart, radiographic studies, and relevant literature.Results: The patient underwent direct surgical decompression and stabilization of the cervicothoracic junction and the lumbar region during treatment of two distinct sites of metastatic pathology.Conclusions: Treatment of epidural compression from metastatic GIST with direct decompression and stabilization is safe and feasible.

Editorial Board

2012-01-01

The Spine Journal

Five-year trends in spine care: the impact of health care reform

Injection of AAV2-BMP2 and AAV2-TIMP1 into the nucleus pulposus slows the course of intervertebral disc degeneration in an in vivo rabbit model

Commentary: A promising gene therapy approach to treat disc degeneration

Morbidity and mortality of major adult spinal surgery. A prospective cohort analysis of 942 consecutive patients

Utilization characteristics of spinal interventions

Cost-utility of lumbar decompression with or without fusion for patients with symptomatic degenerative lumbar spondylolisthesis

The development of a model for translation of the Neck Disability Index to utility scores for cost-utility analysis in cervical disorders

Low back pain in the United States: incidence and risk factors for presentation in the emergency setting

Commentary: Back pain epidemiology—the challenge of case definition and developing new ideas

Postoperative spinal alignment remodeling in Lenke 1C scoliosis treated with selective thoracic fusion

Commentary: Postoperative spinal alignment remodeling in Lenke 1C scoliosis treated with selective thoracic fusion

A rare case of life-threatening giant plexiform schwannoma

Risk factors for immediate postoperative complications and mortality following spine surgery: a study of 3475 patients from the National Surgical Quality Improvement Program. Schoenfeld AJ, Ochoa LM, Bader JO, Belmont PJ Jr. J Bone Joint Surg Am 2011;93(17):1577–82

The effect of lumbosacral manipulation on corticospinal and spinal reflex excitability on asymptomatic participants. Fryer G, Pearce AJ. J Manipulative Physiol Ther 2011 Oct 28. [Epub ahead of print]

Heritability of scoliosis. Grauers A, Rahman I, Gerdhem P. Eur Spine J 2011 Nov 18. [Epub ahead of print]

Lumbar plexus anatomy within the psoas muscle: implications for the transpsoas lateral approach to the L4-L5 disc. Davis TT, Bae HW, Mok JM, Rasouli A, Delamarter RB. J Bone Joint Surg Am 2011;93(16):1482-7.

Executive function in chronic pain patients and healthy controls: different cortical activation during response inhibition in fibromyalgia. Glass JM, Williams DA, Fernandez-Sanchez ML, et al. J Pain 2011;12(12):1219–29. Epub 2011 Sep 25

The maturation of grafted bone after posterior lumbar interbody fusion with an interbody carbon cage: a prospective five-year study. Kanemura T, Ishikawa Y, Mstsumoto A, et al. J Bone Joint Surg Br 2011;93(12):1638–45.

Malpractice claims associated with medication management for chronic pain. Fitzgibbon DR, Rathmell JP, Michna E, Stephens LS, Posner KL, Domino KB. Anesthesiology 2010;112(4):948–56.

Prevalence of heterotopic ossification after cervical total disc arthroplasty: a meta-analysis. Chen J, Wang X, Bai W, Shen X, Yuan W. Eur Spine J 2011 Dec 2. [Epub ahead of print]

Exploring the care experience of patients undergoing spinal surgery: a qualitative study. Davis RE, Vincent C, Henley A, McGregor A. J Eval Clin Pract 2011 Oct 26. [Epub ahead of print]

Meetings Calendar

Spinal glioblastoma multiforme of the conus medullaris with holocordal and intracranial spread in a child: a case report and review of the literature

Metastatic gastrointestinal stromal tumor to the thoracic and lumbar spine: first reported case and surgical treatment

Editorial Board

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