The Spine Journal

The vertebroplasty affair: the mysterious case of the disappearing effect size

Eugene J. Carragee — 2010-03-01

Looking back Watson, it may have seemed too good to be true. There were the usual clues. For instance, in 1997, an early report on the treatment of 47 osteoporotic compression fractures with the new vertebroplasty technique found that patients who had severe pain did well, incredibly well. In fact, 90% had pain relief within 24 hours. In short order, another group reported “complete pain relief” in 78% of patients with osteoporotic compression fractures treated with vertebroplasty . Not to be outdone, a third group in 1998 reported “immediate … complete relief of symptoms” in 90% of 80 patients with osteoporosis treated with vertebroplasty . Onward and upward, an arms race for more and more fantastic results, no control groups need apply.

Comparison of anterior cervical fusion after two-level discectomy or single-level corpectomy: sagittal alignment, cervical lordosis, graft collapse, and adjacent-level ossification

Yung Park, Takeshi Maeda, Woojin Cho, K. Daniel Riew — 2009-10-22

Abstract: Background context: Single-level corpectomy and two-level discectomy with anterior cervical plating have been reported to have comparable fusion and complication rates. However, there are few large series that have compared the two for sagittal alignment, cervical lordosis, graft subsidence, and adjacent-level ossification.Purpose: To determine the differences between these two procedures for patients with two-level spondylosis by comparing the pre- and postoperative radiographic data.Study design: Retrospective review of prospectively collected data in an academic institution.Patient sample: Fifty-two with a single-level corpectomy and 45 with a two-level anterior cervical discectomy and fusion (ACDF).Outcome measures: Pre- and postoperative radiographic data for sagittal alignment, cervical lordosis, subsidence, and adjacent-level ossification.Methods: We retrospectively reviewed the lateral cervical radiographs of patients who had a solid fusion after a single-level cervical corpectomy or a two-level ACDF for the treatment of a degenerative cervical spondylosis by a surgeon at an academic institution. The choice of the operation was dependent on the presence or absence of retrovertebral compression. All patients underwent anterior cervical fusion using fibula strut allograft and variable-angle screw-plate fixation. None had had prior cervical spine surgery. Twenty-five were excluded because of inadequate radiographs and follow-up. There were 52 with a single-level corpectomy and 45 with a two-level ACDF. The following were analyzed: 1) sagittal alignment (modified method of Toyama); 2) cervical lordosis measured by Cobb angles of fusion constructs (fusion Cobb) and C2–C7 (C2–C7 Cobb); 3) graft collapse determined by the subsidence of anterior/posterior body height of fused segments (anterior/posterior subsidence) and the cranial/caudal plate-to-disc distances (cranial/caudal subsidence), and the difference between anterior and posterior body height for the fused levels (anteroposterior [AP] difference); and 4) the severity of ossification at two adjacent levels.Results: The mean durations of follow-up were 23.3±6.6 (corpectomy) and 25.7±6.2 (ACDF) months, range 12 to 45 months. There were no significant differences between the two groups in sagittal alignment, cervical lordosis, graft collapse, and adjacent-level ossification. Graft subsidence and loss of cervical lordosis occurred significantly more during the first 6 weeks after surgery (all measurements, p<.0001) than after 6 weeks, with no significant difference between the two groups. Posterior and caudal end plate subsidence significantly progressed after 6 weeks in Group 1 (p=.04, p=.02). The final follow-up Cobb angle positively correlated with preoperative and immediate postoperative Cobb angles (r=0.437, p<.0001; r=0.727, p<.0001), caudal subsidence (r=0.270, p=.008), and the final AP difference (r=0.915, p<.0001) but did not correlate with surgery level, preoperative and final sagittal alignments, anterior/posterior subsidence, and cranial subsidence. Anterior/posterior subsidence was significantly more strongly related with caudal subsidence (r=0.607, p<.0001; r=0.424, p<.0001) than cranial (r=0.277, p=.007; r=0.211, p=.040) but did not correlate with pre- and postoperative fusion Cobb, and preoperative and the last sagittal alignments.Conclusions: Our data suggest that the two procedures yield comparable results in terms of sagittal alignment, cervical lordosis, graft subsidence, and adjacent-level ossification. Graft subsidence and loss of cervical lordosis appeared to occur mainly during the first 6 weeks after surgery. Single-level corpectomy and fusion continued to subside at the posterior portion of caudal end plate even after 6 weeks. On the other hand, graft subsidence did not correlate with preoperative and final postoperative sagittal alignments.

Computed tomography–evaluated features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain

Leonid Kalichman, David H. Kim, Ling Li, Ali Guermazi, David J. Hunter — 2009-12-14

Abstract: Background context: Although the role of radiographic abnormalities in the etiology of nonspecific low back pain (LBP) is unclear, the frequent identification of these features on radiologic studies continues to influence medical decision making.Purpose: The primary purposes of the study were to evaluate the prevalence of lumbar spine degeneration features, evaluated on computed tomography (CT), in a community-based sample and to evaluate the association between lumbar spine degeneration features. The secondary purpose was to evaluate the association between spinal degeneration features and LBP.Study design: This is a cross-sectional community-based study that was an ancillary project to the Framingham Heart Study.Sample: A subset of 187 participants were chosen from the 3,529 participants enrolled in the Framingham Heart Study who underwent multidetector CT scan to assess aortic calcification.Outcome measures: Self-report measures: LBP in the preceding 12 months was evaluated using a Nordic self-report questionnaire. Physiologic measures: Dichotomous variables indicating the presence of intervertebral disc narrowing, facet joint osteoarthritis (OA), spondylolysis, spondylolisthesis, and spinal stenosis and the density (in Hounsfield units) of multifidus and erector spinae muscles were evaluated on CT.Methods: We calculated the prevalence of spinal degeneration features and mean density of multifidus and erector spinae muscles in groups of individuals with and without LBP. Using the χ2 test for dichotomous and t test for continuous variables, we estimated the differences in spinal degeneration parameters between the aforementioned groups. To evaluate the association of spinal degeneration features with age, the prevalence of degeneration features was calculated in four age groups (less than 40, 40–50, 50–60, and 60+ years). We used multiple logistic regression models to examine the association between spinal degeneration features (before and after adjustment for age, sex, and body mass index [BMI]) and LBP, and between all degeneration features and LBP.Results: In total, 104 men and 83 women, with a mean age (±standard deviation) of 52.6±10.8 years, participated in the study. There was a high prevalence of intervertebral disc narrowing (63.9%), facet joint OA (64.5%), and spondylolysis (11.5%) in the studied sample. When all spinal degeneration features as well as age, sex, and BMI were factored in stepwise fashion into a multiple logistic regression model, only spinal stenosis showed statistically significant association with LBP, odds ratio (OR) (95% confidence interval [CI]): 3.45 [1.12–10.68]. Significant association was found between facet joint OA and low density of multifidus (OR [95% CI]: 3.68 [1.36–9.97]) and erector spinae (OR [95% CI]: 2.80 [1.10–7.16]) muscles.Conclusions: Degenerative features of the lumbar spine were extremely prevalent in this community-based sample. The only degenerative feature associated with self-reported LBP was spinal stenosis. Other degenerative features appear to be unassociated with LBP.

Spine journals: is reviewer agreement on publication recommendations greater than would be expected by chance?

Bradley K. Weiner, Jacob P. Weiner, Harvey E. Smith — 2010-03-01

Abstract: Background context: It is commonly believed that the peer-review process is reliable and consistent. It appears, however, that depending on the journal and the editorial leadership, agreement by reviewers on whether to publish submitted articles varies widely; from substantial to slightly greater than one would expect with random assignments of acceptance or rejection.Purpose: The purpose was to assess peer-review agreement in major spine journals.Study design/Setting: This study is for the assessment of reviewer agreement.Samples: The study consisted of consecutive reviews of 200 submitted articles.Outcome measures: Agreement via Kappa statistics.Methods: Group A consisted of 200 consecutive article reviews for which the senior author was involved in the review or editorial process over the past 8 years for two major spine journals. Reviewers' recommendations were placed into one of two groups: accept/minimal revisions or major revision/reject. Standard Kappa statistics were used to assess reviewer agreement. Group B consisted of a similar set, but with wholly randomly generated recommendations. Again, Kappa statistics were used.Results: Kappa for Group A was 0.155 with a range of 0.017 to 0.294 at 95% confidence interval and agreement at 0.6; suggesting “slight” reviewer agreement. Kappa for Group B behaved as expected, with “poor” agreement.Conclusions: Agreement regarding peer-review recommendations for publication in spine journals appears to be better than would be expected in the random situation; but still only “slight.” This suggests that review methodology varies considerably among reviewers and that further study should be undertaken to determine “ideal” agreement levels and ways to increase review consistency/quality commensurate with the editorial missions of the journals.

Cytokine evaluation in individuals with low back pain using discographic lavage

2010-03-01

Abstract: Background context: The pathophysiology underlying degenerative disc disease and its implication in painful syndromes remain unclear. However, spine magnetic resonance imaging (MRI) can demonstrate changes in disc water content and the annulus; provocative discography purportedly identifies degenerate discs causing serious low back pain; and biochemical assays have identified local inflammatory markers. No study to date has correlated pain on disc injection during discography evaluation with relevant MRI findings and biochemical markers.Purpose: The purpose of this study was to correlate concordant pain on during discography to biochemical markers obtained by disc lavage and MRI findings.Study design: This is a Phase 1 Diagnostic Test Assessment Cohort Study (Sackett and Haynes).Patient sample: The patient sample included 21 symptomatic patients with suspected discogenic pain and three Phase 1 control subjects.Outcome measures: The outcome measures included discography pain scores, MRI degenerative grades, and immunoreactivity to various inflammatory cytokine concentrations present in disc lavage samples.Methods: Twenty-one symptomatic patients with lumbar degenerative disc disease and three control subjects underwent discography, MRI, and biochemical analysis of disc lavage fluid. Lumbar MRI was scored for Pfirrmann grading of the lumbar discs, and annular disruption was identified by nuclear disc lavage. Disc lavage samples were analyzed for biochemical markers by high-sensitivity immunoassay.Results: Eighty-three discs from 24 patients were studied: 67 discs from 21 patients with axial back pain (suspected discogenic pain group) and 16 discs from 3 scoliosis patients without back pain (Phase 1 control subjects). Among the biochemical markers surveyed, interferon gamma (IFN-γ) immunoreactivity was most consistently identified in patients with axial back pain. Discs with annular disruption and concordant pain reproduction at a visual analog scale of 7 to 10/10 had greater IFN-γ immunoreactivity than those without this finding (p=.003); however, at least some IFN-γ immunoreactivity was found in all but one disc in the symptomatic group.Conclusions: Among the potential inflammatory markers tested in this Phase 1 study, IFN-γ immunoreactivity was most commonly elevated in discogram “positive” discs but absent in asymptomatic controls. However, this marker was also frequently elevated in degenerative but “negative” discography discs. From these findings, Phase 2 and Phase 3 validity studies are reasonable to pursue. Phase 4 utility studies may be performed concurrently to assess this method's predictive value in outcome studies.

Comprehensive computed tomography assessment of the upper cervical anatomy: what is normal?

2010-03-01

Abstract: Background context: High-speed computed tomography (CT) exams have replaced traditional radiographs for assessment of cervical spine injuries in many emergency departments. Recent evidence demonstrates that even subtle displacements can indicate significant upper cervical spine injuries. Many different anatomical measurements have been described in the upper cervical spine to date, most of them based on X-ray. The range of anatomical relationships that exist in an uninjured population must be known to reliably detect abnormal relations. The measurements with the lowest normal variation are likely to be most useful in detecting injuries.Purpose: The purpose of this study was to describe the normal quantitative anatomical relationships as well as the threshold measurements most likely to detect injury in the upper cervical spine.Study design/Setting: Retrospective anatomical case review.Patient sample: Seventy-six thin-sliced cervical CT scans randomly selected from a trauma population, all negative for injury in the cervical spine.Methods: Forty-two different anatomical measurements were made of the upper cervical spine. These included traditional historical measurements and other detailed dimensions to characterize occipitocervical (OC) and atlantoaxial (AA) joint relationships.Results: After review of all the anatomical measurements performed in the upper cervical spine, direct measurements of the joint space had the least variation. The mean OC joint space was 0.6mm, with an upper 95% confidence interval (CI) of 1mm at the most anterior or posterior aspects of the joints. This was true for both sagittal and coronal measurements. The mean AA joint space was 0.6mm, with an upper 95% CI of 1.2mm at the lateral aspect of the joint on the coronal image only. The midsagittal structures demonstrated significantly higher standard deviation and variability.Conclusions: These results revealed consistently narrow joint spaces and left-right symmetry in the upper cervical spine joints that do not vary according to demographics. There was distinctly greater consistency in the coronal plane, which enabled more precise diagnostic measurement and side-to-side comparison of measurements. This precision will enable more accurate identification of abnormal scans, which should prompt consideration for additional workup. Thus, better understanding of these relationships may enable earlier detection of subtle craniocervical dissociative injuries based on CT scan data. This is important, because the only evidence of a severe injury on CT can be subtle misalignment.

Reference data for assessing widening between spinous processes in the cervical spine and the responsiveness of these measures to detecting abnormalities

2010-03-01

Abstract: Background context: Traumatic injury to the spine is evaluated and treated based on the perceived stability of the spine. Recent classification schemes have established the importance of evaluating the discoligamentous complex to fully comprehend stability. There are a variety of techniques to evaluate the discoligamentous complex, including assessment of interspinous distance. However, there currently are no clinically validated methods to define and assess abnormal interspinous widening.Purpose: The purpose of the study was to provide reference data and evidence to support the objective use of spinous process widening in the diagnosis of cervical spine injury and instability.Study design: The study was designed to be biomechanical and observational.Methods: Distances between spinous processes were measured from lateral flexion-extension X-rays of 156 skeletally mature asymptomatic subjects who reported never having had neck symptoms as well as 12 whole human cadavers before and after creating increasingly severe damage to posterior structures. Cervical interspinous distances were measured and then normalized to the width of the C4 vertebral end plate. The change in the distance from flexion to extension was also calculated.Results: Descriptive statistics, including the 95% confidence intervals for each cervical level were tabulated for 863 levels in 149 analyzable asymptomatic volunteers. In the simulated cadaver model, interspinous widening was highly specific and mildly sensitive for detecting damage to the posterior structures of the cervical spine.Conclusions: This study provides reference data that can be used to quantitatively assess interspinous process widening in the cervical spine. Application of the reference data to a cadaver model of cervical trauma suggests that although objective evidence of abnormal widening may be uncommon, when present, it is suggestive of extensive damage to the cervical spine. Derived from this data were two “rule of thumb” criteria to identify abnormal interspinous widening in flexion X-rays; when greater than 30% relative to an adjacent level (40% between C1–C2 and C2–C3) or greater than 50% of the anterior-posterior width of the C4 vertebral body (30% for C2–C3).

North American Spine Society: Newly released vertebroplasty randomized controlled trials: a tale of two trials

2009-10-12

This commentary is a product of the North American Spine Society (NASS). It was approved by the NASS Board of Directors and accepted for publication outside The Spine Journal's peer review process.

Vertebroplasty: when randomized placebo-controlled trial results clash with common belief

Rachelle Buchbinder, David F. Kallmes — 2010-03-01

COMMENTARY ON: Bono C, Heggeness M, Mick C, et al. North American Spine Society: Newly released vertebroplasty randomized controlled trials: a tale of two trials. Spine J 2010;10:238-240 (in this issue).

Determination of the in vivo posterior loading environment of the Coflex interlaminar-interspinous implant

2009-12-11

Abstract: Background context: The in vivo loading environment of load-bearing implants is generally largely unknown. Loads are typically approximated from cadaver tests or biomechanical calculations for the preclinical assessment of a device's safety and efficacy.Purpose: To determine the actual in vivo loading environment of an elastic interlaminar-interspinous implant (Coflex).Study design: A retrospective radiographic study to noninvasively measure the in vivo implant loads of 176 patients.Methods: For this study, neutral, flexion, and extension radiographs were quantitatively analyzed using validated image analysis technology. The angle between the Coflex arms was measured for each radiograph and statistically evaluated. Separately, the Coflex implant was characterized using mechanical test data and finite element analysis, which resulted in a load-deformation formula that describes the implant load as a function of its size and elastic deformation. Using the formula and the elastic implant deformation data obtained from the radiographic analysis, the exact implant load was calculated for each patient and each posture. For statistical analysis, the patients were grouped by indication and procedure, which resulted in 12 different groups. The determined loads were compared with the strength of the posterior lumbar spinal elements obtained from the literature and with the static and dynamic mechanical limits of the Coflex interlaminar-interspinous implant.Results: The force data were independent of implant size, diagnosis (with one exception), number of levels of the decompression procedure, number of levels of implantations (one or two), and follow-up time. The median compressive force acting on the Coflex implant was found to be 45.8 N. The maximum load change between flexion and extension was 140 N; the maximum overall load exceeded 239 N in extension.Conclusions: The average loads exerted by the Coflex implant on the spinous process and lamina are 11.3% and 7.0% of their respective static failure load. The implant fatigue strength is significantly higher than the measured median force, which explains the extremely rare observation of a Coflex fatigue failure.

Causal assessment of occupational sitting and low back pain: results of a systematic review

Darren M. Roffey, Eugene K. Wai, Paul Bishop, Brian K. Kwon, Simon Dagenais — 2010-01-25

Abstract: Background context: Low back pain (LBP) is a common and disabling musculoskeletal disorder that often occurs in a working-age population. Determining the precise causation of LBP remains difficult. Any attempt to implicate a specific occupational activity in the genesis of LBP requires a methodologically rigorous approach.Purpose: To conduct a systematic review of the scientific literature focused on evaluating the causal relationship between occupational sitting and LBP.Study design: Systematic review of the literature using Medline, EMBASE, CINAHL, Cochrane Library, Occupational Safety and Health database, grey literature, hand-searching occupational health journals, reference lists of included studies, and content experts. Evaluation of study quality using a modified version of the Newcastle-Ottawa Scale. Summary levels of evidence supporting Bradford-Hill criteria for different categories of sitting and types of LBP.Samples: Studies reporting an association between occupational sitting and LBP.Outcome measures: Numerical association between different levels of exposure to occupational sitting and the presence or severity of LBP.Methods: A systematic review was performed to identify, evaluate, and summarize the literature related to establishing a causal relationship, according to Bradford-Hill criteria, between occupational sitting and LBP.Results: This search yielded 2,766 citations. Twenty-four studies met the inclusion/exclusion criteria and five were high-quality studies, including two case-controls and three prospective cohorts. Strong, consistent evidence was found for no association between occupational sitting and LBP. A moderate level of evidence was found for the absence of any dose-response trend. Risk estimates evaluating temporality were not statistically significant. Biological plausibility was not discussed in these studies. No evidence was available to assess the experiment criterion.Conclusions: This review failed to uncover high-quality studies to support any of the Bradford-Hill criteria to establish causality between occupational sitting and LBP. Strong and consistent evidence did not support criteria for association, temporality, and dose response. Based on these results, it is unlikely that occupational sitting is independently causative of LBP in the populations of workers studied.

Causal assessment of occupational standing or walking and low back pain: results of a systematic review

Darren M. Roffey, Eugene K. Wai, Paul Bishop, Brian K. Kwon, Simon Dagenais — 2010-03-01

Abstract: Background context: Low back pain (LBP) is a widespread musculoskeletal condition that frequently occurs in the working-age population. Numerous occupational physical activities have been implicated in its etiology.Purpose: To conduct a systematic review establishing a causal relationship between occupational standing or walking and LBP.Study design: Systematic review of the literature.Sample: Studies reporting an association between occupational standing or walking and LBP.Outcome measures: Numerical association between exposure to standing or walking and the presence of LBP.Methods: A systematic review was performed to identify, evaluate, and summarize the literature related to establishing a causal relationship, according to Bradford-Hill criteria for causality, between occupational standing or walking and LBP. A search was conducted using MEDLINE, Embase, CINAHL, Cochrane Library, and Occupational Safety and Health database, gray literature, hand-searching occupational health journals, reference lists of included studies, and expert knowledge. Evaluation of methodological quality was performed using a modified Newcastle-Ottawa Scale.Results: This search yielded 2,766 citations. Eighteen studies met the inclusion criteria. Five were high-quality studies related to standing, and two were high-quality studies related to walking. For occupational standing and LBP, there was moderate to strong evidence against the association criterion, the only study examining dose response did not support this criterion, four studies examining temporality failed to support this criterion, and only one study discussed the biological plausibility criterion. For occupational walking and LBP, there was moderate evidence against a causal relationship with respect to the association, temporality, dose response, and biological plausibility criteria. No studies assessed the experiment criterion for these activities.Conclusions: A summary of existing studies was not able to find any high-quality studies that satisfied more than two of the Bradford-Hill causation criteria for occupational standing or walking and LBP. Based on the evidence reviewed, it is unlikely that occupational standing or walking is independently causative of LBP in the populations of workers studied.

Teriparatide and raloxifene reduce the risk of new adjacent vertebral fractures in postmenopausal women with osteoporosis. Results from two randomized controlled trials. Bouxsein ML, Chen P, Glass EV, Kallmes DF, Delmas PD, Mitlak BH. J Bone Joint Surg Am. 2009;91(6):1329–38

2010-03-01

BACKGROUND: Vertebral fractures increase the risk of new vertebral fractures; however, we are not aware of any study addressing the risk of new vertebral fractures adjacent to existing vertebral fractures. Therefore, we sought to determine the influence of the number and severity of prevalent (preexisting) vertebral fractures on the risk of new adjacent vertebral fractures and to determine whether teriparatide (rhPTH [recombinant human parathyroid hormone] [1-34]) or raloxifene treatment reduces the incidence of adjacent vertebral fractures in postmenopausal women with osteoporosis.

A prospective, masked 18-month minimum follow-up on neurophysiologic changes in persons with spinal stenosis, low back pain, and no symptoms. Haig AJ, Yamakawa KS, Parres C, Chiodo A, Tong H. PM R. 2009;1(2):127–36

2010-03-01

OBJECTIVES: To describe neurophysiologic changes over time in persons with and without spinal complaints and to assess whether paraspinal denervation predicts change in stenosis on magnetic resonance imaging (MRI) and clinical course.

Defining substantial clinical benefit following lumbar spine arthrodesis. Glassman SD, Copay AG, Berven SH, Polly DW, Subach BR, Carreon LY. J Bone Joint Surg Am. 2008;90(9):1839–47

2010-03-01

BACKGROUND: Validated health-related quality-of-life measures have become important standards in the evaluation of the outcomes of lumbar spine surgery. However, there are few well-defined criteria for clinical success based on these measures. The minimum clinically important difference is an important demarcation, but it could be considered a floor value rather than a goal in defining clinical success. Therefore, we sought to define thresholds of substantial clinical benefit for commonly used health-related quality-of-life measures following lumbar spine arthrodesis.

The ProDisc-C total disc replacement system was effective for symptomatic cervical disc disease. Bohlman HH. J Bone Joint Surg Am. 2009;91(11):2748

2010-03-01

BACKGROUND CONTEXT: Cervical total disc replacement (TDR) is intended to address radicular pain and preserve functional motion between two vertebral bodies in patients with symptomatic cervical disc disease (SCDD). PURPOSE: The purpose of this trial is to compare the safety and efficacy of cervical TDR, ProDisc-C (Synthes Spine Company, L.P., West Chester, PA), to anterior cervical discectomy and fusion (ACDF) surgery for the treatment of one-level SCDD between C3 and C7.

The effect of an anterior cervical operation for cervical radiculopathy or myelopathy on associated headaches. Riina J, Anderson PA, Holly LT, Flint K, Davis KE, Riew KD. J Bone Joint Surg Am. 2009;91(8):1919–23

2010-03-01

BACKGROUND: Headaches related to the cervical spine have been reported by various authors, and modalities of treatment are as varied as their speculated causes. The purpose of this study was to determine if anterior cervical reconstructive surgery (cervical arthrodesis and disc arthroplasty) for the treatment of radiculopathy or myelopathy also helps to alleviate associated headaches.

Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. Four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. Weinstein JN, Lurie JD, Tosteson TD, et al. J Bone Joint Surg Am. 2009;91(6):1295–304

2010-03-01

BACKGROUND: The management of degenerative spondylolisthesis associated with spinal stenosis remains controversial. Surgery is widely used and has recently been shown to be more effective than nonoperative treatment when the results were followed over two years. Questions remain regarding the long-term effects of surgical treatment compared with those of nonoperative treatment.

Improved outcome after lumbar microdiscectomy in patients shown their excised disc fragments: a prospective, double blind, randomised, controlled trial. Tait MJ, Levy J, Nowell M, et al. J Neurol Neurosurg Psychiatry. 2009;80(9):1044–6

2010-03-01

BACKGROUND: Lumbar microdiscectomy (LMD) is a commonly performed neurosurgical procedure. We set up a prospective, double blind, randomised, controlled trial to test the hypothesis that presenting the removed disc material to patients after LMD improves patient outcome.

Recombinant human bone morphogenetic protein-2 on an absorbable collagen sponge with an osteoconductive bulking agent in posterolateral arthrodesis with instrumentation. A prospective randomized trial. Dawson E, Bae HW, Burkus JK, Stambough JL, Glassman SD. J Bone Joint Surg Am. 2009;91(7):1604–13

2010-03-01

BACKGROUND: Recombinant human bone morphogenetic protein-2 (rhBMP-2) on an absorbable collagen sponge has been shown to be a safe and effective replacement for iliac crest bone graft when used with a threaded fusion device in anterior lumbar interbody arthrodesis. Use of rhBMP-2 on an absorbable collagen sponge in posterolateral lumbar arthrodesis requires the addition of a bulking agent to provide resistance against compression and to serve as an osteoconductive scaffold for new bone formation.

Spinal flexibility in scoliosis: roots “bending” to antiquity

Dino Samartzis, Frank La Marca — 2010-03-01

Scoliosis is a common spinal deformity affecting individuals worldwide. In recent times, much attention has been devoted to the “flexibility” of the scoliotic curve to assist in determining management options for curve correction and their outcomes. In individuals with scoliosis, various methods using radiographic imaging have been proposed to assess the flexibility of the spine, such as the supine bending, traction, push-prone, and fulcrum-bending radiographs . Many of these methods use traction techniques or active/static forces to assess the curve's flexibility. However, such principles in evaluating spinal flexibility are not that novel but have roots stemming to antiquity.

Is a barrier really necessary to prevent radiculitis when using recombinant human bone morphogenetic protein-2 in proximity of nerve roots?

Tomislav Smoljanovic, Mislav Cimic, Ivan Bojanic — 2010-03-01

We read with interest the article about complications associated with single-level transforaminal lumbar interbody fusion assisted with either autograft iliac crest or recombinant human bone morphogenetic protein-2 absorbed on collagen sponge (rhBMP-2/ACS) (Infuse; Medtronic Sofamor Danek, Memphis, TN, USA) by Rihn et al. . A thin layer of Duraseal (Confluent Surgical, Waltham, MA, USA) was applied posterior to the interbody cage at the annulotomy site and over the exposed dura and nerve root, theoretically providing a watertight seal at the annulotomy site. The rationale behind the use of Duraseal in this fashion was to prevent rhBMP-2 from leaking through the annulotomy into the spinal canal and around the nerve root. According to Dr Vaidya , the authors have shown that the barrier was helpful in transforaminal lumbar interbody fusion surgery to prevent radiculitis when using rhBMP-2 and that rhBMP-2 in itself can lead to this complication.

Reply

Jeffrey A. Rihn — 2010-03-01

This study was a retrospective review of the complications associated with transforaminal lumbar interbody fusion (TLIF) using either iliac crest autograft or recombinant human bone morphogenetic protein-2 (rhBMP-2). A few years ago, there was a gradual transition at our institution from the use of iliac crest autograft to the use of rhBMP-2 in the TLIF procedure. This explains the significant difference that existed in the length of clinical follow-up between these two groups, with the iliac crest autograft group having longer clinical follow-up (autograft 35.8 months vs. rhBMP-2 24.4 months, p<.001). A detailed clinical comparison of the autograft and rhBMP-2 groups and a detailed description of the surgical procedure were not included in this manuscript because of revisions made throughout the peer-review process. The surgical technique is described in a previous publication . The approach for a TLIF is different from the approach used for posterior lumbar interbody fusion. It theoretically requires less medial retraction of the traversing nerve root as a result of the transforaminal approach.

Re: “Classifications in spine: a tectonic shift” by Chapman

Marc Malberg — 2010-03-01

I read with interest, Dr Chapman's commentary article on the article by Dr Sethi et al. about the evolution of thoracolumbar injury classification systems. The second paragraph was very insightful and touched on the importance of historical perspectives. However, it had a familiar ring to it. Dr Chapman stated, “After the fundamentally sound binary differentiation of treatable and not-to-be-treated spinal injuries as presented in the Edwin Smith papyruses, ‘An ailment I will treat’ and ‘An ailment not to be treated,’ further attempts at classifying skeletal injuries lay largely dormant until the period of the industrial revolution in the late 19th century brought about technological advancements that enabled greater insights through improved care infrastructure in general radiography specifically.”

Meetings Calendar

2010-03-01

Isolated tuberculosis of the lumbar apophyseal joint

Ashwin Avadhani, Ajoy P. Shetty, S. Rajasekaran — 2010-01-25

Abstract: Background context: Posterior element tuberculosis is rare accounting for only 3% to 5% of all spinal tuberculosis. To our knowledge, no case of isolated facet joint tuberculosis with coronal decompensation has been reported in literature so far.Purpose: The purpose of this study was to describe a case of tuberculous arthritis of the lumbar facet joint and its effect on coronal balance of the spine.Study design: The study design was a case report.Methods: A 14-year-old boy presented with a 3-month history of back pain without radiation and with normal neurological findings. Computed tomography and magnetic resonance imaging showed destruction of the right L4–L5 facet joint with L5–S1 spondylolytic listhesis. Despite 2 months of antitubercular medication after a core biopsy confirmation of L4–L5 facet tuberculosis, there was progression of coronal decompensation of the spine with severe pain. Instrumentation with intertransverse fusion was done as a secondary procedure.Results: The patient was completely relieved of symptoms after instrumented fusion along with antitubercular medication.Conclusion: Isolated lumbar facet joint tuberculosis is a rare entity with a potential for coronal decompensation of the spine, which makes early instrumented fusion with antitubercular medication a viable treatment modality.

Editorial Board

2010-03-01

The Spine Journal

The vertebroplasty affair: the mysterious case of the disappearing effect size

Comparison of anterior cervical fusion after two-level discectomy or single-level corpectomy: sagittal alignment, cervical lordosis, graft collapse, and adjacent-level ossification

Computed tomography–evaluated features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain

Spine journals: is reviewer agreement on publication recommendations greater than would be expected by chance?

Cytokine evaluation in individuals with low back pain using discographic lavage

Comprehensive computed tomography assessment of the upper cervical anatomy: what is normal?

Reference data for assessing widening between spinous processes in the cervical spine and the responsiveness of these measures to detecting abnormalities

North American Spine Society: Newly released vertebroplasty randomized controlled trials: a tale of two trials

Vertebroplasty: when randomized placebo-controlled trial results clash with common belief

Determination of the in vivo posterior loading environment of the Coflex interlaminar-interspinous implant

Causal assessment of occupational sitting and low back pain: results of a systematic review

Causal assessment of occupational standing or walking and low back pain: results of a systematic review

Teriparatide and raloxifene reduce the risk of new adjacent vertebral fractures in postmenopausal women with osteoporosis. Results from two randomized controlled trials. Bouxsein ML, Chen P, Glass EV, Kallmes DF, Delmas PD, Mitlak BH. J Bone Joint Surg Am. 2009;91(6):1329–38

A prospective, masked 18-month minimum follow-up on neurophysiologic changes in persons with spinal stenosis, low back pain, and no symptoms. Haig AJ, Yamakawa KS, Parres C, Chiodo A, Tong H. PM R. 2009;1(2):127–36

Defining substantial clinical benefit following lumbar spine arthrodesis. Glassman SD, Copay AG, Berven SH, Polly DW, Subach BR, Carreon LY. J Bone Joint Surg Am. 2008;90(9):1839–47

The ProDisc-C total disc replacement system was effective for symptomatic cervical disc disease. Bohlman HH. J Bone Joint Surg Am. 2009;91(11):2748

The effect of an anterior cervical operation for cervical radiculopathy or myelopathy on associated headaches. Riina J, Anderson PA, Holly LT, Flint K, Davis KE, Riew KD. J Bone Joint Surg Am. 2009;91(8):1919–23

Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. Four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. Weinstein JN, Lurie JD, Tosteson TD, et al. J Bone Joint Surg Am. 2009;91(6):1295–304

Improved outcome after lumbar microdiscectomy in patients shown their excised disc fragments: a prospective, double blind, randomised, controlled trial. Tait MJ, Levy J, Nowell M, et al. J Neurol Neurosurg Psychiatry. 2009;80(9):1044–6

Spinal flexibility in scoliosis: roots “bending” to antiquity

Is a barrier really necessary to prevent radiculitis when using recombinant human bone morphogenetic protein-2 in proximity of nerve roots?

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Re: “Classifications in spine: a tectonic shift” by Chapman

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Isolated tuberculosis of the lumbar apophyseal joint

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