The Spine Journal

Dream from our President: Barack Obama and evidence-based medicine

Conor O'Neill — 2010-02-01

“We …. are making a major investment in research to identify the best treatments for a variety of ailments and conditions. We need to … let doctors focus on practicing medicine, and encourage broader use of evidence-based guidelines. I want … a health care system where doctors can pull up on a computer all the medical information and latest research they'd ever want to meet that patient's needs.” President Barack Obama, in a speech to the American Medical Association, June 15, 2009.

Economic impact of improving outcomes of lumbar discectomy

2009-10-12

Abstract: Background: Lumbar discectomy is usually a successful operation with a relatively low cost. Potential adjunctive procedures, such as repairing the anulus fibrosus or nucleus replacements, necessitate a cost-benefit analysis.Purpose: This economic analysis was performed to understand the potential value of advanced implantable technologies designed to improve outcomes after discectomy.Study design/setting: Using an insurance claims–based database, the economics of less-than-favorable outcomes after lumbar discectomy were studied. Estimates of improved clinical outcomes because of adjunctive surgical procedural items were modeled.Patient sample: Using Current Procedural Terminology (CPT-4) codes and International Classification of Diseases, Clinical Modification procedure codes (ICD-9 CM), all lumbar discectomy patients were identified in a 6-month period from a large, 2002, commercially available claims-based data set representing 3.1 million insured lives.Outcome measures: Not applicable.Methods: Longitudinal data analysis from 3 years (2002–2004) of the database was performed for evidence of claims after the insured's discectomy (up to 18 months post) as a utilization estimate of surgical and medical treatment resultant of less-than-favorable outcomes. Incidence and cost of secondary operations, medical management, and complications were determined. Using these inputs, an economic model was generated to estimate the effect of improvement in discectomy outcomes.Results: Of the 494 patients who had a discectomy within a 6-month period, 137 (28%) had subsequent claims that suggested the outcome was less than favorable within 18 months. Patients whose insurance claims included codes for a second operation (n=52 patients with 56 operations; 11%) and patients being medically/nonsurgically managed (n=85, 17%) were studied. Average reimbursed charges incurred (2006 dollars) of repeated discectomy (80% of cases) was $6,907 and for arthrodesis (20% of cases) was $24,375. Average additional medical treatment cost to diagnose or manage poor outcome requiring another surgery was $3,365. Procedure-related complications within 40 days of surgery were evident in 15% of the group; with additional average cost to manage of $3,939.Conclusions: Substantial cost associated with poor discectomy outcomes is often overlooked or underappreciated. Surgical technologies that can improve outcomes of discectomy by 50% to 70% thus improving patient quality of life can be overall cost-neutral between $971 and $1,655 additionally per patient.

Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: a pilot randomized controlled trial

Mitchell Haas, Adele Spegman, David Peterson, Mikel Aickin, Darcy Vavrek — 2009-10-19

Abstract: Background context: Systematic reviews of randomized controlled trials suggest that spinal manipulative therapy (SMT) is efficacious for care of cervicogenic headache (CGH). The effect of SMT dose on outcomes has not been studied.Purpose: To compare the efficacy of two doses of SMT and two doses of light massage (LM) for CGH.Patient sample: Eighty patients with chronic CGH.Main outcome measures: Modified Von Korff pain and disability scales for CGH and neck pain (minimum clinically important difference=10 on 100-point scale), number of headaches in the last 4 weeks, and medication use. Data were collected every 4 weeks for 24 weeks. The primary outcome was the CGH pain scale.Methods: Participants were randomized to either 8 or 16 treatment sessions with either SMT or a minimal LM control. Patients were treated once or twice per week for 8 weeks. Adjusted mean differences (AMD) between groups were computed using generalized estimating equations for the longitudinal outcomes over all follow-up time points (profile) and using regression modeling for individual time points with baseline characteristics as covariates and with imputed missing data.Results: For the CGH pain scale, comparisons of 8 and 16 treatment sessions yielded small dose effects: |AMD|≤5.6. There was an advantage for SMT over the control: AMD=−8.1 (95% confidence interval=−13.3 to −2.8) for the profile, −10.3 (−18.5 to −2.1) at 12 weeks, and −9.8 (−18.7 to −1.0) at 24 weeks. For the higher dose patients, the advantage was greater: AMD=−11.9 (−19.3 to −4.6) for the profile, −14.2 (−25.8 to −2.6) at 12 weeks, and −14.4 (−26.9 to −2.0) at 24 weeks. Patients receiving SMT were also more likely to achieve a 50% improvement in pain scale: adjusted odds ratio=3.6 (1.6 to 8.1) for the profile, 3.1 (0.9 to 9.8) at 12 weeks, and 3.1 (0.9 to 10.3) at 24 weeks. Secondary outcomes showed similar trends favoring SMT. For SMT patients, the mean number of CGH was reduced by half.Conclusions: Clinically important differences between SMT and a control intervention were observed favoring SMT. Dose effects tended to be small.

Influence of perioperative resuscitation status on postoperative spine surgery complications

2009-11-16

Abstract: Background context: Restrictive transfusion criteria have led to decreased morbidity and mortality in critically ill patients. Their use has been extended to other patient groups. In adult spine surgery, ongoing postoperative blood losses and soft-tissue trauma may make these patients not appropriate for restrictive transfusion practices.Purpose: The purpose of this study was to assess the influence of postoperative hemoglobin (HGB) level and use of packed red blood cells (pRBC) or fresh frozen plasma on postoperative patient morbidity, mortality, and hospital length of stay (LOS).Study design/setting: This was a retrospective study in a high-volume tertiary hospital.Patient sample: The sample comprised 300 consecutive patients who underwent spinal surgeries with blood losses of more than 2 L.Outcome measures: The outcome measures were postoperative patient morbidity, mortality, and LOS.Methods: The records of patients who underwent adult spinal surgeries with blood loss of 2 or more L (N=300) were abstracted for patient characteristics, operative characteristics, transfusion, and HGB level over time. Intensive care unit and hospital LOS, discharge location, death, pulmonary embolism, stroke, seizures, surgical site infections (SSI), and myocardial infarctions were noted. Logistic regression analyses (SAS software version 9.2) were used.Results: Twelve (3%) patients had a postoperative HGB level of less than 8 g/dL, 126 (41.3%) had 8 g/dL or more but less than 10 g/dL, and 167 (54.8%) had 10 g/dL or more. There was no significant difference in morbidity or mortality between the two groups with higher HGB levels. Multiple regression analysis revealed that patients with initial postoperative HGB level of less than 8 g/dL were six times more likely to develop SSI (odds ratio 6.37, 95% confidence interval 1.15–35.28). Deep SSI rates were increased with greater postoperative pRBC use (p=.002). Fresh frozen plasma use in the operation room was lower in cases that developed SSI (1.50 vs. 2.69, p=.042). Intensive care unit and ward LOS were longer with increased postoperative blood product use.Conclusion: Patients with high blood loss (more than 2 L) during spine surgery who are under-resuscitated (HGB level less than 8 g/dL) have a significant increased risk of SSI.

Lag screw fixation of remote bilateral pedicle fractures of the fourth and fifth lumbar vertebrae after a single gunshot wound: a case report and technical pearl

Kingsley R. Chin, Karen Boselli, Stephen Cairone — 2009-12-14

Abstract: Background context: Of the injuries involving the lumbar spine, pedicle fractures are among the least common; those involving bilateral pedicles are rare.Purpose: The aims of the study were to provide the first documentation of bilateral pedicle fractures at two consecutive levels after a gunshot, to review the mechanism of injury, and to evaluate a nonfusion treatment option for pedicle fractures.Study design: This is a technical note and case report.Outcome measure: The outcome measures were lumbar range of motion, return of motor and sensory functions, and return to normal activities.Methods: A 20-year-old male sustained bilateral pedicle fractures at L4 and L5 with a massive dural tear, progressive neurologic deficits, and urinary incontinence. He underwent repair of the dural tear and lag screw fixation of the pedicle fractures without fusion.Results: The patient had full range of motion of his lumbar spine, full strength in his lower extremities, and bladder control.Conclusions: This is the first report of bilateral multilevel lumbar pedicle fractures after a single penetrating gunshot wound. The case documents this injury pattern after a gunshot, reviews the mechanism of injury, and presents the successful application of a nonfusion treatment option.

A biomimetic artificial intervertebral disc system composed of a cubic three-dimensional fabric

2009-11-30

Abstract: Background context: In the quest for clinically functional artificial intervertebral discs (AIDs), multidisciplinary technologies have been employed. Existing solid mobile AIDs essentially consist of the superposition of solid plates and core materials; however, it is thought that an ideal surgical AID technology has not yet been developed. To overcome the limitation of these existing AIDs, we developed a unique flexible AID disc system on the basis of our original biomimetic concept. The AID is composed of a cubic three-dimensional fabric (3DF) with a triaxial fiber alignment, which offers biomimetic long-term dynamic mechanical behavior along with durability.Purpose: This article substantiates the potential clinical use of the 3DF disc system that quite differs from existing ones.Study design: We designed the lumbar and cervical 3DF discs that improved the structural weaknesses caused by the collagenous fiber alignment of biological intervertebral disc. Bioresorbable hydroxyapatite particles were deposited on the surface layer of the 3DF disc to promote new bony ingrowth and to ensure secure binding at the interface of the contacting vertebral bodies. A stand-alone system was devised for surgical reliability in terms of both positioning and fixation, allowing tight press fitting with the vertebral bodies. Bioactive and bioresorbable pins were penetrated through the 3DF disc body and projected from the surface to allow ideal insertion and fixation to the disc space, preserving the precise position during dynamical movement. In vitro endurance of the 3DF disc was examined under long-term alternating stresses, and the in vivo animal tests were conducted in the intervertebral lumbar discs at L5–L6 excised from baboons and replaced with the lumbar 3DF disc.Methods: The static mechanical endurance was assessed through a creep test. In vitro endurance of the 3DF disc under repetitive stresses including axial compressing, flexion-extension, torsional twisting, and lateral bending were applied to the 3DF disc for a long-term for up to 105 million stresses, which is roughly equivalent to exposure of natural biological movement for more than 50 years. In the animal test, eight baboons were euthanized 6 months postoperatively. To their extracted spines, six pure moments (flexion and extension, left and right lateral bending, and left and right torsion) were applied vertically to the superior end of the specimen and then values of range of motions (ROMs) were calculated. Histological analyses were conducted on 12 reticuloendothelial and systemic tissues.Results: The 3DF disc retained its biomimetic “J-shaped” stress-strain behavior without generating wear debris for up to 105 million stresses. A 130-N loading for the creep test decreased the height of 0.3mm during 80 to 1,000 hours. In the biomechanical test, ROM values of axial rotation and flexion-extension showed no significant difference from the intact excluding that of lateral bending because the location of each pin to stand alone certainly controlled the bending behavior only. The histological analysis indicated no significant pathologic changes induced by the 3DF disc.Conclusions: The 3DF disc system is clinically suitable for human disc replacement arthroplasty based on the findings of long-term durability with dynamic motion in vitro and effective animal tests in vivo. This system surely overcomes the limitations of existing solid AIDs, and the clinical potential of the biomimetic 3DF discs has been verified. This new biomaterial technology delivers most of the functions and characteristics required by a clinically available AID if applied correctly by surgeons.

Volumetric analysis of thoracic and lumbar vertebral bodies

Worawat Limthongkul, Eldin E. Karaikovic, Jason W. Savage, Alexander Markovic — 2010-02-01

Abstract: Background context: During the last decade, vertebral augmentation techniques with cement (kyphoplasty and vertebroplasty) have revealed that 75% to 100% of individuals with osteoporotic vertebral compression fractures have good to moderate pain relief postoperatively, as well as adequate restoration of the vertebral body height. The volume of cement injected into a vertebra varied in different reports. To our knowledge, there are no studies that report on the physiological distribution of thoracic and lumbar vertebrae body volumes.Purpose: The purpose of this study was to quantitatively evaluate thoracic and lumbar vertebral body volumes.Study design/setting: Forty computed tomography (CT) scans of the thoracic and lumbar spines were used to measure a volume of each vertebral body.Methods: Forty CT scans with standard 2.5-mm bone window cuts of the thoracic and lumbar vertebrae (20 men and 20 women) were analyzed to measure the volumetric capacity of vertebral bodies using a BrainLAB Software (iPlan RT image 4.0) program. The software was tested for validity and reliability in two pilot studies. Mean and standard deviations for each vertebral body volume were calculated and recorded. The vertebral body working distance and the so-called “safe zone” were also measured to determine a size of a balloon to be used in kyphoplasty.Results: Vertebral body volume increased gradually from T1 to L4 with the exception of L5, which measured to be smaller than L4. The mean thoracic vertebrae volume was 15.0 cm3 (ranged in the absolute values from 5.2 to 39.5 cm3), and the mean lumbar vertebrae volume was 35 cm3 (ranged in the absolute values from 19.7 to 61.5 cm3). Men had larger volume vertebral bodies only in the lumbar spine compared with women. The average vertebral body working distances from T1 to T4 was 23.4±2.7 mm, from T5 to T9 was 30.3±3.6 mm, and from T10 to L5 was 35.5±3.9 mm.Conclusions: Knowing the physiological variability of vertebral body volumes may help prevent complications as a result of underaugmentation or overaugmentation with excessive amount of cement during kyphoplasty or vertebroplasty in osteoporotic compression fractures. We recommend using 10 mm balloons from T1 to T4, 15 mm balloons from T5 to T9, and 20 mm balloons from T10 to L5 for kyphoplasty.

Effect of bupivacaine on intervertebral disc cell viability

2009-10-05

Abstract: Background context: Bupivacaine is a local anesthetic commonly used to relieve or control pain in interventional spine procedures. Bupivacaine has been shown to be toxic to articular cartilage, which has similarities to intervertebral disc (IVD) cartilage, raising concern over a potentially negative effect of bupivacaine on the disc.Purpose: To determine bupivacaine's effect on cell viability of IVD cells in vitro and to elucidate whether this is through apoptosis or necrosis.Study design: In vitro controlled study of bupivacaine effect on cell viability in human and rabbit IVD cells.Subjects: Rabbit annulus fibrosus (AF) tissue, nucleus pulposus (NP) cells, and knee articular chondrocytes were isolated from New Zealand white rabbits. Human AF and NP cells were isolated from stage 3 to 4 degenerative disc surgical specimens.Outcome measures: Cell viability was assessed after exposure to bupivacaine via trypan blue staining or flow cytometry.Methods: Annulus fibrosus and NP cells were grown in monolayer and alginate beads, respectively, to simulate their physiologic environment. The cells were then exposed to bupivacaine or saline control at 60 and 120 minutes and examined for cell viability.Results: Rabbit NP cell death demonstrated a time and dose dependence in response to bupivacaine. In addition, cell death was greater than that observed for articular chondrocytes. Rabbit AF tissue also demonstrated increased cell death in response to bupivacaine exposure. Human NP cells demonstrated time-dependent cell death, with greater necrosis than apoptosis. Annulus fibrosus cells grown in monolayers also resulted in similar effects, with greater necrosis rather than apoptosis.Conclusions: Despite its pain relieving properties, bupivacaine decreases cell viability in rabbit and human disc cells in a time-dependent manner. In addition, the changes observed are greater than that seen for articular chondrocytes. This increase in cell death appears to be related to an increase in necrosis rather than apoptosis. Whether bupivacaine exerts similar effects in vivo or how this relates to overall clinical outcome remains to be explored.

Outcomes of lumbar discectomy

Jon D. Lurie — 2009-12-17

COMMENTARY ON: Sherman J, Cauthen J, Schoenberg D, et al. Economic impact of improving outcomes of lumbar discectomy. Spine J 2010;10:108–116 (in this issue).

Choosing a treatment for cervicogenic headache: when? what? how much?

Scott Haldeman, Simon Dagenais — 2009-12-11

COMMENTARY ON: Haas M, Spegman A, Peterson D, et al. Dose-response and efficacy of spinal manipulation for chronic cervicogenic headache: a pilot randomized controlled trial. Spine J 2010;10:117–128 (in this issue).

Effect of bupivacaine on chondrocyte viability

Jason L. Dragoo, Stephanie Y. Pun — 2010-02-01

COMMENTARY ON: Lee H, Sowa G, Vo N, et al. Effect of bupivacaine on intervertebral disc cell viability. Spine J 2010;10:159–166 (in this issue).

Effect of circumferential constraint on nucleus pulposus tissue in vitro

Darla J. Hamilton, Robert M. Pilliar, Stephen Waldman, Rita A. Kandel — 2009-12-14

Abstract: Background context: Degeneration of the intervertebral disc (IVD) involves structural changes in the annulus fibrosus (AF), which could alter the mechanical forces imposed on the nucleus pulposus (NP) tissue. This could contribute to degenerative changes that occur in the NP.Purpose: The purpose of the study was to determine whether circumferential constraint affects anabolic and catabolic gene expression, biochemical composition, and mechanical properties of NP tissue.Study design: Nucleus pulposus cells were isolated from bovine caudal IVD and allowed to form tissue for a period of two weeks. The effect of no, intermediate, or high circumferential constraint on biochemical composition (cellularity and proteoglycan and collagen synthesis), gene expression, and compressive mechanical properties was evaluated.Results: Increasing the rigidity of circumferential constraint surrounding in vitro formed NP tissue resulted in decreased gene expression of aggrecan and type II collagen and increased expression of MMP-1 and ADAMTS-5. This was associated with decreased accumulation of extracellular matrix and a deterioration of the compressive mechanical properties of the tissue.Conclusions: As increased circumferential constraint can have a significant negative effect on the composition and quality of NP tissue and this raises the possibility that the AF may contribute to the degenerative or age-related alterations that occur in the NP. Further study in a functional spinal unit is required to validate this.

A randomized trial of vertebroplasty for osteoporotic spinal fractures. Kallmes DF, Comstock BA, Heagerty PJ, et al. N Engl J Med. 2009;361(6): 569–79

2010-02-01

BACKGROUND: Vertebroplasty is commonly used to treat painful, osteoporotic vertebral compression fractures. METHODS: In this multicenter trial, we randomly assigned 131 patients who had one to three painful osteoporotic vertebral compression fractures to undergo either vertebroplasty or a simulated procedure without cement (control group). The primary outcomes were scores on the modified Roland-Morris Disability Questionnaire (RDQ) (on a scale of 0 to 23, with higher scores indicating greater disability) and patients' ratings of average pain intensity during the preceding 24hours at 1 month (on a scale of 0 to 10, with higher scores indicating more severe pain). Patients were allowed to cross over to the other study group after 1 month.

A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. Buchbinder R, Osborne RH, Ebeling PR, et al. N Engl J Med 2009;361(6):557–68

2010-02-01

BACKGROUND: Vertebroplasty has become a common treatment for painful osteoporotic vertebral fractures, but there is limited evidence to support its use. METHODS: We performed a multicenter, randomized, double-blind, placebo-controlled trial in which participants with one or two painful osteoporotic vertebral fractures that were of less than 12 months' duration and unhealed, as confirmed by magnetic resonance imaging, were randomly assigned to undergo vertebroplasty or a sham procedure. Participants were stratified according to treatment center, sex, and duration of symptoms (< 6 weeks or > or = 6 weeks). Outcomes were assessed at 1 week and at 1, 3, and 6 months. The primary outcome was overall pain (on a scale of 0 to 10, with 10 being the maximum imaginable pain) at 3 months.

Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Wardlaw D, Cummings SR, Van Meirhaeghe J, et al. Lancet. 2009;373(9668):1016–24

2010-02-01

BACKGROUND: Balloon kyphoplasty is a minimally invasive procedure for the treatment of painful vertebral fractures, which is intended to reduce pain and improve quality of life. We assessed the efficacy and safety of the procedure.

Corticosteroids in peri-radicular infiltration for radicular pain: a randomised double blind controlled trial. One year results and subgroup analysis. Tafazal S, Ng L, Chaudhary N, Sell P. Eur Spine J 2009;18(8):1220–5

2010-02-01

The objective of this study is to evaluate the efficacy of corticosteroids in patients with radicular pain due to lumbar disc herniation or lumbar spinal stenosis through a prospective randomised, double blind controlled trial, and whether there was an effect on subsequent interventions such as additional root blocks or surgery. Peri-radicular infiltration of corticosteroids has previously been shown to offer no additional benefit in patients with sciatica compared to local anaesthetic alone. It is not known if the response to peri-radicular infiltration is less marked in certain subgroups of patients such as those with radicular pain due to lumbar spinal stenosis. Previous studies have suggested that peri-radicular infiltration of corticosteroids may obviate the need for subsequent interventions and we therefore further investigated this in the current study. We randomised 150 patients to receive a single injection with either bupivacaine alone or bupivacaine and methylprednisolone. Patients were assessed at 6 weeks and 3 months after the injection using standard outcome measures including Oswestry Disability Index (ODI), visual analogue score for leg pain and patient's subjective assessment of outcome. At 1-year follow-up, we looked at the outcome in terms of the need for subsequent interventions such as additional root blocks or surgery. At 3-month follow-up, there was no statistically significant difference in the standard outcome measures between the two injection groups. At a minimum 1-year post injection, there was no difference in the need for subsequent interventions in either group. Patients with lumbar spinal stenosis had a less marked reduction in the ODI at 3 months with a mean change of 3.3 points when compared with 15 points for patients with lumbar disc herniation. In conclusion, peri-radicular infiltration of corticosteroids for sciatica does not provide any additional benefit when compared to local anaesthetic injection alone. Corticosteroids do not obviate the need for subsequent interventions such as additional root blocks or surgery.

Value of diagnostic lumbar selective nerve root block: a prospective controlled study. Yeom JS, Lee JW, Park KW, et al. AJNR Am J Neuroradiol 2008;29(5):1017–23

2010-02-01

BACKGROUND AND PURPOSE: Although diagnostic lumbar selective nerve root blocks are often used to confirm the pain-generating nerve root level, the reported accuracy of these blocks has been variable and their usefulness is controversial. The purpose of this study was to evaluate the accuracy of diagnostic lumbar selective nerve root blocks to analyze potential causes of false results in a prospective, controlled, single-blinded manner.

Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Cohen SP, Hurley RW, Buckenmaier CC 3rd, Kurihara C, Morlando B, Dragovich A. Anesthesiology 2008;109(2):279–88

2010-02-01

BACKGROUND: Sacroiliac joint pain is a challenging condition accounting for approximately 20% of cases of chronic low back pain. Currently, there are no effective long-term treatment options for sacroiliac joint pain.

Cost effectiveness of two rehabilitation programmes for neck and back pain patients: A seven year follow-up. Jensen IB, Busch H, Bodin L, Hagberg J, Nygren A, Bergström G. Pain 2009;142(3): 202–8

2010-02-01

The cost effectiveness of work-oriented rehabilitation for persons on long-term sick leave needs to be assessed. This prospective observational study presents a follow-up seven years after rehabilitation using two different evidence-based work-oriented regimens. Individuals on sick leave for neck and back pain were referred to two rehabilitation programmes in Sweden. The first programme was a relatively low-intensity programme based on orthopaedic manual therapy and exercise programme (OMTP). The second programme was a full-time multidisciplinary programme (MDP). The primary outcome was sickness absence seven years after intervention. Cost effectiveness was calculated on the basis of loss of production due to sickness absence. The results show that participants referred to MDP and with less than 60 sick days before rehabilitation have reduced sickness absence after intervention as compared to matched controls. This corresponds to a cost reduction of about 94,494 EUR per referred individual. Further, the results indicate that participants of the OMTP who have more than 60 sick days before rehabilitation have a statistically significant increased risk of disability pension. This means increased cost in terms of loss of production of 44,593 EUR per referred individual. The results of this study show that MPD but not OMTP achieves the goal of working life-oriented rehabilitation. A direct comparison between the rehabilitation programmes strengthened the assumption that long-term sickness absence prior to rehabilitation is associated with more days on sick leave after rehabilitation. This analysis also indicated the importance of participants' pain self-efficacy beliefs and recovery beliefs on rehabilitation outcome.

Opioid therapy for nonspecific low back pain and the outcome of chronic work loss. Volinn E, Fargo JD, Fine PG. Pain 2009;142(3):194–201

2010-02-01

Outcomes of opioid therapy for noncancer pain remain to be more fully explored. Loss of work is among these outcomes. Especially when work loss becomes “chronic” (persists >or=90 days), it has profound psycho-social repercussions that compound suffering of those already in pain. Furthermore, costs escalate as work loss persists. We thus explored associations between opioid therapy for back pain and chronic work loss. Data consisted of workers compensation claims for nonspecific low back pain. We used multivariate analyses to control for diverse covariates. Workers with no opioid prescriptions constituted the reference group. Findings included the following: compared with the (no opioid) reference group, odds of chronic work loss were six times greater for claimants with schedule II ("strong") opioids; compared with the reference group, odds of chronic work loss were 11-14 times greater for claimants with opioid prescriptions of any type during a period of >or=90 days; and three years after injury, costs of claimants with schedule II opioids averaged $19,453 higher than costs of claimants in the reference group. Our analysis was not designed to ascertain antecedent causes, or why chronic work loss occurred in the first place. Rather, we focused on an ensuing consequence of opioid therapy, i.e., the outcome of chronic work loss, which occurred far removed in time (>or=90 days) after the worker's recorded date of back injury. The strong associations observed suggest that for most workers opioid therapy did not arrest the cycle of work loss and pain.

Aggressive end plate decortication as a cause of osteolysis after rhBMP-2 use in cervical spine interbody fusion

Tomislav Smoljanovic, Mislav Cimic, Ivan Bojanic — 2010-02-01

Drs. Klimo and Peelle presented 22 patients in whom 38 cervical levels were fused using polyetheretherketone spacers and varying doses of recombinant human bone morphogenetic protein-2 (rhBMP-2) (from 2.1 mg per level, then 1.4 mg per level, and finally 1.1 mg per level). All patients underwent detailed postoperative radiologic analysis using a computed tomography scan obtained at least 6 months postoperatively and plain X-rays obtained at regular intervals. Moderate or severe osteolysis of the end plates occurred in 57% of levels, and this led to subsidence of the construct and loss of some of the segmental sagittal alignment.

Reply

Paul Klimo, Michael W. Peelle — 2010-02-01

We appreciate the insightful thoughts of the authors and the opportunity to offer our ideas regarding these unresolved issues. First, to clarify the quoted 57% end-plate resorption rate, we want to emphasize that this was a subgroup of patients who demonstrated moderate-to-severe end-plate resorption with graft subsidence. We observed that nearly all the remaining patients demonstrated lesser degrees of osteolysis of the end plates, which appears concordant to the findings of Meisel and Vaidya et al.; because no significant sequela was noted from mild osteolysis, it was not emphasized in the paper.

Meetings Calendar

2010-02-01

High-dose bone morphogenetic protein–induced ectopic abdomen bone growth

Harel Deutsch — 2009-12-14

Abstract: Background context: Infuse [bone morphogenetic protein (BMP)] is increasingly used in spinal fusion surgery.Purpose: The authors report a rare complication of BMP use.Study design: This is a case report.Patient sample: A 55-year-old male underwent a thoracic T8 to the pelvis fusion for degenerative lumbar disc disease and pseudarthrosis at another institution. The procedure involved an anterior and posterior approach with the use of multiple units of BMP.Methods: The patient presented to our institution with complaints of weight loss, pain, tenderness, and increasing solid growth in the left lower quadrant several months after his surgery. A computed tomography revealed ectopic bone growth in the retroperitoneal area and pelvis contiguous to the anterior lumbar exposure.Results: The anterior wound was reexplored, and a large sheet of ectopic bone was removed from the retroperitoneal space.Conclusions: We report a rare case of extraspinal ectopic bone growth because of the use of multiple packages of BMP.

An unusual occurrence of chondromyxoid fibroma with secondary aneurysmal bone cyst in the cervical spine

2009-12-28

Abstract: Background context: Chondromyxoid fibroma (CMF) and aneurysmal bone cysts (ABCs) are rare bone tumors and even rarer in the spine. To date, no report has been made of CMF with secondary ABC in the cervical spine.Purpose: The purpose of this study was to describe the diagnosis and surgical treatment of a case of CMF with secondary ABC of C6, a rare occurrence in an uncommon location.Study design: The study design is a case report.Methods: A 27-year-old woman presented with numbness with paresthesias of the right upper extremity. Diagnostic imaging revealed diffuse enlargement of the right C6 lamina extending into the pedicle and medial facet joint. Surgical treatment consisted of complete C6 laminectomy, total resection of the extradural cervical mass, posterior lateral fusion at C5–C7, and posterior segmental instrumentation from C5 to C7. Histopathology was consistent with CMF with secondary ABC.Results: Laminectomy and instrumented segmental fusion provided an excellent clinical outcome. The instrumented fusion maintained the sagittal balance of the spine and stabilized across a complete facetectomy. The excision will likely avoid recurrence of the lesion.Conclusions: Treatment of CMF and ABC is challenging in the spine because of the proximity to neural structures. Aggressive surgical treatment makes recurrence less likely but creates the risk of spinal instability. Adequate surgical treatment needs to provide spinal stability.

Pediatric transverse sacral fracture with cauda equina syndrome

Ashwin Avadhani, Ajoy P. Shetty, S. Rajasekaran — 2009-12-28

Abstract: Background context: Transverse sacral fracture in pediatric patients is extremely uncommon with only nine cases reported in literature so far.Purpose: The purpose of this study was to heighten awareness and treatment options of a rare injury of traumatic pediatric transverse sacral fracture with cauda equina syndrome.Study design: This is a clinical case report and literature review.Methods: We report a case of a 13-year-old girl with a Type III Roy-Camille, Zone III Denis sacral fracture whose only neurological deficit was a cauda equina syndrome with bowel and bladder involvement. She underwent emergent sacral laminectomy and surgical stabilization to decompress the cauda equina.Results: The patient regained bowel and bladder function at 6-month follow-up.Conclusions: This case is presented to highlight the rarity of a pediatric transverse sacral fracture, which requires a high index of suspicion as early decompression helps in reversing the neurological deficit.

Editorial Board

2010-02-01

The Spine Journal

Dream from our President: Barack Obama and evidence-based medicine

Economic impact of improving outcomes of lumbar discectomy

Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: a pilot randomized controlled trial

Influence of perioperative resuscitation status on postoperative spine surgery complications

Lag screw fixation of remote bilateral pedicle fractures of the fourth and fifth lumbar vertebrae after a single gunshot wound: a case report and technical pearl

A biomimetic artificial intervertebral disc system composed of a cubic three-dimensional fabric

Volumetric analysis of thoracic and lumbar vertebral bodies

Effect of bupivacaine on intervertebral disc cell viability

Outcomes of lumbar discectomy

Choosing a treatment for cervicogenic headache: when? what? how much?

Effect of bupivacaine on chondrocyte viability

Effect of circumferential constraint on nucleus pulposus tissue in vitro

A randomized trial of vertebroplasty for osteoporotic spinal fractures. Kallmes DF, Comstock BA, Heagerty PJ, et al. N Engl J Med. 2009;361(6): 569–79

A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. Buchbinder R, Osborne RH, Ebeling PR, et al. N Engl J Med 2009;361(6):557–68

Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Wardlaw D, Cummings SR, Van Meirhaeghe J, et al. Lancet. 2009;373(9668):1016–24

Corticosteroids in peri-radicular infiltration for radicular pain: a randomised double blind controlled trial. One year results and subgroup analysis. Tafazal S, Ng L, Chaudhary N, Sell P. Eur Spine J 2009;18(8):1220–5

Value of diagnostic lumbar selective nerve root block: a prospective controlled study. Yeom JS, Lee JW, Park KW, et al. AJNR Am J Neuroradiol 2008;29(5):1017–23

Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Cohen SP, Hurley RW, Buckenmaier CC 3rd, Kurihara C, Morlando B, Dragovich A. Anesthesiology 2008;109(2):279–88

Cost effectiveness of two rehabilitation programmes for neck and back pain patients: A seven year follow-up. Jensen IB, Busch H, Bodin L, Hagberg J, Nygren A, Bergström G. Pain 2009;142(3): 202–8

Opioid therapy for nonspecific low back pain and the outcome of chronic work loss. Volinn E, Fargo JD, Fine PG. Pain 2009;142(3):194–201

Aggressive end plate decortication as a cause of osteolysis after rhBMP-2 use in cervical spine interbody fusion

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High-dose bone morphogenetic protein–induced ectopic abdomen bone growth

An unusual occurrence of chondromyxoid fibroma with secondary aneurysmal bone cyst in the cervical spine

Pediatric transverse sacral fracture with cauda equina syndrome

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