The Spine Journal - Articles in Press

Predictors of low back pain in physically active conscripts with special emphasis on muscular fitness - Corrected Proof

2012-02-02

Abstract: Background context: Association between low physical fitness and low back pain (LBP) is contradictory in previous studies.Purpose: The objective of the present prospective cohort study was to investigate the predictive associations of various intrinsic risk factors in young conscripts for LBP, with special attention to physical fitness.Study design: A prospective cohort study.Patient sample: A representative sample of Finnish male conscripts. In Finland, military service is compulsory for male citizens and 90% of young men enter into the service.Outcome measures: Incidence of LBP and recurrent LBP prompting a visit at the garrison health clinic during 6-month military training.Methods: Four successive cohorts of 18- to 28-year-old male conscripts (N=982) were followed for 6 months. Conscripts with incidence of LBP were identified and treated at the garrison clinic. Predictive associations between intrinsic risk factors and LBP were examined using multivariate Cox proportional hazard models.Results: The cumulative incidence of LBP was 16%, the incidence rate being 1.2 (95% confidence interval [CI], 1.0–1.4) per 1,000 person-days. Conscripts with low educational level had increased risk for incidence of LBP (hazard ratio [HR], 1.6; 95% CI, 1.1–2.3). Conscripts with low dynamic trunk muscle endurance and low aerobic endurance simultaneously (ie, having coimpairment) at baseline also had an increased risk for incidence of LBP. The strongest risk factor was coimpairment of trunk muscular endurance in tests of back lift and push-up (HR, 2.8; 95% CI, 1.4–5.9).Conclusions: The increased risk for LBP was observed among young men who had a low educational level and poor fitness level in both muscular and aerobic performance.

Risk factors for medical complication after spine surgery: a multivariate analysis of 1,591 patients - Corrected Proof

2012-01-16

Abstract: Background context: Several studies have examined the occurrence of medical complication after spine surgery. However, many of these studies have been done using large national databases. Although these allow for analysis of thousands of patients, potentially influential covariates are not accounted for in these retrospective studies. Furthermore, the accuracy of these retrospective data collection in these databases has been called into question.Purpose: Using multivariate analysis on a prospectively collected data registry to determine significant risk factors for medical complication after spine surgery.Study design: Retrospective multivariate analysis of prospectively collected registry data. The registry is a prospectively collected database of all patients who underwent spine surgery in our two institutions from January 1, 2003 to December 31, 2004.Methods: Extensive demographic and medical information were prospectively recorded as described previously by Mirza et al. Complications were defined in detail a priori, and they were prospectively recorded for at least 2 years after surgery. We analyzed risk factors for medical complication after spine surgery using univariate and multivariate analyses.Results: We analyzed data from 1,591 patients who met out inclusion criteria. The cumulative incidences of complication after spine surgery per organ system are as follows: cardiac, 8.4%; pulmonary, 13%; gastrointestinal, 3.9%; neurological, 7.35%; hematological, 10.75%; and urological complications, 9.18%. The occurrence of cardiac or respiratory complication after spine surgery was significantly associated with death within 2 years (relative risk, 4.11 and 10.76, respectively). Surgical invasiveness and age were significant risk factors for complications in five of the six organ systems evaluated. Individual organ system-specific elative risk values with 95% confidence intervals and p values are listed in Tables 3 and 4.Conclusions: Risk factors identified in this study can be beneficial to clinicians and patients alike when considering surgical treatment of the spine. Future analyses and models that predict the occurrence of medical complication after spine surgery may be of further benefit for surgical decision making.

Impact of coexistent lumbar spine disorders on clinical outcomes and physician charges associated with total hip arthroplasty - Corrected Proof

2012-01-09

Abstract: Background context: Despite the common prevalence of lumbar spine and degenerative hip disorders, there are few descriptions of patients with coexisting hip disorders and lumbar spine disorders (LSDs). The independent economic burden of each disorder is substantial, but the financial burden when the disorders are coexisting is unknown.Purpose: To determine the prevalence of coexisting hip disorders and LSDs in a large cohort of patients with hip osteoarthritis (OA) treated with total hip arthroplasty (THA) as well as the impact on pain and functional THA outcomes and physician charges.Study design: This is a retrospective study performed at a tertiary university.Patient sample: Three thousand two hundred six patients underwent total hip replacement from 1996 to 2008.Outcome measures: Self-report measures: visual analog scale. Functional measures: modified Harris Hip Score (mHHS) and University of California Los Angeles (UCLA) hip questionnaire. Economic impact measures: physician medical charges.Methods: International Classification of Diseases, Version 9, billing codes related to LSDs were cross-referenced with the 3,206 patients who had undergone a THA to determine which patients were also evaluated by a spine specialist. Demographic, hip clinical outcomes, and physician charges for patients with THA alone (THA alone) were compared with patients treated with THA and diagnosed with an LSD (THA+LSD).Results: Of 3,206 patients who underwent THA, 566 (18%) were also evaluated by a spine specialist. Of those with an LSD, 334 (59%) were women with an older average age (64.5±13.3 years) compared with patients treated with THA alone (51%, 58.5±15.5 years, p=.0001). Patients in the THA alone group as compared with the THA+LSD group had greater improvement in the mHHS (p=.0001), UCLA score (p=.0001), and pain (p=.0001). Patients in the THA+LSD group incurred on average $2,668 more in charges per episode of care as compared with patients in the THA alone group (p<.001). Patients in the THA+LSD group had more days per episode of care (p=.001).Conclusions: Patients undergoing THA alone had greater improvement in function and pain relief with fewer medical charges as compared with patients undergoing a THA and treatment for an LSD. The prevalence of coexisting hip disorders and spine disorders is likely higher than currently documented. Further study is needed to improve therapeutic recommendations and determine the potential for reduction in medical expenses associated with concurrent treatment of hip OA and LSDs.

Predictors of short-term work-related disability among active duty US Navy personnel: a cohort study in patients with acute and subacute low back pain - Corrected Proof

2012-01-09

Abstract: Background context: Musculoskeletal disorders of the spine in the US military account for the single largest proportion of the absence of sickness causes leading to early termination. We explored if selected psychological and physical factors were associated with poor outcome after episodes of low back pain (LBP).Purpose: To identify clinical, demographic, and psychological factors predictive of work duty status after a complaint of LBP.Study design: A prospective clinical cohort of US Navy personnel treated for LBP.Patient sample: Eligible cases were active duty US Navy or Marine Corps personnel presenting to an emergency clinic or primary care clinic with a complaint of LBP, where the index episode of LBP was no more than 12 weeks duration before enrollment.Outcome measures: The subject’s work status (full duty, light duty, sick in quarters [SIQ], limited duty, or medically released to full duty) was abstracted from the subject’s electronic medical record at approximately 4 weeks and then again 12 weeks after study enrollment. Work status in this study population is assigned by a Navy health-care provider at the time of a clinical visit and based on the health-care provider’s determination of medical fitness for duty. This study collapsed work status into two groups, “full duty” (consisting of “full duty” and “medically released to full duty”) and “not at full duty” (consisting of “light duty,” “SIQ,” and “limited duty”).Methods: Volunteers completed a baseline questionnaire consisting of recommended well-validated measures, including attitudes and beliefs about LBP and work (Fear-Avoidance Beliefs Questionnaire [FABQ] and the Tampa Scale of Kinesiophobia), distress (the Pain Catastrophizing Scale), clinical depression (The Center for Epidemiologic Studies Depression scale), a numeric pain intensity scale, self-perceived disability (Oswestry Disability Index), and general health status (12-Item Short Form Health Survey). Navy health-care providers conducted a back pain–specific medical evaluation. Associations are expressed as multivariate-adjusted prevalence ratios (PRs) estimated using Poisson regression.Results: Two hundred fifty-three participants were enrolled. Work status outcome was collected for 239 participants. Predictors of “not at full duty” at 4 weeks after enrollment included having back pain for 4 weeks or less before study enrollment (PR, 2.69; 95% CI, 1.21–5.97) and increased FABQ Work subscale score (PR, 1.05; 95% CI, 1.01–1.08). The sole predictor of work status at 12 weeks after enrollment was increased FABQ Physical Activity (FABQ Physical) subscale score (PR=1.14; 95% CI, 1.00–1.30).Conclusions: The findings that fear-avoidance beliefs were predictive of subsequent work status among active duty service personnel in this study population (after adjusting for clinical, demographic, and psychological covariates) suggest the clinical utility of addressing these factors during treatment of back pain episodes in the military. These findings reflect the important role that psychological factors may play in the return to work process in an active duty military population.

Quantification of walking ability in subjects with neurogenic claudication from lumbar spinal stenosis—a comparative study - Corrected Proof

2012-01-03

Abstract: Background context: Walking limitations caused by neurogenic claudication (NC) are typically assessed with self-reported measures, although objective evaluation of walking using motorized treadmill test (MTT) or self-paced walking test (SPWT) has periodically appeared in the lumbar spinal stenosis (LSS) literature.Purpose: This study compared the validity and responsiveness of MTT and SPWT for assessing walking ability before and after common treatments for NC.Study design: Prospective observational cohort study.Patient sample: Fifty adults were recruited from an urban spine center if they had LSS and substantial walking limitations from NC and were scheduled to undergo surgery (20%) or conservative treatment (80%).Outcome measures: Walking times, distances, and speeds along with the characteristics of NC symptoms were recorded for MTT and SPWT. Self-reported measures included back and leg pain intensity assessed with 0 to 10 numeric pain scales, disability assessed with Oswestry Disability Index, walking ability assessed with estimated walking times and distances, and NC symptoms assessed with the subscales from the Spinal Stenosis Questionnaires.Methods: Motorized treadmill test used a level track, and SPWT was conducted in a rectangular hallway. Walking speeds were self-selected, and test end points were NC, fatigue, or completion of the 30-minute test protocol. Results from MTT and SPWT were compared with each other and self-reported measures. Internal responsiveness was assessed by comparing changes in the initial results with the posttreatment results and external responsiveness by comparing walking test results that improved with those that did not improve by self-reported criteria.Results: Mean age of the participants was 68 years, and 58% were male. Neurogenic claudication included leg pain (88%) and buttock(s) pain (12%). Five participants could not safely perform MTT. Walking speeds were faster and distances were greater with SPWT, although the results from both tests correlated with each other and self-reported measures. Of the participants, 72% reported improvement after treatment, which was confirmed by significant mean differences in self-reported measures. Motorized treadmill test results did not demonstrate internal responsiveness to change in clinical status after treatment but SPWT results did, with increased mean walking times (6 minutes) and distances (387 m). When responsiveness was assessed against external criterion, both SPWT and MTT demonstrated substantial divergence with self-reported changes in clinical status and alternative outcome measures.Conclusions: Both MTT and SPWT can quantify walking abilities in NC. As outcome tools, SPWT demonstrated better internal responsiveness than MTT, but neither test demonstrated adequate external responsiveness. Neither test should be considered as a meaningful substitution for disease-specific measures of function.

Wartime spine injuries: understanding the improvised explosive device and biophysics of blast trauma - Corrected Proof

Daniel G. Kang, Ronald A. Lehman, Eugene J. Carragee — 2011-12-26

Abstract: The improvised explosive device (IED) has been the most significant threat by terrorists worldwide. Blast trauma has produced a wide pattern of combat spinal column injuries not commonly experienced in the civilian community. Unfortunately, explosion-related injuries have also become a widespread reality of civilian life throughout the world, and civilian medical providers who are involved in emergency trauma care must be prepared to manage casualties from terrorist attacks using high-energy explosive devices. Treatment decisions for complex spine injuries after blast trauma require special planning, taking into consideration many different factors and the complicated multiple organ system injuries not normally experienced at most civilian trauma centers. Therefore, an understanding about the effects of blast trauma by spine surgeons in the community has become imperative, as the battlefield has been brought closer to home in many countries through domestic terrorism and mass casualty situations, with the lines blurred between military and civilian trauma. We set out to provide the spine surgeon with a brief overview on the use of IEDs for terrorism and the current conflicts in Iraq and Afghanistan and also a perspective on the biophysics of blast trauma.

Dynamic changes of elasticity, cross-sectional area, and fat infiltration of multifidus at different postures in men with chronic low back pain - Corrected Proof

2011-12-26

Abstract: Background Context: Multifidus cross-sectional area was often measured in chronic low back pain (LBP) patients to estimate the muscle activity for spinal stability. However, such estimation may be inadequate as the contribution of muscle elasticity in muscle activity is ignored. In vivo quantitative data on multifidus elasticity is therefore important for the study of muscle contractile function in response to motor control for spinal stability in chronic LBP patients.Purpose: The purpose of this study was to quantify the elasticity, cross-sectional area, and fat area of the multifidus for the contractile function and the distribution of deformable muscle tissue and nondeformable fat tissue at different postures in patients with and without chronic LBP.Study Design/Setting: This is a prospective study. Force-deformation data of the multifidus were acquired using ultrasound elastography. The anatomical changes of the multifidus were measured on the cross-sectional images of the multifidus acquired using B-mode ultrasound imaging.Patient Sample: The sample comprised 12 adult male patients with chronic LBP and 12 asymptomatic male controls.Outcome Measures: The outcome measure was the elasticity of the multifidus at the L4 level for the assessment of muscle contractile function when patients were in the prone, upright, and 25° and 45° forward stooping positions. The cross-sectional area and fat area were also measured on the B-mode ultrasound images of the multifidus acquired at the same vertebral level and the postures.Methods: With the patients in each of the prone, upright, and 25° and 45° forward stooping positions, ultrasound elastography and B-mode ultrasound imaging were performed on the left and right multifidus at the L4 level. The elasticity of multifidus indicated by the effective Young’s modulus was derived from the force-deformation data acquired using ultrasound elastography. The cross-sectional area and fat area were assessed on the B-mode ultrasound images. The effective Young’s modulus, cross-sectional area, and fat area were analyzed with multivariate general linear model analysis to investigate the possible effects of LBP and posture.Results: There was an increasing stiffness of multifidus demonstrated by increasing effective Young’s modulus from the prone to upright position and 25° and 45° forward stooping positions. Differences in multifidus stiffness between chronic LBP patients and asymptomatic controls were shown in the upright and 25° and 45° forward stooping positions but not in the prone position. The cross-sectional area of the multifidus increased from the prone position to the greatest value in the upright position and decreased in 25° and 45° forward stooping positions. Smaller multifidus cross-sectional area was demonstrated in chronic LBP patients than that in controls at all postures. No effect of posture on fat area within the multifidus was shown although the fat area within the multifidus was larger in chronic LBP patients.Conclusions: Different, changing patterns of elasticity and cross-sectional area were identified in the multifidus in relation to posture. Increased stiffness of multifidus in response to the physiologic range of static loads and smaller cross-sectional area was characterized in the chronic LBP condition for spinal stability. Ultrasound elastography offers in vivo assessment of muscle contractile function of deep trunk muscles, which benefits the future investigation of the neuromuscular regulating mechanism in LBP. It can also be applied to refine the palpatory skill for the physical assessment in sports training and physical therapy.

Health-related quality of life and comorbidities associated with lumbar spinal stenosis - Corrected Proof

Michele C. Battié, C. Allyson Jones, Donald P. Schopflocher, Richard W. Hu — 2011-12-23

Abstract: Background context: Spinal stenosis is one of the most commonly diagnosed pathologies of the lumbar spine and the leading indication for spine surgery in adults aged 65 years and older. Yet, the burden of lumbar spinal stenosis (LSS) alone, and in combination with common comorbidities, on health-related quality of life (HRQL) is unknown as are comorbidities specifically associated with this chronic condition.Purpose: To estimate the illness burden of LSS on HRQL, adjusting for the effects of specific comorbidities, age, and gender, and investigate whether specific comorbidities are associated with the condition.Study design/setting: A community-based cohort of 245 patients diagnosed with LSS was assembled and compared with a representative sample of 7,489 adults from the base population of Albertans responding to the Canadian Community Health Survey on HRQL and comorbidities.Methods: Health-related quality-of-life data were acquired through interviews for both groups using the Health Utilities Index Mark 3 (HUI3). Both groups were also queried about the presence of 13 specific chronic conditions. Linear regression was used to model HUI3 scores as a function of group, age, gender, and specific comorbid conditions. Logistic regression was used to compare the odds of having particular comorbid conditions between the LSS and general population groups.Results: The mean unadjusted overall HUI3 scores were 0.60 for the LSS group and 0.85 for the general population (1=perfect health). After adjustment, HRQL deficits four times that deemed a clinically important difference remained between the groups. Controlling age and gender, the prevalence of arthritis, migraines, hypertension, and incontinence was significantly greater in the LSS group as compared with the general population sample.Conclusions: Diagnosed LSS is associated with a very substantial burden of illness that is compounded by associated comorbidities, with implications for clinical care, health-care policy decisions, and research. Attention to comorbidities is particularly important in LSS.

Repeat surgery after lumbar decompression for herniated disc: the quality implications of hospital and surgeon variation - Corrected Proof

2011-12-23

Abstract: Background context: Repeat lumbar spine surgery is generally an undesirable outcome. Variation in repeat surgery rates may be because of patient characteristics, disease severity, or hospital- and surgeon-related factors. However, little is known about population-level variation in reoperation rates.Purpose: To examine hospital- and surgeon-level variation in reoperation rates after lumbar herniated disc surgery and to relate these to published benchmarks.Study design/setting: Retrospective analysis of a discharge registry including all nonfederal hospitals in Washington State.Methods: We identified adults who underwent an initial inpatient lumbar decompression for herniated disc from 1997 to 2007. We then performed generalized linear mixed-effect logistic regressions, controlling for patient characteristics and comorbidity, to examine the variation in reoperation rates within 90 days, 1 year, and 4 years.Results: Our cohort included 29,529 patients with a mean age of 47.5 years, 61% privately insured, and 15% having any comorbidity. The age-, sex-, insurance-, and comorbidity-adjusted mean rate of reoperation among hospitals was 1.9% at 90 days (95% confidence interval [CI], 1.2–3.1), with a range from 1.1% to 3.4%; 6.4% at 1 year (95% CI, 3.9–10.6), with a range from 2.8% to 12.5%; and 13.8% at 4 years (95% CI, 8.8–19.8), with a range from 8.1% to 24.5%. The adjusted mean reoperation rates of surgeons were 1.9% at 90 days (95% CI, 1.4–2.4) with a range from 1.2% to 4.6%, 6.1% at 1 year (95% CI, 4.8–7.7) with a range from 4.3% to 10.5%, and 13.2% at 4 years (95% CI, 11.3–15.5) with a range from 10.0% to 19.3%. Multilevel random-effect models suggested that variation across surgeons was greater than that of hospitals and that this effect increased with long-term outcomes.Conclusions: Even after adjusting for patient demographics and comorbidity, we observed a large variation in reoperation rates across hospitals and surgeons after lumbar discectomy, a relatively simple spinal procedure. These findings suggest uncertainty about indications for repeat surgery, variations in perioperative care, or variations in quality of care.

The effect of vehicle protection on spine injuries in military conflict - Corrected Proof

2011-12-19

Abstract: Background context: To evaluate the effect of critical time periods in vehicle protection on spine injuries in the Global War on Terror.Purpose: To characterize the effect of method of movement on and around the battlefield during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2009 in terms of its impact on the incidence and severity of spinal fractures sustained in combat.Study design/setting: Retrospective study.Patient sample: Mounted and dismounted American servicemembers who were injured during combat.Methods: Extracted medical records of servicemembers identified in the Joint Theater Trauma Registry from October 2001 to December 2009. Methods of movement were defined as mounted or dismounted. Two time periods were compared. Cohorts were created for 2×2 analysis based on method of movement and the time period in which the injury occurred. Time period 1 and 2 were separated by April 1, 2007, which correlates with the initial fielding of the modern class of uparmored fighting vehicles with thickened underbelly armor and a V-shaped hull. Our four comparison groups were Dismounted in Time Period 1 (D1), Dismounted in Time Period 2 (D2), Mounted in Time Period 1 (M1), and Mounted in Time Period 2 (M2).Results: In total, 1,819 spine fractures occurred over the entire study period. Four hundred seventy-two fractures (26%) were sustained in 145 servicemembers who were mounted at the time of injury, and 1,347 (74%) were sustained by 404 servicemembers who were dismounted (p<.0005). The incidence of fractures in the dismounted cohort (D1+D2) was significantly higher than in the mounted cohort (M1+M2) in both time periods (D1 vs. M1, 13.75 vs. 3.95/10,000 warrior-years [p<.001] and D2 vs. M2, 11.15 vs. 4.89/10,000 warrior-years [p<.0001]). In both the mounted and dismounted groups, the thoracolumbar (TL) junction was the most common site of injury (36.1%). Fractures to the TL junction (T10–L3) increased significantly from Time Period 1 to 2 (34% vs. 40% of all fractures, respectively, p=.03). Thoracolumbar fractures were significantly more severe in that there were more Arbeitsgemeinschaft fur Osteosynthesefragen/Magerl Type A injuries versus all TL fractures, 1.75 versus 2.68/10,000 or 27% of all spine fractures in Time Period 1 versus 40% in Time Period 2 (p=.007). Furthermore, there were significantly fewer minor fractures (spinous process and transverse process fractures) (p<.0001). In Time Period 2, significantly more TL spine fractures were classified as major fractures, according to the Denis classification system, in both the mounted and dismounted groups; M1 group, 61 of 226 (27%) versus the M2 group, 86 of 246 (34%) (p<.0005) and 173 of 786 (22%) in the D1 group versus 193 of 561 (34%) in the D2 group. The spinal cord injury (SCI) incidence did not change in the mounted groups in Time Period 1 (7 of 71, 9.9%) versus Time Period 2 (7 of 74, 9.5%) (p=.935). In the dismounted groups, SCI actually decreased from D1 (55 of 228, 24%) to D2 (28 of 176, 16%) (p=.0428).Conclusions: The incidence of spine fractures and SCI is significantly higher in dismounted operations. The data suggest that current uparmored vehicles convey greater protection against spinal fracture compared with dismounted operations in which servicemembers are engaged on foot, outside their vehicles. The TL junction is at greatest risk for spine fractures sustained in mounted and dismounted combat operations. Recently, the incidence of TL fractures, especially severe fractures, has significantly increased in mounted operations. Although there has been an increased incidence of TL spine fractures, in context of the number of servicemembers deployed in support of Operation Enduring Freedom/Operation Iraqi Freedom, these severe fractures still represent a relatively rare event.

Open lumbosacral spine fractures with thecal sac ligation after combat blast trauma - Corrected Proof

Daniel G. Kang, John P. Cody, Ronald A. Lehman — 2011-12-02

A 22 year-old male soldier sustained combat blast trauma from an improvised explosive device, resulting in open L4 vertebral body and L5 burst fractures and an open comminuted lumbopelvic dissociation injury (), as well as multiple other injuries (open right comminuted iliac wing fracture, significant presacral/gluteal soft-tissue injuries, and bilateral traumatic above knee amputations). His open spine injuries required irrigation and debridement, followed by L2/L3 laminectomies and ligation of his violated thecal sac at L2. The thecal ligation resulted in bowel and bladder dysfunction requiring chronic colonic diversion, suprapubic catheter, and artificial uretheral sphincter implantation.

Complications associated with military spine injuries - Corrected Proof

2011-11-21

Abstract: Background context: To assess the presence of complications associated with spine injuries in the Global War on Terror.Purpose: To characterize the effect of complications in and around the battlefield during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2009.Study design/setting: Retrospective study.Patient sample: American servicemembers sustaining spine injury during combat.Methods: Extracted medical records of warriors identified by the Joint Theater Trauma Registry from October 2001 to December 2009. Complications were defined as unplanned medical events that required further intervention. Complications were classified as major or minor and further subdivided among groups, including surgical and nonsurgical management, mounted (in an armored vehicle) or dismounted at the time of injury, and blunt or penetrating trauma.Results: Major complications were encountered in 55 servicemembers (9%), and 38 (6%) sustained minor complications. Forty-four percent (n=24) of those with major complications had more than one complication. Eleven servicemembers sustained three or more complications. There were five intraoperative complications, and 50 occurred in the perioperative period. Intraoperative complications included gastrointestinal injury, dural tear, and instrument malposition. Among patients who sustained complications, precipitating spinal injuries occurred primarily in combat (n=43 [78%]) and resulted from blunt (18) or penetrating (25) mechanisms. Complications occurred in 10 (3%) of those treated nonoperatively and 45 (25%) of those receiving surgery. Complications were higher in the dismounted group (80%) as compared with those who were mounted in vehicles at the time of injury (20%). Thirty-five percent (n=24) of surgically treated, dismounted, and penetrating injured servicemembers had complications. Seventeen percent (n=8) of surgically treated and blunt injured mounted servicemembers and 20% (n=13) of dismounted servicemembers had complications. Among the dismounted and nonspinal cord–injured servicemembers, both blunt (p=.002) and penetrating injured (p<.0005) treated with surgery were correlated with complications. Only the dismounted servicemembers with spinal cord injuries because of a penetrating mechanism were also at an increased risk for complications (p<.0005).Conclusions: Patients treated with surgery appear to be at increased complication risk regardless of the mechanism of injury. Uparmored vehicles may safeguard servicemembers from spine injuries and complications associated with their treatment. This may be reflective of the fact that less severe spinal and concomitant injuries are sustained in the precipitating trauma because of the protection afforded by the vehicle. Dismounted soldiers had more complications in all groups regardless of type of management or injury mechanism.

Military penetrating spine injuries compared with blunt - Corrected Proof

2011-11-21

Abstract: Background context: The nature of blunt and penetrating injuries to the spine and spinal column in a military combat setting has been poorly documented in the literature. To date, no study has attempted to characterize and compare blunt and penetrating spine injuries sustained by American servicemembers.Purpose: The purpose of this study was to compare the military penetrating spine injuries with blunt spine injuries in the current military conflicts.Study design/setting: Retrospective study.Patient sample: All American military servicemembers who have been injured while deployed in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) whose medical data have been entered into the Joint Theater Trauma Registry (JTTR).Methods: The JTTR was queried for all American servicemembers sustaining an injury to the spinal column or spinal cord while deployed in Iraq or Afghanistan. These data were manually reviewed for relevant information regarding demographics, mechanism of injury, surgical intervention, and neurologic injury.Results: A total of 598 servicemembers sustained injuries to the spine or spinal cord. Isolated blunt injuries were recorded in 396 (66%) servicemembers and 165 (28%) sustained isolating penetrating injuries. Thirty servicemembers (5%) sustained combined blunt and penetrating injuries to the spine. The most commonly documented injuries were transverse process fractures, compression fractures, and burst fractures in the blunt-injured servicemembers versus transverse process fractures, lamina fractures, and spinous process fractures in those injured with a penetrating injury. One hundred four (17%) servicemembers sustained spinal cord injuries, comprising 10% of blunt injuries and 38% of penetrating injuries (p<.0001). Twenty-eight percent (28%) of blunt-injured servicemembers underwent a surgical procedure compared with 41% of those injured by penetrating mechanisms (p=.4). Sixty percent (n=12/20) of blunt-injured servicemembers experienced a neurologic improvement after surgical intervention at follow-up compared with 43% of servicemembers (n=10/23) who underwent a surgical intervention after a penetrating trauma (p=.28). Explosions accounted for 58% of blunt injuries and 47% of penetrating injuries, whereas motor vehicle collisions accounted for 40% of blunt injuries and 2% of penetrating injuries. Concomitant injuries to the abdomen, chest, and head were common in both groups.Conclusions: Blunt and penetrating injuries to the spinal column and spinal cord occur frequently in the current conflicts in Iraq and Afghanistan. Penetrating injuries result in significantly higher rates of spinal cord injury and trend toward increased rates of operative interventions and decreased neurologic improvement at follow-up.

Spine-area pain in military personnel: a review of epidemiology, etiology, diagnosis, and treatment - Corrected Proof

2011-11-21

Abstract: Background context: Nonbattle illnesses and injuries are the major causes of unit attrition in modern warfare. Spine-area pain is a common disabling injury in service members associated with a very low return-to-duty (RTD) rate.Purpose: To provide an overview of the current understanding of epidemiology, possible causes, and relative prognosis of spine-area pain syndromes in military personnel, including a discussion of various treatment options available in theaters of operation.Study design: Literature review.Methods: Search focusing on epidemiology, etiology and associative factors, and treatment of spinal pain using electronic databases, textbooks, bibliographic references, and personal accounts.Results: Spine-area pain is the most common injury or complaint “in garrison” and appears to increase during training and combat deployments. Approximately three-quarters involve low back pain, followed by cervical and midback pain syndromes. Some predictive factors associated with spine-area pain are similar to those observed in civilian cohorts, such as psychosocial distress, heavy physical activity, and more sedentary lifestyle. Risk factors specific to military personnel include concomitant psychological trauma, g-force exposure in pilots and airmen, extreme shock and vibration exposure, heavy combat load requirements, and falls incurred during airborne, air assault, and urban dismounted ground operations. Effective forward-deployed treatment has been difficult to implement, but newer strategies may improve RTD rates.Conclusions: Spine-area pain syndromes comprise a major source of unit attrition and are often the result of duty-related burdens incurred during combat operations. Current strategies in theaters of operation that may improve the low RTD rates include individual and unit level psychological support, early resumption of at least some forward-area duties, multimodal treatments, and ergonomic modifications.

Psychological distress in a Department of Veterans Affairs spine patient population - Corrected Proof

2011-11-17

Abstract: Background context: The veteran population presents a unique confluence of biopsychosocial factors in the treatment of spinal conditions. In addition to poorer health status and higher numbers of chronic medical conditions compared with the general population, previous reports have highlighted the high prevalence of psychological disorders within the Department of Veterans Affairs (VA) health system. To our knowledge, no study has specifically evaluated psychological distress in patients with a spinal disorder within the VA health system.Purpose: To determine the prevalence of psychological distress among spine patients in a VA hospital and if higher levels of distress correlated with patient demographics and self-reported patient outcome scores.Study design/setting: Cross-sectional evaluation of adult patients at a regional VA outpatient orthopedic spine surgery clinic.Patient sample: One hundred forty-nine adult patients presenting for treatment of spine-related disorders.Outcome measures: Patients were evaluated using the Distress and Risk Assessment Method (DRAM), a validated survey consisting of the Zung Depression Scale and the Modified Somatic Perception Questionnaire. In addition, self-reported pain, disability, and quality of life were assessed using the visual analog scale (VAS) for neck or back pain and the Neck Disability Index or Oswestry Disability Index (ODI) depending on the patient’s location of pain.Methods: The DRAM survey was used to determine the prevalence of psychological distress by classifying patients into normal, at-risk, and severe distress groups. Visual analog scale scores for neck and back pain, and self-reported disability scores, and demographic data including age, gender, combat experience, and use of antidepressant, anxiolytic, or narcotic medications were obtained at the time of enrollment.Results: The DRAM survey identified 79.9% of patients as having some degree of psychological distress, whereas the remaining 20.1% were classified as normal. Among those with psychological distress, 43.6% of patients were categorized as severe distress. Compared with the normal group, a history of combat was more frequent in all distressed patient groups including the at-risk (p=.04) and severe distress (p=.009) groups. Those in the severe distress category more commonly reported the use of narcotics (p=.043) and antidepressant/anxiolytics medications (p=.0001). Those in the severe distress group had significantly higher ODI scores (p<.0001) and back pain VAS scores (p=.0360) compared with the normal group.Conclusions: We identified a large number of patients (80%) with some level of psychological distress and 43% with severe distress. The percent of patients with severe psychological distress in the VA was double that previously reported in a non-VA patient setting. Patients with severe distress had higher ODI scores, back pain VAS scores, use of narcotics and antidepressants, and a reported history of combat when compared with those without distress.

Multiple associated injuries are common with spine fractures during war - Corrected Proof

2011-11-04

Abstract: Background context: The nature of concomitant injuries associated with spine fractures in American military personnel engaged in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) has been poorly documented in the literature.Purpose: To characterize the incidence and epidemiology of associated injuries (AIs) in American military personnel with spine fractures sustained during OEF and OIF from 2001 to 2009.Study design: Retrospective study.Patient sample: American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR).Outcome measures: Not applicable.Methods: The JTTR was queried using International Statistical Classification of Disease, Ninth Revision codes to identify all individuals who sustained spine injuries in OEF or OIF from October 2001 to December 2009. Medical records of all identified service members were abstracted to ensure accuracy and avoid duplication. Demographic information, including sex, age, and military rank, were obtained for all patients. Information regarding fracture type, spine region, mechanism of injury, and the presence of AIs was collected for all patients.Results: Seventy-eight percent of patients with a spine fracture sustained at least one AI, with an average of 3.4 AIs per patient. Musculoskeletal injuries were most common, followed by chest, abdomen, and traumatic brain injuries. Most patients were injured by an explosive mechanism (62%). Head and face traumas were more common with cervical fractures, chest with thoracic injuries, and abdominopelvic injuries with lumbosacral fractures. Pelvis and acetabulum fractures were common after helicopter crashes, tibia/fibula injuries after explosions, thoracoabdominal injuries after gunshot wounds, and traumatic brain injuries after falls. Most patients (76%) sustained multiple spine fractures.Conclusion: Spine fractures sustained in OEF and OIF have high rates of AIs. Musculoskeletal AIs are the most common, but visceral injuries adjacent to the spine fracture frequently occur. Multiple spine injuries are more prevalent after military trauma.

Corrected Proof

Jean-Claude G. D’Alleyrand — 2011-10-24

The injuries sustained by America’s service members deployed in the current wars in Iraq and Afghanistan are of a much higher level of energy than those incurred in prior conflicts. Improvements in body and vehicular armor, as well as advances in combat resuscitative techniques and rapid evacuation to centers of surgical care, are allowing wounded individuals to survive injuries that previously would have been uniformly fatal. Moreover, these injuries are usually sustained as a result of a blast mechanism, which by their nature create injuries of the highest possible energy. As a result, the military orthopedic community has been treating an unprecedented number of extremely complex injuries. In “Combat Orthopedic Surgery: Lessons Learned in Iraq and Afghanistan,” editors Owens and Belmont attempt to catalog the general types of orthopedic injuries treated in the military during the first 10 years of these conflicts, along with the most recent evidence- and practice-based guidelines regarding the surgical care thereof. Their goal is to provide a comprehensive and definitive text to optimally guide the surgical treatment of these injuries both in-theater and at the final treatment facility.

Are spine injuries sustained in battle truly different? - Corrected Proof

2011-10-17

Abstract: Background context: The severity and prognosis of combat-related injuries to the spine and spine injuries sustained unrelated to direct combat have not been previously compared. Differences may have implications on tactics, treatment strategies, and directions for future research.Purpose: Compare the severity and prognosis of battle and nonbattle injuries to the spine.Study design: Retrospective study.Patient sample: American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR).Methods: The JTTR was queried using International Statistical Classification of Diseases, Ninth Revision codes to identify all individuals who sustained battle and nonbattle injuries to the neck, back, spinal column, or spinal cord in Operation Iraqi Freedom or Operation Enduring Freedom from October 2001 to December 2009. Medical records of all identified servicemembers were individually reviewed. Demographic information, including sex, age, military rank, date of injury, and final disposition, was obtained for all patients. Spinal injuries were categorized according to anatomic location, associated neurologic involvement, precipitating mechanism of injury (MOI), and concomitant wounds. These data points were compared for the groups battle spine injuries (BSIs) and nonbattle spine injuries (NBSIs).Results: Five hundred two servicemembers sustained a total of 1,834 battle injuries to the spinal column, including 1,687 fractures (92%), compared with 92 servicemembers sustaining 267 nonbattle spinal column injuries, with 241 (90%) fractures. Ninety-one BSI servicemembers (18% of patients) sustained spinal cord injuries (SCIs) with 41 (45%) complete SCIs, compared with 13 (14% of patients) nonbattle SCIs with six (46.2%) complete injuries (p=.92). The reported MOI for 335 BSI servicemembers (66.7%) was an explosion compared with one NBSI explosive injury. Eighty-four patients (17%) sustained gunshot wounds (GSWs) in battle compared with five (5.2%) nonbattle GSWs. Fifteen patients (3.0%) sustained a battle-related fall compared with 29 (30%) nonbattle-related falls. Battle spine injury servicemembers underwent significantly higher rates of surgical interventions (p<.0001), were injured by high-energy injury mechanisms at a significantly greater rate (p<.0001), and demonstrated a trend toward lower neurologic recovery rates after SCI (p=.16).Conclusions: Battle spine injury and NBSI are separate entities that may ultimately have disparate long-term prognoses. Nonbattle spine injury patients, although having similar MOIs compared with civilian spinal trauma, maintain a different patient demographic. Further research must be directed at accurately quantifying the long-term disabilities of all spine injuries sustained in a combat theater, whether they are the result of battle or not.

Electromyographic thresholds after thoracic screw stimulation depend on the distance of the screw from the spinal cord and not on pedicle cortex integrity - Corrected Proof

2011-10-13

Abstract: Background context: Present studies concerning the safety and reliability of neurophysiological monitoring during thoracic pedicle screw placement remain inconclusive, and therefore, universally validated threshold levels that confirm osseous breakage of the instrumented pedicles have not been properly established.Purpose: The objective of this work was to analyze whether electromyographic (EMG) thresholds, after stimulation of the thoracic pedicle screw, depend on the distance between the neural structures and the screws. The modifier effect of different interposed tissues between a breached pedicle and neural structures was also investigated.Study design: This experimental study uses a domestic pig model.Methods: Electromyographic thresholds were recorded after the stimulation of 18 thoracic pedicle screws that had been inserted into five experimental animals using varying distances between each screw and the spinal cord (8 and 2 mm). Electromyographic thresholds were also registered after the medial pedicle cortex was broken and after different biological tissues were interposed (blood, muscle, fat, and bone) between the screw and the spinal cord.Results: Mean EMG thresholds increased to 14.1±5.5 mA for screws with pedicle cortex integrity that were placed 8 mm away from the dural sac. After the medial pedicle cortex was broken and without varying the distance of the screw to the dural sac, the mean EMG thresholds were not appreciably changed (13.6±6.3 mA). After repositioning the screw at a distance of 2 mm from the spinal cord and after medial cortical breach of the pedicle, the mean threshold significantly slowed to 7.4±3.4 mA (p<.001). When the screw was placed in contact with the spinal dural sac, even lower EMG thresholds were registered (4.9±1.9, p<.001). Medial pedicle cortex rupture and the interposition of different biological tissues in experimental animals did not alter the stimulation thresholds of the thoracic pedicle screws.Conclusions: In the experimental animals, the observed electrical impedance depended on the distance of screws from the neural structures and not on the integrity of the pedicle cortex. The screw-triggered EMG technique did not reliably discriminate the presence or absence of bone integrity after pedicle screw placement. The response intensity was not related to the type of interposed tissue.

Low lumbar burst fractures: a unique fracture mechanism sustained in our current overseas conflicts - Corrected Proof

2011-10-10

Abstract: Background context: The most common location for burst fractures occurs at the thoracolumbar junction, where the stiff thoracic spine meets the more flexible lumbar spine. With our current military conflicts in Iraq and Afghanistan, we have seen a disproportionate number of low lumbar burst fractures.Purpose: To report our institutional experience in the management of low lumbar burst fractures.Study design: Retrospective review.Methods: We performed a retrospective review of medical records and radiographs for all patients treated at our institution with combat-related injuries and thoracolumbar fractures. We included all patients who had sustained a burst fracture from T12 to L5 and had at least 1-year clinical follow-up.Results: Thirty-two patients sustained burst fractures. Nineteen patients (59.4%) had low lumbar (L3–L5) burst fractures, and 12 patients (37.5%) had thoracolumbar junction (T12–L2) burst fractures as their primary injury. Additionally, seven patients sustained less severe burst fractures at an additional level. One patient sustained burst fractures at both upper and lower lumbar levels. Of the low lumbar fractures, 52.6% had evidence of neurologic injury, two of which were complete. Similarly, in the upper lumbar group, 58.2% sustained a neurologic injury, two of which were complete. Twenty-two patients underwent surgical intervention, complicated by infection in 18%. At most recent follow-up, all but one patient with presenting neurologic injury had persistent deficits.Conclusion: Low lumbar burst fractures are the predominant combat-related spine injury in our current military conflicts. The rigidity offered by current body armor may effectively lower the transition zone that normally occurs at the thoracolumbar junction, thereby, transferring forces into the lower lumbar spine. Increased awareness of this fracture pattern is warranted by all surgeons because of unique clinical challenges associated with its treatment. Although the incidence is increased in the military population, other surgeons may be involved with long-term care of these patients on completion of their military service.

Preoperative Zung Depression Scale predicts outcome after revision lumbar surgery for adjacent segment disease, recurrent stenosis, and pseudarthrosis - Corrected Proof

2011-09-22

Abstract: Background context: Persistent back pain and leg pain after index surgery is distressing to patients and spinal surgeons. Revision surgical treatment is technically challenging and has been reported to yield unpredictable outcomes. Recently, affective disorders, such as depression and anxiety, have been considered potential predictors of surgical outcomes across many disease states of chronic pain. There remains a paucity of studies assessing the predictive value of baseline depression on outcomes in the setting of revision spine surgery.Purpose: To assess the predictive value of preoperative depression on 2-year postoperative outcome after revision lumbar surgery for symptomatic pseudarthrosis, adjacent segment disease (ASD), and same-level recurrent stenosis.Study design: Retrospective cohort study.Patient sample: One hundred fifty patients undergoing revision surgery for symptomatic ASD, pseudarthrosis, and same-level recurrent stenosis.Outcome measures: Patient-reported outcome measures were assessed using an outcomes questionnaire that included questions on health-state values (EQ-5D), disability (Oswestry Disability Index [ODI]), pain (visual analog scale), depression (Zung Self-Rating Depression Scale), and 12-Item Short Form Health Survey physical and mental component scores.Methods: One hundred fifty patients undergoing revision neural decompression and instrumented fusion for ASD (n=50), pseudarthrosis (n=47), or same-level recurrent stenosis (n=53) were included in this study. Preoperative Zung Self-Reported Depression Scale score was assessed for all patients. Preoperative and 2-year postoperative visual analog scale for back pain and leg pain scores and ODI were assessed. The association between preoperative Zung Depression Scale score and 2-year improvement in disability was assessed via multivariate regression analysis.Results: Compared to preoperative status, VAS-BP was significantly improved 2 years after surgery for ASD (8.72±1.85 vs. 3.92±2.84, p=.001), pseudoarthrosis (7.31±0.81 vs. 5.06±2.64, p=.001), and same-level recurrent stenosis (9.28±1.00 vs. 5.00±2.94, p=.001). Two-year ODI was also significantly improved after surgery for ASD (28.72±9.64 vs. 18.48±11.31, p=.001), pseudoarthrosis (29.74±5.35 vs. 25.42±6.00, p=.001), and same-level recurrent stenosis (36.01±6.00 vs. 21.75±12.07, p=.001). Independent of age, BMI, symptom duration, smoking, comorbidities, and level of preoperative pain and disability, increasing preoperative Zung depression score was significantly associated with less 2-year improvement in disability (ODI) after revision surgery for ASD, pseudoarthrosis, and recurrent stenosis.Conclusions: Our study suggests that the extent of preoperative depression is an independent predictor of functional outcome after revision lumbar surgery for ASD, pseudoarthrosis, and recurrent stenosis. Future comparative effectiveness studies assessing outcomes after revision lumbar surgery should account for depression as a potential confounder. The Zung depression questionnaire may help risk stratify patients presenting for revision lumbar surgery.

Combat-related L3 fracture treated with L2–L4 posterior spinal fusion complicated by multidrug-resistant acinetobacter infection - Corrected Proof

Theodora C. Dworak, Daniel G. Kang, Ronald A. Lehman — 2011-07-26

A 22-year-old active duty soldier injured by an improvised explosive device sustained an L3 compression fracture with right L3 pedicle and superior facet fractures and right L1, L2, and L3 transverse process fractures (). The patient also sustained a C7 spinous process fracture and left closed tibia fracture. On arrival to our institution, the patient had normal sensation and motor function in all extremities. At 11 days after injury, the patient underwent L2–L4 posterior spinal fusion (). On postoperative Day 6, he underwent an irrigation and debridement and antibiotic-impregnated cement bead placement for persistent serosanguinous drainage from his wound (). Intraoperative tissue cultures were positive for multidrug-resistant Acinetobacter spp. The patient continued to have episodic fevers and required two additional irrigation and debridement procedures with antibiotic bead placement before tissue cultures were negative. The wound was closed primarily with retained instrumentation 20 days after the index surgery. He was presumed to have osteomyelitis and was treated with 6 weeks of intravenous meropenem and oral rifampin. At 4-month follow-up, the patient denied constitutional signs of infection or significant back pain, and imaging showed stable L2–L4 instrumentation (). Infection of traumatic wounds with multidrug-resistant organisms has been an increasing problem in injured soldiers returning from Iraq and Afghanistan . Primary osteomyelitis in injured combat veterans is often polymicrobial, with gram-negative rods, such as Acinetobacter spp, Klebsiella pneumoniae, and Pseudomonas aeruginosa being the most common organisms. In the combat casualty with suspected infection after spinal surgery, spinal instrumentation is usually retained, particularly in the setting of an unstable spine fracture. Aggressive debridement, wound irrigation, and antibiotic bead placement are repeated until negative tissue cultures, and an extended course of intravenous antibiotics is warranted to decrease the risk of chronic osteomyelitis and pseudarthrosis .

Combat-related lumbopelvic dissociation treated with percutaneous sacroiliac screw placement - Corrected Proof

John P. Cody, Daniel G. Kang, Ronald A. Lehman — 2011-07-18

A 25-year-old male active duty soldier injured in an improvised explosive device blast sustained a stable U-type sacral fracture (S1/S2, bilateral Zone II) with 20° sacral kyphosis (). The patient also sustained left L5 transverse process and facet fracture with L5/S1 retrolisthesis. He had no neurologic deficits on arrival to our institution and was placed in a thoracolumbar support orthosis for his lumbar spine injury. On postinjury Day 12, the patient underwent bilateral SI screw placement. Six-months postoperative, the patient had resumed jogging activities without difficulty and did not exhibit lower extremity weakness, bowel/bladder dysfunction, or perineal numbness. Postoperative radiographs demonstrate adequate screw placement without evidence of progressive kyphosis, implant failure, or loosening (). The patient was released for activity as tolerated. At our institution, we have seen an increased incidence of lumbopelvic dissociation injury because of the high-energy blast mechanisms associated with combat in current conflicts. The patient in the above case did not require posterior decompression because of lack of neurologic compromise and was managed with bilateral sacroiliac screw placement, which has shown comparable results with regard to fracture healing and neurologic recovery .

Combat-related lumbopelvic dissociation treated with L4 to ilium posterior fusion - Corrected Proof

Daniel G. Kang, John P. Cody, Ronald A. Lehman — 2011-07-18

A 25-year-old active duty soldier injured in an improvised explosive device blast sustained a comminuted H-type sacral fracture (Zone III) with 100% displacement of S1 on S2 with 23° kyphosis, bilateral sacroiliac joint disruption, and right L2/L4/L5 transverse process fractures (). In the blast, the patient also sustained bilateral transtibial amputations, left acetabular fracture, liver laceration, multiple rib fractures, and left pneumothorax. On presentation, the patient had normal rectal tone and sensation, with sensation intact to light touch throughout both residual lower extremities. The patient required multiple procedures for his associated injuries, was stable for prone positioning at 4 weeks after injury, and subsequently underwent L4 to ilium posterior fusion (). At 2-year follow-up, a computed tomography scan demonstrated fracture consolidation without evidence of loosening or failure of implants (). However, he complained of skin irritation associated with a prominent left ilium screw, which was removed without significant sequelae (). He returned to ambulating with bilateral lower extremity prosthetics without difficulty.

Combat-related L5 burst fracture treated with L4–S1 posterior spinal fusion - Corrected Proof

Daniel G. Kang, Theodora C. Dworak, Ronald A. Lehman — 2011-07-18

A 27-year-old active duty soldier after blast injury from an improvised explosive device sustained an L5 burst fracture and L4 compression fracture, disruption of the posterior ligamentous complex, and posterior displacement of the L5 vertebral body with 50% narrowing of the spinal canal (). The patient's other injuries included bilateral transfemoral amputations and multiple facial fractures. On arrival to our institution, the patient's examination demonstrated normal rectal tone, with intact bilateral thigh and sacral nerve root sensation, and intact bilateral hip flexion and abduction limited by pain from his amputations. Three weeks after injury, the patient underwent an L4–S1 posterior spinal fusion with pedicle screw and rod instrumentation (). The patient started physical therapy on postoperative Day 2. At 7-month follow-up, the patient complained of persistent bilateral sharp radicular pain in his residual lower extremities. Imaging demonstrated no evidence of instrumentation failure or loosening, and no residual canal compromise (). The patient was treated with interlaminar corticosteroid injections, radio frequency nerve ablation therapy, and Botox injections. At 16-month follow-up, the patient was pain free, spending over 12 hours a day in his bilateral lower extremity prostheses, and able to independently walk over one-mile.

Bearing surfaces for total disc arthroplasty: metal-on-metal versus metal-on-polyethylene and other biomaterials - Corrected Proof

S. Raymond Golish, Paul A. Anderson — 2011-06-23

Abstract: Background context: Concerns about the effect of metallic wear debris from metal-on-metal bearing surfaces in total hip arthroplasty have increased. Some spinal arthroplasty devices include metal-on-metal bearing surfaces.Purpose: To review the literature for clinical reports of complications because of wear debris from metal-on-metal spinal arthroplasty devices. To review the biology of wear debris from metal-on-metal bearing surfaces drawn from the hip arthroplasty literature and place it in the context of global regulatory actions and clinical and laboratory studies.Study design: Literature review.Methods: To identify clinical reports, the PubMed database from the United States National Library of Medicine was queried using Medical Subject Headings terms and additional keyword terms. In addition, experts from academia and regulatory agencies were questioned regarding their knowledge of reports, including experts who attended the US Food and Drug Administration roundtable in September 2010.Results: Three case reports and one case series including seven total cases were identified in which abnormal inflammatory reactions and soft-tissue masses after metal-on-metal disc replacements were consistent with pseudotumor and metal hypersensitivity. Spinal cases are present as pain and neurologic symptoms. On plain radiography, there is no clear periprosthetic osteolysis or loosening. On magnetic resonance imaging, there is increased magnetic susceptibility artifact because of metallic debris that renders images inadequate. Computed tomography myelography demonstrates a soft-tissue mass, which exhibits epidural extension surgically. Histologically, large areas of necrotic debris and exudates are interspersed with chronic inflammatory cells. Lymphocyte or macrophage predominance is determined by the rate of wear and the presence of gross, microscopic, or submicron metallic wear debris. The metallurgy of the involved devices is cobalt-chromium-molybdenum (CoCrMo) alloy, and the bearing surface is CoCrMo-on-CoCrMo.Conclusions: Metal-on-metal spinal arthroplasty devices are subject to postoperative complications because of metallic wear debris with similar clinical, radiographic, histologic, gross anatomic, and device-related features to those found in metal-on-metal bearing surfaces in total hip arthroplasty.

Evaluation and management of combat-related spinal injuries: a review based on recent experiences - Corrected Proof

Andrew J. Schoenfeld, Ronald A. Lehman, Joseph R. Hsu — 2011-06-03

Abstract: Background context: The current approach to the evaluation and treatment of military casualties in the Global War on Terror is informed by medical experience from prior conflicts and combat encounters from the last 10 years. In an effort to standardize the care provided to military casualties in the ongoing conflicts, the Department of Defense (DoD) has published Clinical Practice Guidelines (CPGs) that deal specifically with the combat casualty sustaining a spinal injury. However, the combat experience with spine injuries in the present conflicts remains incompletely described.Purpose: To describe the CPGs for the care of the combat casualty with suspected spine injuries and discuss them in light of the published military experience with combat-related spinal trauma.Study design: Literature review.Methods: A literature review was conducted regarding published works that discussed the incidence, epidemiology, and management of combat-related spinal trauma. The CPGs, established by the DoD, are discussed in light of actual military experiences with spine trauma, the present situation in the forward surgical teams and combat support hospitals treating casualties in theater, and recent publications in the field of spine surgery.Results: In the conventional wars fought by the United States between 1950 and 1991 (Korea, Vietnam, Gulf War I), the incidence of spine injuries remained close to 1% of all combat casualties. However, in the Global War on Terror, the enemy has relied on implements of asymmetric warfare, including sniper attacks, ambush, roadside bombs, and improvised explosive devices. The increase in explosive mechanisms of injury has elevated the number of soldiers exposed to blunt force trauma and, consequently, recent publications reported the highest incidence of combat-related spinal injuries in American military history. Wounded soldiers are expeditiously evacuated through the echelons of care but typically do not receive surgical management in theater. The current CPGs for the care of soldiers with combat-related spinal injuries should be re-examined in light of data regarding the increasing number of spine injuries, new injury patterns, such as lumbosacral dissociation and low lumbar burst fractures, and recent reports within the field of spine surgery as a whole.Conclusions: American and coalition forces are sustaining the highest spine combat casualty rates in recorded history and previously unseen injuries are being encountered with increased frequency. While the CPGs provide useful direction in terms of the evaluation and management of combat casualties with spine injuries, such recommendations may warrant periodic re-evaluation in light of recent combat experiences and evolving scientific evidence within the spine literature.

Epidemiology of cervical spine fractures in the US military - Corrected Proof

2011-03-10

Abstract: Background context: The epidemiology of cervical spine fractures and associated spinal cord injury (SCI) has not previously been estimated within the American population.Purpose: To determine the incidence of cervical spine fractures and associated SCI and identify potential risk factors for these injuries in a large multicultural military population.Study design: Query of a prospectively collected military database.Patient sample: The 13,813,333 military servicemembers serving in the US Armed Forces between 2000 and 2009.Outcome measures: The Defense Medical Epidemiology Database (DMED) was queried to identify all servicemembers diagnosed with cervical spine fractures with and without SCI during the time period under investigation. Data were used to determine the incidence of cervical spine fractures and SCI as well as identify risk factors for their development.Methods: The DMED was queried for the years 2000 to 2009 using the International Classification of Diseases, Ninth Revision, Clinical Modification code for cervical spine fractures with and without SCI (805.0, 805.1, 806.0, and 806.1). The database was also used to determine the total number of servicemembers within the military during the same period. The incidence of cervical spine fractures and fractures associated with SCI was determined, and unadjusted incidence rates were calculated for the demographic characteristics of sex, race, military rank, branch of service, and age. Adjusted incidence rate ratios were then determined using multivariate Poisson regression analysis to control for other factors in the model and identify significant risk factors for cervical spine fractures and cervical injuries associated with SCI.Results: From 2000 to 2009, there were 4,048 cervical spine fractures in a population at risk of 13,813,333 servicemembers. The overall incidence of cervical spine fractures was 0.29 per 1,000 person-years, and the incidence of fracture associated SCI was 70 per 1,000,000. The cohorts at highest risk of cervical spine fracture were males, whites, Enlisted personnel, those serving in the Army, Navy, or Marine Corps, and servicemembers aged 20 to 29. Risk of fracture-associated SCI was significantly increased in males, Enlisted personnel, servicemembers in the Army, Navy, or Marines, and those aged 20 to 29.Conclusions: This study is the largest population-based investigation to be conducted within the United States regarding the incidence of SCI and the only study addressing incidence and risk factors for cervical spine fractures. Male sex, white race, Enlisted military rank, service in the Army, Navy, or Marine Corps, and ages 20 to 29 were found to significantly increase the risk for cervical fractures and/or fracture associated SCI. Our findings support previously published data but also represent best available evidence based on the size and diversity of the population under study.Level of evidence: Prognostic; Level II.

Minimum acceptable outcomes after lumbar spinal fusion - Corrected Proof

Eugene J. Carragee, Ivan Cheng — 2011-02-03

Abstract: Background Context: Defining success after spinal surgery remains problematic. The minimal clinically important difference (MCID) in pain or functional outcomes is a common metric often calculated independent of perceived risk and morbidity, which is an important consideration in large procedures such as spinal fusion and instrumentation.Purpose: The purpose of this study was to describe a method of assessing treatment success based on prospective, patient-reported “minimum acceptable” outcome for which they would undergo a procedure. These goals can then be compared at follow-up to gauge how frequently patient goals are met and determine correlation with patient satisfaction.Study Design: This is a clinical descriptive study of the patient-reported minimum acceptable outcomes for spinal fusion surgery.Outcome Measures: Minimum acceptable outcomes were determined by patients on preoperatively administered standard questionnaires regarding ultimate pain intensity, functional outcome (Oswestry Disability Index [ODI]), medication usage, and work status. Satisfaction with outcomes was assessed at 2-year follow-up.Methods: One hundred sixty-five consecutive patients undergoing lumbar fusion for either isthmic spondylolisthesis or disc degeneration were asked to preoperatively define on standard questionnaires their minimum acceptable outcomes after surgery. Two-year outcomes and satisfaction were subsequently reported and compared with the preoperatively determined minimum acceptable outcomes.Results: Both the spondylolisthesis and the degenerative disc disease (DDD) groups reported that a high degree of improvement was the minimum acceptable threshold for considering spinal fusion. A large majority indicated that the minimum acceptable outcomes included at least a decrease in pain intensity to 3/10 or less, an improvement in ODI of 20 or more, discontinuing opioid medications, and return to some occupational activity. Achieving the minimum acceptable outcome was strongly associated with satisfaction at 2 years after surgery. Patients with compensation claims, psychological distress, and other psychosocial stressors were more likely to report satisfaction in the absence of achieving their minimum acceptable outcome.Conclusions: Patients with spondylolisthesis and DDD both have relatively high minimum acceptable outcomes for spinal fusion. In these cohorts, few subjects considered more commonly proposed MCIDs for pain and function as an acceptable outcome and report that they would not have surgery if they did not expect to achieve more than those marginal improvements. Although there was good concordance between achieving the minimum acceptable outcomes and ultimate satisfaction, patients with significant psychosocial factors (compensation claims, psychological distress, and others) are less likely to associate satisfaction with outcomes with actually achieving these improvements.

Characterization of combat-related spinal injuries sustained by a US Army Brigade Combat Team during Operation Iraqi Freedom - Corrected Proof

Andrew J. Schoenfeld, Gens P. Goodman, Philip J. Belmont — 2010-06-14

Abstract: Background Context: The United States is presently engaged in the largest scale armed conflict since Vietnam. Despite recent investigations into the scope of injuries sustained by soldiers in Iraq and Afghanistan, little information is available regarding the incidence and epidemiology of spine trauma in this population.Purpose: Characterize the incidence and epidemiology of spinal injuries sustained during combat by soldiers of a US Army Brigade Combat Team (BCT) that participated in Operation Iraqi Freedom.Study Design: Descriptive epidemiologic study.Patient Sample: A total of 4,122 soldiers who served in Iraq with an Army BCT during “The Surge” operation.Outcome Measures: Spine injury epidemiology was calculated for the BCT, including the spine combat casualty rate, and percent medically evacuated (MEDEVAC).Methods: Unit rosters were obtained, and a comprehensive database identifying all combat-related spine injuries was created by querying each soldiers' electronic medical record and the unit's casualty rosters. Demographic information was recorded including age, sex, rank, injury mechanism, presence of polytrauma, and injury outcome. Injury outcomes were classified as killed in action, died of wounds, MEDEVAC, or returned to duty. The incidence of spine injuries was determined, and epidemiology was characterized using calculations of the spine combat casualty rate and percent MEDEVAC. Comparisons were made to published reports from previous conflicts.Results: A total of 29 soldiers sustained 31 combat-related spine injuries. These accounted for 7.4% (29 out of 390) of all casualties sustained during combat. Blunt trauma to the spine, often resulting from an explosive mechanism, was encountered in 65% of cases. Closed fractures of the spine occurred in 21% of casualties and open injuries occurred in 7%. The spine combat casualty rate was 5.6 out of 1,000 soldier combat-years, and the percent MEDEVAC was 19%.Conclusions: This investigation is the first of its kind, documenting the nature of spine trauma in a major American conflict. The incidence of spine injuries in this study is the highest ever documented and is indicative of the tactics used by the enemy in the current war. Given this fact, it is likely that the prevalence of combat-related spine trauma will increase in the future. Larger, more extensive, studies of this kind must be conducted in the future.

Back disorders among Israeli youth: a prevalence study in young military recruits - Corrected Proof

2010-06-11

Abstract: BACKGROUND CONTEXT: Back problems are reported with increasing frequency in adults and adolescents. Most information is from self-reported questionnaires or studies with small sample sizes. Reports were usually focused on specific diseases and biased toward overdiagnosis.PURPOSE: To assess the prevalence of common back disorders among a large cohort of 17-year-old males and females recruited by the Israel Defense Forces (IDF).STUDY DESIGN: A retrospective cross-sectional prevalence study.PATIENT SAMPLE: Seventeen-year-old Israeli male and female military recruits reporting as directed by the IDF for preinduction medical examination between January 01, 1998 and December 31, 2006.OUTCOME MEASURES: Military functional limitation Grades 1 to 7 per diagnosis category.METHODS: Military recruits were examined and classified based on medical and orthopedic diagnoses. They were referred for orthopedic consultation as necessary. Four orthopedic classifications were used: spinal deformity (including kyphosis and scoliosis), back pain (including neck and radicular syndromes), spondylolysis/olisthesis, and limitations resulting from trauma or spinal surgery. Data were coded into a central database, and descriptive statistics are presented.RESULTS: The overall prevalence of back disorders among 828,171 17-year-old military recruits (61.5% male) was 16.8%. Back disorders resulting in significant functional limitation were diagnosed in 0.8% of recruits. The most prevalent diagnoses were spinal deformities (kyphosis and scoliosis, females 11.9%, males 11.5%) and back pain (females 3.0%, males 5.6%). Most of these diagnoses were rated as mild.CONCLUSIONS: When using objective criteria, overall back disorders in a large population of 17-year-old recruits were 17%, considerably lower than most reports. Back morbidity severe enough to prevent combat duty occurred at a rate of less than 1%, suggesting that serious back morbidity is not a frequent finding in this age group.LEVEL OF EVIDENCE: Symptom prevalence study, Level III.

REMOVED: In defense of King et al.: the validity of manual examination in assessing patients with neck pain - Corrected Proof

Nikolai Bogduk — 2008-11-10

This article has been removed consistent with Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). The Publisher apologizes for any inconvenience this may cause.

Evaluation of five scoring systems for cervical spondylogenic myelopathy - Corrected Proof

Kristina Dalitz, Hans-Ekkehart Vitzthum — 2008-09-09

Abstract: Background context: Comparison of measured clinical deficits and outcomes is vital for international discussion about the identification and treatment of cervical spondylotic myelopathy (CSM). There is currently little information comparing outcomes as assessed by different CSM scoring systems.Purpose: To qualitatively and quantitatively analyze five specific CSM outcome scores that are frequently used to assess the grade of severity and outcome after operative decompression.Study design: This retrospective study evaluated the Nurick score, the Japanese Orthopedic Association score (JOA score), the Cooper myelopathy scale (CMS), the Prolo score, and the European myelopathy score (EMS).Patient sample: The study included 43 patients with clinical and morphological signs of CSM, who underwent ventral decompression. Data were evaluated in sufficient detail to objectively assess the scores.Outcome measures: Clinical findings (funicular and radicular symptoms), recovery rate, symptom duration, age, economic situation, time away from employment, somatic-evoked potentials, and radiological findings were assessed.Methods: Scores were assessed using both pre- and postoperative clinical data. Correlations between scores, score improvement, and how well the scores reflected the clinical, diagnostic, and anamnestic data were analyzed using nonparametric, descriptive statistical tests. The recovery rate, as a measure of cumulative outcome, was also assessed and compared for each scoring system.Results: All five scores were suitable for qualitatively assessing the clinical characteristics and progression of cervical myelopathy. All showed a statistically significant correlation (p<.05), and measured postoperative improvement (p<.001). All scores also reflected clinical deficits except for the Prolo score, which rates the severity of CSM with an emphasis on data related to the economic impact on the patient's situation rather than on clinical symptoms per se. Quantitative assessment of clinical symptom improvement varied greatly among the scores, for example, Nurick score (33%) versus JOA score (81%). The recovery rates, as a measure of cumulative improvement, showed less variation among most of the scores. The Nurick score and the EMS measured clinical deficit improvements in significantly fewer patients than did the JOA score (p<.05).Conclusions: Evaluating the recovery rate is essential for comparing the results of the five CSM scores evaluated in this study. There was a large quantitative difference among the scores as the result of the different criteria used to produce each score. Qualitatively, all five scores allowed evaluation of cervical myelopathy, but only the recovery rate allowed for statistical comparison. Advancements in the treatment of CSM depend on the ability of clinicians to evaluate the therapeutic results of CSM studies. This study suggests that using the recovery rate to assess outcome is best for comparing studies that use different scores.