Spine

Nielsen, Ena;Andras, Lindsay M.;Bellaire, Laura L.;Fletcher, Nicholas D.;Minkara, Anas;Vitale, Michael G.;Troy, Michael;Glotzbecker, Michael;Skaggs, David L.

doi: 10.1097/BRS.0000000000002888pmid: 30299416

Study Design. A multicenter retrospective study. Objective. The aim of this study was to compare pelvic obliquity correction and reoperation rate in neuromuscular scoliosis patients who had their pelvis included in a posterior spinal fusion (pelvic fusion, PF) at their index procedure versus revision procedures. Summary of Background Data. There is limited information on outcomes specific to fusing to the pelvis for neuromuscular scoliosis in a revision operation versus index surgery. Methods. Charts and radiographs were reviewed of patients with PF for neuromuscular scoliosis from January 2003 to August 2015 at four high-volume pediatric spine centers with >2 year follow-up. Results. Two hundred eighty-five patients met inclusion criteria; 271 had PF done at index surgery and 14 had PF done during revision surgery. Before index procedure, there were no significant differences in Cobb angle (P = 0.13). Before PF, there was no difference in pelvic obliquity (P = 0.26). At the time of fusion to the pelvis, estimated blood loss (P = 0.23) and operative time (P = 0.43) did not differ between index and revision groups. Percent correction in pelvic obliquity was similar for both groups (P = 0.72). Overall, 69 patients had complications requiring return to the operating room. Excluding the revision surgery for inclusion of the pelvis for the revision group, there was still a lower reoperation rate with index PF (22.9%, n = 62/271) than revision PF (50.0%, n = 7/14) (P = 0.02). Implant failures were significantly higher in the revision group (index = 7.4%, 20/271; revision = 42.9%, 6/14; P < 0.001). Conclusion. PF at the index spinal fusion led to similar correction of pelvic obliquity with approximately half the reoperation rate compared with PF at a revision surgery. Operative time and blood loss were similar between index and revision spinal fusion. Level of Evidence: 4 Pelvic fusion at index spinal fusion led to similar correction of pelvic obliquity with half the reoperation rate compared to PF at revision surgery. While we would intuitively think that extension to the pelvis is a relatively small procedure, operative time and blood loss were similar to the index fusion. ∗Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA †Emory University Hospital, Atlanta, GA ‡Columbia University Medical Center, New York, NY §Boston Children's Hospital, Boston, MA. Address correspondence and reprint requests to David L. Skaggs, MD, MMM, Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA 90027; E-mail: [email protected] Received 21 May, 2018 Revised 27 August, 2018 Accepted 7 September, 2018 The manuscript submitted does not contain information about medical device (s)/drug (s). No funds were received in support of this work. Relevant financial activities outside the submitted work: board membership, consultancy, stocks, grants, payment for lecture, patents, royalties.

Marchand, Andrée-Anne;Tétreau, Charles;O'Shaughnessy, Julie;Descarreaux, Martin

doi: 10.1097/BRS.0000000000002896pmid: 30312270

Study Design. An observational prospective study. Objective. The study objective was to assess the reliability and validity of the French-Canadian version (FCSSSQ) of the Swiss Spinal Stenosis questionnaire (SSSQ). Summary of Background Data. The SSSQ is a validated disease-specific tool developed to assess pain, function, and satisfaction with care in patients with lumbar spinal stenosis (LSS). Methods. The French-Canadian translation and adaptation of the SSSQ was completed following a four-stage approach: (1) forward translation; (2) synthesis; (3) expert committee review; and (4) testing of the questionnaire prefinal version. Psychometric properties were subsequently determined in patients who had undergone decompressive surgery for degenerative LSS. Patients completed the SSSQ adapted version, the Numerical Rating Scale, and the Oswestry Disability Index. Test-retest reliability was assessed with weighted Kappa score and intraclass correlation coefficient. Construct validity was evaluated using the Spearman correlation coefficient and responsiveness with the mean standardized response as well as the area under the receiver operating characteristic curve (AUROC). Floor and ceiling effects and internal consistency were also evaluated. Results. Twenty-five and 50 patients were included for the adaptation and validation processes, respectively. The test-retest reliability of the FCSSSQ total score was excellent [intraclass correlation coefficient (ICC) = 0.996; 95% confidence interval (95% CI) 0.938–0.982]. High Spearman correlation coefficients were also found between the total FCSSSQ score and the leg pain Numerical Rating Scale (NRS, 0.801), back pain NRS (0.705), and the Oswestry Disability Index (ODI, 0.825) scores. External responsiveness analysis was satisfactory with an AUROC of 0.875 (95% CI 0.744–1.0). The lowest FCSSSQ possible score was observed in five patients (10%), whereas no patients reported the highest possible score. The Cronbach α coefficient ranged from 0.810 to 0.945 indicating good to excellent internal consistency. Conclusion. The French-Canadian version of the SSSQ is a reliable and valid questionnaire consistent with the original English version. This new version will help French-speaking clinicians and scientists document changes in condition and treatment satisfaction in patients with LSS. Level of Evidence: 2 The Swiss Spinal Stenosis Questionnaire is a tool for patients with lumbar spinal stenosis. In this study, we propose a French-Canadian adapted version that is reliable and valid consistent with the original English version. This version should help French-speaking clinicians and scientists document changes in patients with lumbar spinal stenosis. ∗Department of Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada †Department of Human Kinetics, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada ‡Department of Chiropractic, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada. Address correspondence and reprint requests to Andrée-Anne Marchand, DC, MSc, 3351 boulevard des Forges, Trois-Rivières, QC G9A 5H7, Canada; E-mail: [email protected] Received 6 July, 2018 Revised 15 August, 2018 Accepted 10 September, 2018 The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No relevant financial activities outside the submitted work. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.spinejournal.com).

Hirsch, Brandon P.;Khechen, Benjamin;Patel, Dil V.;Cardinal, Kaitlyn L.;Guntin, Jordan A.;Singh, Kern

doi: 10.1097/BRS.0000000000002881pmid: 30234800

Study Design. A retrospective analysis. Objective. The aim of this study was to investigate differences in perioperative outcomes between patients undergoing revision minimally invasive lumbar spine decompression (MIS LD) in the ambulatory and hospital-based surgical settings. Summary of Background Data. Revision LD has been associated with an increased risk of complications compared with primary LD. Furthermore, ambulatory primary LD has been demonstrated to be a safe and viable option in appropriately selected patients. However, there is a paucity of information comparing hospital-based versus ambulatory outcomes in revision LD. Methods. A prospectively maintained surgical registry of patients undergoing revision MIS lumbar laminectomy and/or discectomy for degenerative pathology from 2013 to 2017 was retrospectively reviewed. Propensity score matching was performed to adjust for measured confounding variables, including patient age, comorbidity burden as measured by Charlson Comorbidity Index, and preoperative diagnosis. Differences in operative variables, complication rates, pain scores, narcotics consumption, and reoperation rates were assessed using Pearson Chi-squared analysis (categorical) and Student t test (continuous). Results. Seventy patients were included, of whom 35 underwent revision MIS LD at a hospital-based center (HBC), and 35 underwent surgery at an ambulatory surgical center (ASC). HBC and ASC patients demonstrated similar postoperative visual analog scale pain scores and hourly narcotics consumption during surgical stay (P < 0.001). ASC patients exhibited a significantly shorter length of stay than hospital-based patients (2.7 vs. 11.6 hours, P < 0.001). Conclusion. Patients undergoing revision MIS LD in an ASC demonstrated similar perioperative outcomes as compared to patients undergoing revision MIS LD in a HBC. These results suggest that revision MIS LD can be performed safe and effectively in the ambulatory setting in an appropriately selected surgical population. Further study of patient outcomes following spine surgery performed outside of the traditional hospital setting is crucial, as the delivery of care in the ambulatory setting continues to grow in popularity. Level of Evidence: 3 This study compares outcomes in patients who underwent a revision minimally invasive lumbar decompression (MIS LD) in an ambulatory surgery or hospital-based center. The results demonstrate that revision MIS LD can be safe and effectively performed in either setting. Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL. Address correspondence and reprint requests to Kern Singh, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612; E-mail: [email protected] Received 30 April, 2018 Accepted 31 August, 2018 The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: board membership, consultancy, grants, royalties, stocks.

Yoshida, Go;Ando, Muneharu;Imagama, Shiro;Kawabata, Shigenori;Yamada, Kei;Kanchiku, Tsukasa;Fujiwara, Yasushi;Tadokoro, Nobuaki;Takahashi, Masahito;Wada, Kanichiro;Yamamoto, Naoya;Kobayashi, Sho;Ushirozako, Hiroki;Kobayashi, Kazuyoshi;Yasuda, Akimasa;

Chung, Weng Hong;Chiu, Chee Kidd;Ng, Sherwin Johan;Goh, Saw Huan;Chan, Chris Yin Wei;Kwan, Mun Keong

doi: 10.1097/BRS.0000000000002890pmid: 30299417

Study Design. Retrospective study of prospectively collected data. Objective. To analyze the incidence and the patterns of medial and lateral shoulder discordance among Lenke 1 and 2 patients. Summary of Background Data. Postoperative shoulder imbalance (PSI) is still common in Lenke 1 and 2 adolescent idiopathic scoliosis (AIS). This could be due to presence of medial dan lateral shoulder discordance. Methods. One hundred fifty-one Lenke 1 and 2 AIS patients were recruited. Lenke 1 curves were subclassified into Lenke 1-ve (flexible) (proximal thoracic side bending [PTSB] Cobb angle <15°) and 1+ve curves (stiff) (PTSB Cobb angle between 15° and 24.9°). T1 tilt represented “medial shoulder balance” and radiological shoulder height (RSH) represented “lateral shoulder balance.” We categorized patients into three concordant shoulder pattern types (medial balanced/lateral balanced [MBLB], medial imbalanced+ve/lateral imbalanced+ve (MI+ve/LI+ve), medial imbalanced–ve/lateral Imbalanced–ve (MI–ve/LI–ve), and six discordant shoulder pattern types. Results. The mean age was 16.2 ± 5.7 years. Eighty-one patients (53.6%) had concordant pattern and 70 patients (46.4%) had discordant pattern. Lateral shoulder imbalance was noted in 35.1% of patients and medial shoulder imbalance in 43.7% of patients. In Lenke 1–ve curves, 35 patients (68.6%) had concordant shoulder imbalance with medial imbalanced–ve/lateral imbalanced–ve (MI–ve/LI–ve) being the commonest pattern (68.6%). In Lenke 1+ve curves, 33 patients (55.0%) had concordant shoulder pattern with medial balanced/lateral balanced (MB/LB) being the commonest type (57.6%). In Lenke 2 AIS, 27 patients (67.5%) had discordant pattern with medial imbalanced+ve/lateral balanced (MI+ve/LB) being the commonest pattern (44.4%) (P value = 0.002). Conclusion. 46.4% Lenke 1 and 2 AIS patients had shoulder discordant pattern. This was more prevalent in Lenke 2 curves (67.5%). In Lenke 1-ve (flexible) curves, MI–ve/LI–ve pattern was the commonest pattern. In Lenke 1+ve curves (stiff), there were almost equal number of concordant and discordant shoulder pattern. In Lenke 2 patients, the most common pattern was MI+ve/LB. Level of Evidence: 4 Shoulder discordance was prevalent in 46.4% Lenke 1 and 2 patients. Most of the Lenke 1 −ve curves were concordant (68.6%). In Lenke 1 +ve, the prevalence of concordant (55.0%) and discordant (45.0%) shoulder pattern was almost equal. In Lenke 2, discordant shoulder imbalance was more common (67.5%). Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Address correspondence and reprint requests to Chris Yin Wei Chan, MD, MSOrth, Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia; E-mail: [email protected] Received 6 June, 2018 Revised 16 August, 2018 Accepted 10 September, 2018 The manuscript submitted does not contain information about medical device (s)/drug (s). No funds were received in support of this work. No relevant financial activities outside the submitted work.

Lee, Su Hun;Son, Dong Wuk;Lee, Jun Seok;Sung, Soon Ki;Lee, Sang Weon;Song, Geun Sung

doi: 10.1097/BRS.0000000000002887pmid: 30260831

Study Design. Retrospective study. Objective. To investigate whether loss of cervical lordosis (LCL) after laminoplasty can be predicted from specific preoperative dynamic radiograph measurements. Summary of Background Data. Recent studies have focused on the correlation between LCL after laminoplasty and T1 slope. These studies explain this correlation through the injury of the posterior neck muscular-ligament complex (PMLC); however, this muscle injury model could not explain the less kyphotic change in high T1s patients, as reported in some studies as controversy. We have focused on the PMLC constriction reservoir which was represented by extension function (EF). Methods. We retrospectively analyzed 50 consecutive patients who underwent open-door laminoplasty (>1-year follow-up). EF is defined as extension C2–7 Cobb angle (CA) minus neutral C2–7 CA (Ext CA – CA). LCL is defined as follow-up CA minus preoperative CA (CA [FU] – CA [PRE]), and significant kyphotic change was defined as LCL smaller than –10°. Results. The distribution of LCL was –3.70 ± 7.98 and the significant kyphotic change occurred in 20% of the patients (10/50). EF, C2–7 sagittal vertical axis (PRE), and C2 slope (PRE) were found to be risk factors for LCL by multiple linear regression analysis. The receiver operating characteristic curve analysis revealed that EF could predict the significant kyphotic change well than previously known risk factors. The cutoff value of EF was 14°. No significant kyphotic change occurred at EF greater than or equal to 14°. Upon limiting the number of patients with preoperative straight curvature (n = 28), there is also no significant kyphotic change occurred in any patient whose EF was greater than or equal to 14°. Conclusion. In our study sample, we found that there is no relation between T1 slope and LCL. We have identified a new factor, EF, that could predict LCL after laminoplasty. No significant kyphotic changes after laminoplasty occurred particularly when the EF was greater than or equal to 14°. Level of Evidence: 3 Our study sample showed no correlation between the T1 slope and LCL after laminoplasty, but there are significant correlation between EF and LCL. Especially, no significant kyphotic change occurred at EF ≥14°. This finding could be an important clue in determining the surgical options for straight curvature patients. ∗Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea †Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea ‡Department of Neurosurgery, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea. Address correspondence and reprint requests to Dong Wuk Son, MD, PhD, Department of Neurosurgery, Pusan National University Yangsan Hospital, 20 Geumo-Ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do 626-770, Republic of Korea; E-mail: [email protected] Received 18 July, 2018 Accepted 31 August, 2018 The manuscript submitted does not contain information about medical device (s)/drug (s). No funds were received in support of this work. No relevant financial activities outside the submitted work.

Kinoshita, Hideyuki;Orita, Sumihisa;Inage, Kazuhide;Yamauchi, Kazuyo;Abe, Koki;Inoue, Masahiro;Norimoto, Masaki;Umimura, Tomotaka;Eguchi, Yawara;Fujimoto, Kazuki;Shiga, Yasuhiro;Kanamoto, Hirohito;Aoki, Yasuchika;Furuya, Takeo;Suzuki, Miyako;

Du, Jerry Y.;Schell, Adam J.;Kim, Chang-yeon;Trivedi, Nikunj N.;Ahn, Uri M.;Ahn, Nicholas U.

doi: 10.1097/BRS.0000000000002875pmid: 30234819

Study Design. Retrospective case-control study. Objective. To determine incidence and timing of mortality following surgery for spinal epidural abscess (SEA), identify risk factors for mortality, and identify complications associated with mortality. Summary of Background Data. SEA is a serious condition with potentially devastating sequelae. There is a paucity of literature characterizing mortality following surgery for SEA. Methods. The National Surgical Quality Improvement Program (NSQIP) database was used. Patients with a diagnosis of SEA were included. A Cox proportional hazards model identified independent risk factors for 30-day mortality. A predictive model for mortality was created. Multivariate models identified postoperative complications associated with mortality. Results. There were 1094 patients included, with 40 cases of mortality (3.7%), the majority of which occurred within 2 weeks postoperatively (70%). Independent risk factors for 30-day mortality were age>60 years (hazard ratio [HR]: 2.147, P = 0.027), diabetes (HR: 2.242, P = 0.015), respiratory comorbidities (HR: 2.416, P = 0.037), renal comorbidities (HR: 2.556, P = 0.022), disseminated cancer (HR: 5.219, P = 0.001), and preoperative thrombocytopenia (HR: 3.276, P = 0.001). A predictive algorithm predicts a 0.3% mortality for zero risk factors up to 37.5% for 4 or more risk factors. A ROC area under curve (AUC) was 0.761, signifying a fair predictor (95% CI: 0.683–0.839, P < 0.001). Cardiac arrest (adjusted odds ratio [aOR]: 72.240, 95% confidence interval [CI]: 27.8–187.721, P < 0.001), septic shock (aOR: 15.382, 95% CI: 7.604–31.115, P < 0.001), and pneumonia (aOR: 2.84, 95% CI: 1.109–7.275, P = 0.03) were independently associated with mortality. Conclusion. The 30-day mortality rate following surgery for SEA was 3.7%. Of the mortalities that occurred within 30 days of surgery, the majority occurred within 2 weeks. Independent risk factors for mortality included older age, diabetes, hypertension, respiratory comorbidities, renal comorbidities, metastatic cancer, and thrombocytopenia. Risk for mortality ranged from 0.3% to 37.5% based on number of risk factors. Septic shock, cardiac arrest, and pneumonia were associated with mortality. Level of Evidence: 3 Using the National Surgical Quality Improvement Database, we found a 3.7% rate of 30-day mortality following operative intervention for spinal epidural abscess. Older age, diabetes, hypertension, respiratory comorbidities, renal comorbidities, metastatic cancer, and thrombocytopenia were risk factors for mortality. Septic shock, cardiac arrest, and pneumonia were associated with mortality. ∗Department of Orthopedics, University Hospitals Cleveland Medical Center, Cleveland, OH †MetroHealth Medical Center, Cleveland, OH ‡New Hampshire NeuroSpine Institute, Bedford, NH. Address correspondence and reprint requests to Jerry Y. Du, MD, 11100 Euclid Avenue, Cleveland, OH 44106; E-mail: [email protected] Received 26 July, 2018 Revised 18 August, 2018 Accepted 22 August, 2018 The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: grants. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.spinejournal.com).

,

doi: 10.1097/01.brs.0000557618.97305.ccpmid: 30921266

Lehr, A. Mechteld;Oner, F. Cumhur;Hoebink, Eric A.;Kempen, Diederik H.R.;van Susante, Job L.C.;Castelein, René M.;Kruyt, Moyo C.

doi: 10.1097/BRS.0000000000002882pmid: 30234805

Study Design. A multicenter, randomized, intrapatient controlled trial. Objective. This study investigated whether lumbar fusion patients blinded to the harvest site (A) can identify the iliac crest used for bone harvesting and (B) whether this iliac crest is more painful than the contralateral side. Summary of Background Data. Spinal fusion with iliac crest autograft is a frequently performed surgical procedure. A widely reported disadvantage of the harvesting procedure is potential donor site morbidity. This has driven the development of many bone graft substitutes. However, more recently the incidence and severity of donor site pain is debated, especially in lumbar fusion surgery. Methods. Ninety-two nontraumatic adult patients underwent a posterolateral (thoraco)lumbar fusion. Iliac crest bone graft was harvested unilaterally through the primary midline incision. At 6 weeks, 3 months, 6 months, and 1 year follow-up, patients were asked to identify the donor site and to rate pain in their back, left iliac crest and right iliac crest on a Visual Analogue Scale (VAS). Results. Ninety patients, 44 males and 46 females with a mean age of 54 years, were analyzed. The left/right distribution of the iliac crest donor site was 50/50 and 89% of the patients underwent a lumbar fusion below L3. Only 24% patients identified the harvest site correctly. Moreover, the VAS pain scores for the donor site and contralateral iliac crest did not differ and were at each timepoint lower than the scores for back pain. Conclusion. This study showed that, during the first year after lumbar fusion surgery via a single midline incision approach, patients could not reliably identify the iliac crest used for bone graft harvesting and this iliac crest was not more painful than the untouched contralateral iliac crest. Therefore, donor site pain should not be the main reason to use bone graft alternatives for lumbar spinal fusion. Level of Evidence: 2 Donor site pain after unilateral iliac crest bone graft harvesting for instrumented posterolateral lumbar fusion was analyzed in 90 adult patients blinded to the harvest site. Patients could not reliably identify the harvest site and this iliac crest was not more painful than the untouched contralateral iliac crest. ∗Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands †Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands ‡Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands §Department of Orthopaedic Surgery, Rijnstate Hospital, Arnhem, The Netherlands. Address correspondence and reprint requests to A. Mechteld Lehr, MSc, University Medical Center Utrecht, Department of Orthopaedic Surgery, HP G05.228, Postbox 85500, 3508 GA Utrecht, The Netherlands; E-mail: [email protected] Received 29 May, 2018 Revised 13 July, 2018 Accepted 31 August, 2018 The device is FDA-approved or approved by corresponding national agency for this indication. The Department of Orthopaedic Surgery of the University Medical Center Utrecht received a restricted academic research grant from NuVasive Inc (San Diego, CA) to partially fund this investigator-initiated study. Relevant financial activities outside the submitted work: grants.