Orthopedic Spine Surgery Research Articles

The impact of insurance coverage on access to orthopedic spine care.

Poor socioeconomic status is a significant barrier to health care in the United States. Policy changes have attempted to expand insurance coverage in hopes of improving access to care. These policies have prioritized primary care and preventative medicine. Access to specialty care, particularly orthopaedic care, has not received the same attention. This study examines access to orthopaedic spine surgery practices based on type of insurance coverage. Five offices with board certified orthopaedic spine surgeons were randomly contacted from each state. A fictitious patient provided a scripted surgical indication for their appointment. They provided their insurance coverage as either Medicare, Medicaid or a private plan. Timing of the provided appointment was recorded. Any appointment was subsequently canceled so as not to interfere with the practice's scheduling. Two hundred and thirty-four orthopaedic spine surgery practices were contacted between January and June of 2016. Eighty-six percent of practices accepted a private plan without primary care provider (PCP) referral. Greater than 99% of practices accepted privately insured patients if a PCP referral were included. Those with Medicare were able to obtain an appointment from 81% of practices. No practices contacted in this study offered an appointment to the caller with Medicaid. Policy changes have expanded insurance coverage in order to improve access to care for patients of low socioeconomic status. There was a significant barrier to accessing spine care for patients with Medicaid insurance. Access was greatest for those with private insurance followed by those with Medicare. This study demonstrates that there is a significant disparity in ability to access spine specialists despite having insurance coverage.

Associations between season and surgical site infections in orthopaedic foot and ankle surgery

BackgroundSurgical site infections (SSI) in orthopaedic surgery are common nosocomial complications that contribute significantly to patient morbidity and increased healthcare costs. While past studies support an increase in the incidence of SSI during the summer months in orthopaedic spine surgery and joint arthroplasty, there has not been any study examining the association between season and SSI in the setting of orthopaedic foot and ankle surgery. MethodsA retrospective analysis of data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011–2015 was conducted. 17,939 patients who received at least one of 218 CPT codes specific to orthopaedic foot and ankle surgery were identfied from the NSQIP database. Descriptive statistics of patient demographics, comorbidities, and complications were stratified by quarter of admission. ResultsOf the 17,939 patients, there were 4995 in the 1st quarter (27.8%), 4078 in the 2nd quarter (22.7%), 4333 in the 3rd quarter (24.2%), and 4533 in the 4th quarter (25.3%). The overall rate of surgical complications was 2.3%. The highest incidence of surgical complications was during the summer at 2.7% and the lowest was during the fall at 2.1% (p=0.338). The summer months also demonstrated the highest incidence of medical complications at 5.9% (p=0.524). There were significantly more women undergoing surgery in the winter and summer months (p=0.028). ConclusionThe surgical site infection rate in the setting of orthopaedic foot and ankle surgery was higher, although not significantly, in the summer months. Level of evidenceLevel III retrospective.

Low vitamin D levels affect outcomes of orthopedic spinal surgery: An observational study in clinical practice.

Low vitamin D is a major risk factor for osteoporotic fractures. Evidence also suggests correlation between deficiency and musculoskeletal pain. Non-interventional study in patients undergoing spine surgery to investigate links between vitamin D levels and clinical features. 25-OH vitamin D levels were assessed in two cohorts: Cohort 1 (vertebral fractures; VF) and Cohort 2 (other spinal issues; excluding VF). Lab values as well as painDETECT questionnaires, VAS and Oswestry Disability Index (ODI) were recorded. Follow-up visits were conducted a few days and 6 weeks postoperatively. One hundred and nine patients were enrolled. Mean VAS measured 72 mm in Cohort 1 and 55 mm in Cohort 2. Mean vitamin D concentrations were 16.8 ± 11 ng/ml in Cohort 1 and 18.3 ± 11 ng/ml in Cohort 2. VAS and ODI significantly correlated with vitamin D levels. Median painDETECT scores were 9 in Cohort 1 and 16 in Cohort 2. Six weeks postoperatively mean VAS was 31.4 ± 28 mm in Cohort 1 and 23.3 ± 21 mm in Cohort 2. Median painDETECT scores were 5 in both cohorts. Interactions are apparent between neuropathic pain and vitamin D serum levels. Consequently, vitamin D should be monitored in all patients requiring spinal surgery.

A Review of Current Clinical Applications of Three-Dimensional Printing in Spine Surgery.

Three-dimensional (3D) printing is a transformative technology with a potentially wide range of applications in the field of orthopaedic spine surgery. This article aims to review the current applications, limitations, and future developments of 3D printing technology in orthopaedic spine surgery. Current preoperative applications of 3D printing include construction of complex 3D anatomic models for improved visual understanding, preoperative surgical planning, and surgical simulations for resident education. Intraoperatively, 3D printers have been successfully used in surgical guidance systems and in the creation of patient specific implantable devices. Furthermore, 3D printing is revolutionizing the field of regenerative medicine and tissue engineering, allowing construction of biocompatible scaffolds suitable for cell growth and vasculature. Advances in printing technology and evidence of positive clinical outcomes are needed before there is an expansion of 3D printing applied to the clinical setting.

Device Related Pressure Ulcers Pre and Post Identification and Intervention

ProblemFrom 2014 to 2016, device related pressure injuries accounted for 62–81% of all hospital acquired pressure injuries. From January to June 2014, there were 5 BiPAP/CPAP pressure injuries noted, accounting for 3.579 injuries per 1000 ventilator days. In 2015, hospital data revealed that 26.5% of all hospital acquired pressure injuries occurred to prone surgical spine patients. MethodsCollaborative teams including respiratory therapists and operating room staff were convened and crafted new strategies. InterventionsAdhesive foam dressings on patient faces with BiPAP/CPAP masks and prior to orthopedic spinal surgery were used to prevent device and operating room positioning pressure injuries. ResultsFrom July to December 2014 there were 0 BiPAP/CPAP pressure injuries. After interventions in March of 2016 through the remainder of 2016, zero pressure injuries occurred when the adhesive foam dressings were applied to the potential pressure injury areas pre-operatively. ConclusionsWe used real time patient data to drive efforts and create a new culture in the pediatric setting that honors critical airway maintenance, operative room positioning, and preventative skin protection.

Risk factors associated with massive drainage after posterior spinal orthopaedic surgery for adolescent scoliosis

Objective: To identify risk factors that influence the massive drainage after posterior spinal orthopaedic surgery for adolescent scoliosis. Methods: A total of 1 461 patients from 11 to 18 years old diagnosed with adolescent scoliosis who underwent first posterior spinal orthopaedic surgery in affiliated Drum Tower Hospital, Medical School of Nanjing University between November 2010 and October 2015 were retrospectively reviewed. Patients were categorized on the basis of massive or normal drainage, with the boundary 30(th) percentile of drainage/estimated blood volume. Preoperative factors including age, gender, body mass index(BMI), ASA physical status, diagnostic type of scoliosis, main Cobb angle, laboratory tests, intraoperative factors including the number of fusion level and screws, tranexamic acid used or not, use of osteotomy and thoracoplasty, use of cell salvage technology, duration of operation, the volume of urine output, blood loss, fluid therapy and transfusion, postoperative factors including the length of hospital stay, number of transfusion, the volume of drainage, time of drain were collected. Univariate and multivariate analyses were used to determine risk factors which were independently associated with massive drainage. Results: The average drainage was (856.3±333.4)ml. 479(32.8%) patients had massive drainage(drainage≥30% of drainage/estimated blood volume). Multivariate analysis identified risk factors of massive drainage: BMI<17.63 kg/m(2), odds ratio(OR)=2.90, preoperative platelet count<190×10(9)/L (OR=1.67), preoperative main Cobb angle≥55 degrees(OR=1.66), number of fusion levels≥11(OR=2.33), number of screws≥15(OR=1.73), use of osteotomy(OR=1.54), intraoperative volume of crystalloids≥35.63 ml/kg(OR=1.40), intraoperative volume of colloids≥28.92 ml/kg(OR=1.82), intraoperative volume of transfusion≥19.55 ml/kg(OR=1.72), while the use of tranexamic acid(OR=0.26) was the only protective factor. Conclusion: BMI<17.63 kg/m(2,) preoperative platelet count<190×10(9)/L, preoperative main Cobb angle≥55 degrees, number of fusion levels≥11, number of screws≥15, use of osteotomy, intraoperative volume of crystalloids≥35.63 ml/kg, intraoperative volume of colloids≥28.92 ml/kg, intraoperative volume of transfusion≥19.55 ml/kg were risk factors associated with massive drainage after posterior spinal orthopaedic surgery for adolescent scoliosis, while the use of tranexamic acid could decrease the possibility of massive drainage.

Staphylococcus aureus Infections in German Patients with Type 2 Diabetes Mellitus after Orthopedic Surgery: Incidence, Risk Factors, and Clinical and Health-Economic Outcomes.

This study assessed Staphylococcus aureus infection risk in patients with type 2 diabetes mellitus (T2DM) undergoing an orthopedic knee, hip, or spine surgery. All patients with a diagnosis of T2DM in the period from 2010 to 2012 were identified from a German claims database. First inpatient knee, hip, or spine surgery was used as index date. Cumulative incidence of S. aureus infections was calculated for several time intervals. Risk factors were identified based on a multi-variable Cox regression analysis. A case control analysis was conducted to assess mortality, healthcare resource utilization, and healthcare costs of S. aureus. In total, 9,401 patients with T2DM underwent a knee, hip, or spine surgery. Mean age was 72.58 years, 63.32% were female, and 1.08% experienced an S. aureus infection in the 365-day follow-up period. The difference in all-cause direct treatment costs per patient-year between infected and non-infected patients was 24,437.50$. Mortality rates were 25.52% (S. aureus group) versus 5.22% (non-S. aureus group), based on a 365-day follow-up. Staphylococcus aureus is associated with a substantial healthcare burden and high mortality. Effective infection control measures should be considered to reduce post-surgical S. aureus infection risk in patients with T2DM.

27 - Surgical Intensity and Risk Factors for Prolonged Opioid Use following Spine Surgery

BACKGROUND CONTEXT: Concern is growing that use of prescription opioids following elective surgical interventions may predispose patients to chronic opioid use and abuse. This concern is especially prevalent for patients undergoing elective orthopedic procedures and spine surgery.

Preserving the Legitimacy of Board Certification

The aims of this discussion were to inform the medical community about the American Board of Cosmetic Surgery's ongoing attempts in Louisiana to achieve equivalency to American Board of Medical Specialties (ABMS) member boards so that its diplomates may use the term "board certified" in advertising and to ensure public safety by upholding the standards for medical board certification. In 2011, Louisiana passed a truth in medical advertising law, which was intended to protect the public by prohibiting the use of the term "board certified" by improperly credentialed physicians. An American Board of Cosmetic Surgery diplomate petitioned the Louisiana State Board of Medical Examiners to approve a rule that would establish a pathway to equivalency for non-ABMS member boards, whose diplomates have not completed training approved by the Accreditation Council for Graduate Medical Education (ACGME) in the specialty they are certifying. Physicians and physician organizations representing multiple specialties (facial plastic and reconstructive surgery, otolaryngology [head and neck surgery], orthopedic spine surgery, pediatric neurosurgery, dermatology, and plastic surgery) urged the Louisiana State Board of Medical Examiners to clarify its advertising policy, limiting the use of the term "board certified" to physicians who have completed ACGME-approved training in the specialty or subspecialty named in the certificate. The public equates the term "board certified" with the highest level of expertise in a medical specialty. When a certifying board does not require completion of ACGME or American Osteopathic Association (AOA)-accredited training in the specialty it certifies, the result is an unacceptable degree of variability in the education and training standards applied to its diplomates. Independent, third-party oversight of certifying boards and training programs is necessary to ensure quality standards are upheld. Any system that assesses a non-ABMS member or non-AOA-certified board for equivalency approval must ensure that the training and qualifications required by the non-ABMS or AOA board are equivalent in scope, content, and duration to those required by the ABMS and AOA. This issue must not be misconstrued as a "turf battle" between physicians of 2 competing specialties. Preserving the legitimacy of board certification is incumbent upon all medical specialties and subspecialties. This argument is a truthful, principled defense of the legitimacy of board certification.

Influence of two types of intraoperative colloids infusion on the renal function of adolescent patients with scoliosis: a retrospective study

Objective To compare the renal function between 6% hydroxyethyl starch(130/0.4) and 4% succinylated gelatin during posterior spinal orthopaedic surgery for adolescent patients with scoliosis. Methods One thousand and nineteen adolescent patients with scoliosis who had underwent posterior spinal orthopaedic surgery in Nanjing Drum Tower Hospital from November 2011 to October 2015 were retrospectively reviewed. According to the types of colloids, patients were divided into two groups: hydroxyethyl starch(group H, n=849) and succinylated gelatin(group G, n=170). Patients′ demographic and perioperative information including sex, age, ASA grade, BMI, duration of operation, the volume of intraoperative fluid therapy, blood loss, postoperative drainage, the length of hospital stay after surgery, perioperative blood transfusion and laboratory tests were collected and compared between the two groups. Results The incidence of acute kidney injury(AKI) in group H was higher than group G: 0.08% vs 0, but the difference was not statistically significant(P>0.05). With regards to length of hospital stay after surgery, blood transfusion or postoperative drainage, there were no significant differences between the two groups(P>0.05). Conclusions There were no significant differences in incidence of AKI between hydroxyethyl starch and succinylated gelatin during posterior spinal orthopaedic surgery for adolescent patients with scoliosis. Key words: Hydroxyethyl starch; Succinylated gelatin; Scoliosis; Acute kidney injury

Risk and Protective Factors Associated with Surgical Infections among Spine Patients.

The purpose of the study was to identify patient-specific and procedure-specific risk and protective factors associated with post-operative surgical site infections (SSIs) among surgical spine patients. CINAHL, PubMed, Ovid, Medline, and EBSCO databases were searched for articles within the past 10 years (January 2003-March 2015). The keywords and combinations used in the search included: Spine surgery, post-operative infection, risk factors, orthopedic infections. The search resulted in 842 articles of which 29 met inclusion criteria. This systematic review adheres to preferred reporting items for systematic reviews and meta-analyses guidelines. Evidence about patient-specific and procedure-specific factors associated with increased risk of post-operative SSIs among patients undergoing orthopedic spinal surgery is inconclusive. Gender (male), age, body mass index, cigarette smoking, diabetes mellitus, a history of infection and alcohol abuse were identified as common patient-specific risk factors. Blood transfusion, implantation, and steroid use were found to increase SSIs in certain studies and associated with no significant difference in other studies. Protective factors include the implementation of pre-operative elements to reduce infection; protocols addressing patient-related factors (smoking, weight, glucose) and operation-related factors (antibiotic prophylaxis, prosthetics, length of operation, and pre-operative cultures); incision drains placed intra-operatively; anterior approach; laminar-flow operating theater, and skin antisepsis using chlorhexidine. Interventions focusing on minimizing patient-specific risk factors and operation-specific risk factors and optimizing patient-specific protective factors and operation-specific protective factors are most effective in minimizing the likelihood of a post-operative infection among patients undergoing orthopedic spinal surgical procedures. The studies reviewed provide conflicting evidence relative to risk and protective factors.

Robert W. Williams: Forgotten Pioneer of Spinal Мicrosurgery.

In the 1970's many neurosurgeons gradually adapted microsurgical techniques to spine surgery as the benefits of magnification, illumination, and use of fine instruments in cranial surgery became apparent. In the early 1970 s, Robert W. Williams, а neurosurgeon in private practice in Las Vegas, Nevada, independently began to devise spinal microneurosurgical techniques with the goal of improving surgical outcome in lumbar and cervical surgery. Much of his initial work with microlumbar discectomies and microcervical foraminotomies was presented at annual meetings of the American Association of Neurological Surgeons and Congress of Neurological Surgeons in the 1970s and 1980s. An outsider to organized academic neurosurgery, Dг. Williams found his work was received cautiously and with significant skepticism. He found the orthopedic spine surgery community and journals more receptive, thus much of his earlier work was published in the orthopedic literature. This resulted in an orthopedic and neurosurgical following which was unique at that time. Dr. William's interesting career and contribution to spinal microsurgery is outlined, demonstrating the contributions to surgery, both neurological and orthopedic, that can be achieved by a neurosurgeon in private practice. N/A.

3. Basic IOM principles in orthopedic spine surgery

Intraoperative Neurophysiological Monitoring (IOM) during orthopedic spinal surgery has evolved, through numerous publications in the world literature; and has progressed to the point where the multimodal monitoring technique has become the gold standard for avoiding post-operative complications. The methods used include free-running electromyography (FREMG), triggered electromyography (TGEMG), somatosensory evoked potentials (SSEP) and trans-cranial motor evoked potentials (TCMEP). The basic issues in the application of these methods will be presented on a day-to-day basis in the operating room. We have had daily, practical experience in IOM of spinal orthopedic surgeries for over 21 years and this experience, has taught us some practical tips that make a difference, when making decisions in the operating theater. The continuing development and perfection of methods in orthopedic spinal surgery has not decreased the likelihood of intraoperative damage to the spinal cord and peripheral nerves. The risk ranges from faulty patient positioning; the modern practice of pedicle instrumentation where increased density of bilateral screws per level is the rule; to the recently developed and feared lateral trans-psoas approach. The purpose of this presentation is to help avoid pitfalls in obtaining adequate signals for analysis, deciding what the most important information is, and correlating this with the surgical timing in different orthopedic spinal surgeries. Finally, I will briefly discuss how to proceed in the presence of alarm parameters, and how to identify a false negative or a false positive result.

Factors impacting Press Ganey patient satisfaction scores in orthopedic surgery spine clinic

Background ContextPatient satisfaction is and will continue to become an important metric in the American health care system. To our knowledge, there is no current literature exploring the factors that impact patient satisfaction in outpatient orthopedic spine surgery clinic. PurposeThe purpose of this study was to determine which factors impact patient satisfaction in an outpatient orthopedic spine clinic. Study DesignThis is a case series, level of evidence IV. Patient SampleWe reviewed the Press Ganey Associates database to identify patients seen in an orthopedic spine surgery clinic from 2013 to 2015. Outcome MeasuresOutcome measures were self-reported, which included visual analog pain scores and Press Ganey satisfaction scores. MethodsRetrospective computerized Press Ganey survey review was performed to identify patient demographics and patient visit characteristics. Bivariate analysis was used by splitting the patient response into the following: 0–3 (not satisfied), 4–7 (somewhat satisfied), and 8–11 (satisfied). Kruskal-Wallis test and Fisher exact test were used to evaluate the significance of patient and visit characteristics. Any variable that had a p-value less than .20 was subjected to the Poisson regression model. ResultsOverall, 353 patients were seen in an orthopedic spine surgery clinic and completed the Press Ganey survey. Three hundred and thirty-two patients were satisfied with their visit. Patients who were satisfied had a mean pain score of 4.02; patients who were somewhat satisfied or not satisfied had a pain score of 7 and 6, respectively (p=.009). Of 21 patients who felt the provider did not spend enough time with him or her, five (24%) patients were not satisfied with their visit. Poisson regression model confirmed significance of pain score and “provider time spent with you.” Most impactful was “provider spent enough time with you” where a “yes, definitely” answer predicted a nearly 60% increase in Press Ganey overall satisfaction score. ConclusionsTwo patient variables that have a statistical significance on Press Ganey patient satisfaction scores were pain score and “provider spent enough time with you.”

The Establishment of a Predictive Model for Major Postoperative Complications in Spine Deformity Surgery and Evaluation of Its Clinical Application

Introduction Spinal orthopedic surgery is a risky method for the treatment of spinal deformity. Over the past years, despite of the remarkable progress in the field of spinal surgery, the major complications from spinal surgery still occur. The aim of this study was to establish a predictive model (The Chaoyang risk score) for major complications after surgery to treat spine deformity disease and evaluate its effect for clinical application. Methods Data were collected retrospectively from 245 consecutive patients who underwent surgery for spine deformity disease. We defined the major postoperative complications as the occurrence of infection, nerve injury, organ dysfunction, or death after surgery. The logistic coefficient, and the additive score by odds ratio was used to calculate logistic score. The Chaoyang risk score were applied to predict Postoperative Complications. A C statistic (receiver operating characteristic curve) was used to test discrimination of the model. Calibration was assessed by Hosmer-Lemeshow goodness-of-fit statistic. Results The result of logistic regression showed that preoperative nerve injury, medical history of spine deformity( &gt; 10years), time of surgery(&gt;5 hours), Maximal voluntary ventilation observed/predicted &lt; 50%, intraoperative osteotomy were independent factors for the complications. The simple logistic model of the Postoperative Complications risk score showed very good discriminatory ability (C statistic = 0.866 &gt; 0.75) and calibration (Hosmer-Lemeshow, p = 0.978 &gt; 0.05) in predicting Postoperative Complications. Conclusion The logistic algorithm of the Postoperative Complications risk score is a simple, objective, convenient and accurate scoring system which may be used to predict Complications after surgery to treat scoliosis disease.

Optimization and Simulation of Orthopedic Spine Surgery Cases at Mayo Clinic

Spine surgeries tend to be lengthy (mean time of 4 hours) and highly variable (with some surgeries lasting 18 hours or more). This variability along with patient preferences driving scheduling decisions resulted in both low operating room (OR) utilization and significant overtime for surgical teams at Mayo Clinic. In this paper we discuss the development of an improved scheduling approach for spine surgeries over a rolling planning horizon. First, data mining and statistical analysis was performed using a large data set to identify categories of surgeries that could be grouped together based on surgical time distributions and could be categorized at the time of case scheduling. These surgical categories are then used in a hierarchical optimization approach with the objective of maximizing a weighted combination of OR utilization and net profit. The optimization model is explored to consider trade-offs and relationships among utilization levels, financial performance, overtime allowance, and case mix. The new scheduling approach was implemented via a custom Web-based application that allowed the surgeons and schedulers to interactively identify best surgical days with patients. A pilot implementation resulted in a utilization increase of 19% and a reduction in overtime by 10%.

Defining Avoidable and Unavoidable Complications in Spine Surgery: A Survey-based Study of Spine Fellowship Directors.

A cross-sectional survey of orthopedic spine surgery fellowship directors in the United States. The aim of this study was to investigate whether consensus exists with respect to spine-related adverse events and certain hospital-acquired conditions (HACs) or "never events." As part of a broad effort to improve health care outcomes, providers are no longer reimbursed for HACs, which are deemed avoidable. Although some HACs are unquestionably preventable with proper quality control measures, research suggests that even scrupulous adherence to evidence-based guidelines cannot eliminate others. Surveys were distributed via email and post. Participants rated 27 HACs and selected spine-specific events on an ordinal scale. Interobserver reliability was assessed among all 46 spine directors (respondents) using the intraclass correlation coefficient (ICC), based on a two-way random effects model, assuming that the participants were a representative population sample of spine surgeons. Multivariable linear regression analyses were performed on each of the 27 complications to identify potential demographic factors that could be associated with variation among respondents in their ratings of "avoidable" to "unavoidable." Forty-six fellowship directors responded, of whom 98% were orthopedic spine surgeons. The majority (80.4%) of respondents had greater than 10 years' experience as a spine surgeon, and 66.7% had an annual surgical volume >201 cases. The multivariable linear regression analyses found that demographic factors were not predictive of the directors' ratings. The complications thought to be completely avoidable (median scores 1) included "Incompatible blood," "Retained foreign object," and "Wrong level surgery." The HAC considered least avoidable was "Site infection with risk factors" (median score 8). Among 17 spine-specific complications, "L4-L5 disc re-herniation within 3 months" (median score 9) was considered least avoidable. This survey suggests that orthopedic spine surgeons consider most "never events" neither avoidable nor unavoidable. There is strong consensus only about the HACs resulting from obvious medical error. 4.

Dogged Persistence: Harrington, Post-polio Scoliosis, and the Origin of Spine Instrumentation by Marc A. Asher

Reviewed by: Dogged Persistence: Harrington, Post-polio Scoliosis, and the Origin of Spine Instrumentation by Marc A. Asher Daniel J. Wilson Marc A. Asher. Dogged Persistence: Harrington, Post-polio Scoliosis, and the Origin of Spine Instrumentation. Traverse City, Mich.: Chandler Lake Books, 2015. xx + 395 pp. Ill. $30.00 (978-1-943338-01-6). Marc Asher’s Dogged Persistence is both a biography of Dr. Paul Harrington and a history of the development of his system of spine instrumentation designed to correct scoliosis. Harrington was one of the first surgeons in the post–World War II era to invent, manufacture, and use a system of metal rods to correct moderate to severe spinal curvatures. The existing system of using body casting to straighten the spine and maintain stability following a fusion of the vertebrae involved long periods of immobility and had a high failure rate. Harrington was convinced that he could design metal rods and connectors that could straighten and hold the spine in place with or without an accompanying fusion and without lengthy immobilization. Developing this procedure and instrumentation involved many years of trial and error and overcoming the resistance of his fellow orthopedic surgeons before spine correction using implanted instrumentation became commonplace in the 1960s. Harrington was born in Kansas City, Kansas, in 1911. Educated in the public schools of Kansas City, he was also a standout athlete in basketball and track. He later graduated from the University of Kansas and its medical school. Following graduation, he entered an orthopedic residency in Kansas City with the ambition of becoming “the top in orthopedic surgery” (p. 38). During World War II he served as a surgeon in an evacuation hospital in North Africa and in Europe following D-Day. After the war, Harrington and his wife moved the family to Houston where Harrington joined the newly created Texas Medical Center. He remained in Houston for the rest of his career and died there on November 29, 1980. [End Page 568] The polio epidemics of postwar America resulted in a significant increase in the number of young patients who developed scoliosis as the result of paralyzed or weakened muscles of the torso. Very involved in the care of polio patients in the Houston hospitals, Harrington by the early 1950s had developed a theory to support his evolving ideas on scoliosis treatment. Placing a great deal of emphasis on what he called the “dynamic stability and dynamic balance” (p. 98) of the spine, he designed his instruments to restore that balance. Asher devotes considerable attention to the details of Harrison’s efforts over two decades to design effective rods and connectors and then to modify them based on his experience in the operating room. Asher’s descriptions are helpfully supplemented by many of Harrington’s drawings of the instrumentation. Harrington’s extensive correspondence with Zimmer Manufacturing describes these changes in some detail and portrays the close collaboration as the company worked with the orthopedist to manufacture instrumentation to his specifications. Asher also recounts ways in which Harrington’s rods went from being an experimental instrumentation to an accepted technique in orthopedic spine surgery. Harrington’s rods and procedures initially met significant resistance from other surgeons, and Asher details Harrington’s efforts through publications and presentations to win acceptance for his methods. In addition, Asher describes in detail the creation of the Scoliosis Research Society in which Harrington was a charter member. Asher provides a detailed account of Harrington’s career and surgical innovations, but the reader is sometimes overwhelmed by minute changes in instrument specifications and by summaries of numerous orthopedic conference presentations. Some of this material could have been summarized. The book would also have been stronger had Asher given attention to the patients’ perspectives. It would have been helpful to know, for example, how patients regarded Harrington and how they responded to his surgical interventions. There are apparently patient letters in the Harrington papers, but Asher makes almost no use of them. Dogged Persistence is a traditional medical biography in which Asher emphasizes Paul Harrington’s career and the development of his innovative spinal instrumentation and surgery. Asher concludes that Harrington’s achievement was a significant advance in treating...

Zgodnje prednosti manj invazivne transforaminalne zatrditve ledvene hrbtenice v primerjavi s klasično odprto metodo

AbstractBackgroundLumbar interbody fusion is a standard operative procedure in orthopedic spine surgery. Morphological and functional changes in the multifidus muscle after an open procedure have led to the development of a minimally invasive technique, after which no such muscle changes were observed. MethodsSixty-four patients, with clinical and radiological criteria for one-level transforaminal lumbar interbody fusion were enrolled in our prospective randomized study between December 2011 and March 2014. They were randomized into two groups: open approach (33 patients) vs. minimally invasive approach (31 patients); one patient was excluded from each group due to postoperative complications. Independent samples T-test was used to compare average values of increase in creatin kinase (CK), which is an enzymatic marker of muscle injury, average surgical time, loss of blood during and after surgery, back pain according to the Visual Analogue Scale (VAS) and day of discharge from the hospital. ResultsStatistically important (P&lt; 0.001) lower blood loss (188 ml vs. 527 ml total), less CK increase (15 ukat/L vs. 29 ukat/L), lower VAS score after surgery (7.3 vs. 8.7) and earlier discharge from the hospital (3.5 days vs. 5.2 days) were observed in the minimally invasive transforaminal lumbar interbody fusion group. No significant difference in average surgical time was recorded. Conclusions Our results suggest, that minimally invasive transforaminal lumbar interbody fusion causes is associated with less muscle damage, lower blood loss, less post surgical pain and faster early rehabilitation, which is in accordance with previous studies.

The Internet as a communication tool for orthopedic spine fellowships in the United States

Background contextOrthopedic residents seeking additional training in spine surgery commonly use the Internet to manage their fellowship applications. Although studies have assessed the accessibility and content of Web sites in other medical specialties, none have looked at orthopedic spine fellowship Web sites (SFWs). PurposeThe purpose of this study was to evaluate the accessibility of information from commonly used databases and assess the content of SFWs. Study designThis was a Web site accessibility and content evaluation study. MethodsA comprehensive list of available orthopedic spine fellowship programs was compiled by accessing program lists from the SF Match, North American Spine Society, Fellowship and Residency Electronic Interactive Database (FREIDA), and Orthopaedicsone.com (Ortho1). These databases were assessed for accessibility of information including viable links to SFWs and responsive program contacts. A Google search was used to identify SFWs not readily available on these national databases. SFWs were evaluated based on online education and recruitment content. ResultsEvaluators found 45 SFWs of 63 active programs (71%). Available SFWs were often not readily accessible from national program lists, and no program afforded a direct link to their SFW from SF Match. Approximately half of all programs responded via e-mail. Although many programs described surgical experience (91%) and research requirements (87%) during the fellowship, less than half mentioned didactic instruction (46%), journal clubs (41%), and national meetings or courses attended (28%). Evaluators found an average 45% of fellow recruitment content. Comparison of SFWs by program characteristics revealed three significant differences. Programs with greater than one fellowship position had greater online education content than programs with a single fellow (p=.022). Spine fellowships affiliated with an orthopedic residency program maintained greater education (p=.006) and recruitment (p=.046) content on their SFWs. ConclusionsMost orthopedic spine surgery programs underuse the Internet for fellow education and recruitment. The inaccessibility of information and paucity of content on SFWs allow for future opportunity to optimize these resources.