Previous Spine Research Articles

Risk Factors for Peripheral Nerve Injury After 207,000 Total Hip Arthroplasties Using a New York State Database (Statewide Planning and Research Cooperative System)

BackgroundPeripheral nerve injury (PNI) is a devastating complication following total hip arthroplasty (THA). The purpose of this study was to identify risk factors for PNI after THA using a New York Statewide Planning and Research Cooperative System (SPARCS). MethodsThe SPARCS database was queried to identify patients who had undergone THA from 1996 to 2011. Patient demographics, medical history, surgical details, hospital characteristics, and in-hospital complications were recorded. Cases in which a new unilateral PNI was identified were compiled, as were control cases in which a new PNI did not occur. The characteristics of cases and controls underwent univariate testing and a multivariate logistic regression using Akaike information criterion model selection to identify risk factors for the development of PNI after THA. Results207,981 cases were identified, and 487 were coded as having a new PNI. Preexisting spinal conditions (odds ratio [OR] = 2.55, confidence interval [CI] = 1.61-3.83) were strongly correlated with the development of PNI postoperatively, as was dislocation (OR = 2.58, CI = 1.01-5.30) and diabetes with chronic complications (OR = 2.26, CI = 0.96-4.43). Younger age, in-hospital complications, and thromboembolic events were also associated with postoperative PNI. ConclusionThe incidence of PNI after THA was consistent with previous large-scale studies but may under-represent the true incidence because of undercoding inherent in large database studies. Previous spine disorder, chronic diabetes, younger age, and in-hospital postoperative complications all increased the risk of PNI. This study can help health-care providers and systems identify patients at higher risk of this serious complication.

Cervical Discogenic Pain Treatment with Percutaneous Jellified Ethanol: Preliminary Experience

Background Percutaneous DiscoGel® (Gelscom SAS, France), introduced in 2007 as a promising new minimal invasive technique, showed efficacy and safety in lumbar spine surgery, with limited use and scientific reports with regard to the cervical spine. Since the first publication of its use on the cervical spine (2010), less than 100 cases have been published. We introduce an initial experience with this relatively new procedure. We hypothesized that percutaneous DiscoGel® is a safe and effective option for chronic neck pain of cervical discogenic origin. Method This was a clinical study on 10 patients with chronic discogenic pain operated on for 18 cervical discs with percutaneous DiscoGel®. Inclusion criteria were patients with chronic axial or referred neck pain with MRI showing a cervical disc that is consistent with patient symptoms and failed conservative treatment. Exclusion criteria were clinical myelopathy, motor deficit, severe stenosis or reduced disc height by more than 50%, or previous cervical spine surgery. Results A total of 10 cases consisting of 6 females and 4 males underwent treatment with percutaneous DiscoGel® for 18 cervical discs. C5/C6 was the most affected level. The mean preoperative VAS score was 8; the postoperative VAS scores at 6 weeks and 3 months were 2.2 and 2.9, respectively. There were no postoperative complications or neurological deficits. Conclusion The present study has the limitation of the small number of cases; however, with the limited number of studies and less than 100 published cases in the literature, this initial work shows that cervical percutaneous DiscoGel® is an effective minimally invasive bridging option between conservative and open surgical treatment for cervical discogenic pain, with a high success rate. The differentiation of pain types (nociceptive, referred, radicular, and trapezius myalgia) that can coexist is crucial for procedure selection and improving treatment outcome.

Vertebral osteomyelitis due to Candida species.

We have noted an increased number of cases of vertebral osteomyelitis secondary to Candida species over the past few years at our facility. Our aim was to identify and review these cases to elucidate risk factors, treatment regimens and outcomes. We performed a retrospective chart review using our electronic medical record and microbiology laboratory database to identify cases of vertebral osteomyelitis due to Candida at a single teaching hospital from 2006-2018. We found 15 cases of Candida vertebral osteomyelitis. The majority of cases were due to Candida albicans and affected either the lumbar or the thoracic spine. Injection drug use and previous spine surgery were the two most common risk factors identified. Treatment was largely with intravenous antifungal induction followed by prolonged therapy with oral fluconazole. There was no short-term mortality though we lacked long-term follow-up on most patients. The number of vertebral infections due to Candida may be increasing. This may be partially driven by both a rise in intravenous drug use as well as the growing rate of spine surgery. Management following currently available guidelines seems favorable, though further studies are necessary to determine the optimal treatment regimen.

Reduced Impact of Obesity on Short-Term Surgical Outcomes, Patient-Reported Pain Scores, and 30-Day Readmission Rates After Complex Spinal Fusion (≥7 Levels) for Adult Deformity Correction

In the past decade, prevalence of obesity in the United States have been soaring at a disparaging rate. Previous spine studies have associated obesity with inferior surgical outcomes, increased complication and 30-day readmission rates, and worsening patient-reported outcomes. However, there is a paucity of data identifying whether the impact of obesity is sustained in patients undergoing complex deformity correction involving 7 levels or greater. The aim of this study was to determine whether obesity impacts surgical outcomes, patient-reported pain scores, and 30-day readmission rates after complex spinal fusions ≥7 levels. The medical records of 112 adult patients (≥18 years old) with spine deformity undergoing elective, primary complex spinal fusion (≥7 levels) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. Preoperative body mass index greater than or equal to 30 kg/m2 was classified as obese. Patient demographics, comorbidities, and intraoperative and postoperative complication rates were collected for each patient. Inpatient patient-reported pain scores and ambulatory status also were collected. The primary outcomes of this study were surgical outcomes, patient-reported pain scores, and 30-day readmission rates. Of the 112 patients, 33 (29.5%) were obese (obese: n = 33 vs. non-obese: n = 79). Patient demographics and comorbidities were similar between both cohorts, including age, sex, diabetes, hypertension, and home narcotic use. The median number of fusion levels operated, length of surgery, estimated blood loss, transfusion, and complication rates were similar between both cohorts. Moreover, the postoperative complication profiles between the cohorts also were similar, with a comparable length of hospital stay (obese: 6.5 ± 4.6 days vs. non-obese: 7.0 ± 3.9 days, P = 0.5833) and 30-day readmission rates (obese: 12.1% vs. non-obese: 13.9%, P = 0.7984). Baseline (P = 0.6826), first (P = 0.9691), and last (P = 0.9583) postoperative patient-reported pain scores were similar between cohorts. Analogously, ambulatory status was similar between the cohorts, including days from operating room to ambulation (P = 0.3471) and number of steps on first (P = 0.9173) and last (P = 0.1634) ambulatory day before discharge. Our study suggests that obesity does not significantly affect surgical outcomes, patient-reported pain scores, and 30-day readmission rates after complex spinal surgery requiring ≥7 levels of fusion. Further studies are necessary to corroborate our findings.

Spine Stabilization Is a Risk Factor for the Development of Pelvic Iliac Vein Lesions

Open lumbar spine stabilization surgery often requires mobilization of the left and right common iliac veins (CIVs) and the placement of plates and screws that can impinge on iliac veins. We reviewed our venography experience during the past 3 years to determine whether there is an association between spine stabilization surgery and the development of iliac vein lesions and symptomatic iliac vein outflow obstruction. A retrospective chart review was performed to identify patients who underwent venography with or without venous stenting and who had a history of previous lumbar spine stabilization. From January 2014 to April 2018, venography were performed in 1713 limbs in 1245 patients at the Center for Vascular Medicine. Of the 1245 patients, 17 patients had a history of lumbar spine stabilization procedures (4 anterior-posterior and 13 posterior). Nine had single-level and eight had two- or three-level fusions. All 17 patients demonstrated pelvic lesions, which included the following: one left CIV aneurysm, five left CIV stenoses, three bilateral CIV stenoses, two left CIV and inferior vena cava occlusions, and two external iliac vein stenoses. The aneurysm patient was treated with anticoagulation. Eight patients underwent stenting, and one patient refused stenting because of relocation to another country. One inferior vena cava-CIV occlusion could not be crossed. Fear of dislodging a thrombus and the proximity to a protruding posteriorly placed screw prevented stenting in two patients. Four patients had a venoplasty alone because of undersizing of a stenosis or missed lesions with intravascular ultrasound after review by a blinded reviewer. Lesions in anterior-posterior patients were extremely stenotic, required predilation, and resulted in a residual stenosis requiring venoplasty at a second setting in one patient. Lumbar spine stabilization surgery may be a risk factor for development of symptomatic venous outflow obstruction lesions. During venography and stenting in patients with anterior-posterior approaches, significant scarring may be encountered, resulting in a residual stenosis after stent placement. Predilation venoplasty, before stent deployment, is recommended to prevent stent migration. Furthermore, a history of spine stabilization surgery in patients presenting with pelvic or lower extremity pain or swelling should prompt consideration of a pelvic venous duplex ultrasound examination to assess for the presence of an iliac venous outflow lesion.

Not Every Low Back Pain is a Radiculopathy

A 66-year-old man with a history of chronic low back pain and three previous spine surgical procedures presented with new onset, acute, excruciating low back pain with dysesthesias radiating to the left leg, left leg weakness, and difficulty walking.

Added value of [18F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of post-operative instrumented spine infection.

Post-operative instrumented spine infection (PISI) is an infrequent complication. Diagnosis of spinal implant infection can be difficult, especially in case of chronic infection. This retrospective study attempts to evaluate the diagnostic performance of [18F]fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) in PISI. Imagings were performed between April 2010 and June 2018 among patients referred for suspected chronic spinal implant infection. PET/CT were performed more than 12 weeks after surgery. PET/CT images were re-interpreted independently by two nuclear medicine physicians without knowledge of the patient's conditions. PET/CT data were analyzed both visually and semi-quantitatively (SUVmax). MRI results were collected from medical records. The final diagnosis of infection was based on bacteriological cultures or a twelve-month follow-up. Forty-nine PET/CT were performed in 44 patients (22 women, median age 65.0 years). Twenty-two patients had a diagnosis of infection during follow-up. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for PET/CT were 86.4%, 81.5%, 79.2%, and 88.0%. Sensitivity, specificity, PPV and NPV were 66.7%, 75.0%, 66.0%, 75.0% respectively for MRI and 50.0%, 92.6%, 84.6% and 69.4% for serum C-reactive protein (CRP). Although these values were higher for PET/CT than for MRI or CRP, the differences were not statistically significant. In this setting, false positives with PET/CT can be observed in case of previous spine infection or adjacent segments disc disease. False negatives can result of extensive instrumented arthrodesis or infection with low virulence bacteria. PET/CT is useful for the diagnosis of PISI. These results should be evaluated in further prospective study.

Outcomes of Hip Arthroscopy in Patients With Previous Lumbar Spine Surgery: A Matched-Pair Controlled Comparative Study With Minimum Two-Year Follow-Up

The purpose of this study was to conduct a matched-pair analysis to determine the effect of prior lumbar spine surgery (LSS) on clinical outcomes of hip arthroscopy. Data were prospectively collected on all patients undergoing hip arthroscopy during the study period from April 2008 to December 2012. Patients were excluded if they had previous hip conditions or had undergone prior hip surgery. Patients in the LSS group (history of LSS) were matched in a 1:1 ratio to a control group (no history of LSS) according to age ±5years, gender, body mass index categories, Tönnis grade, and labral treatment. The following outcomes were recorded in each group: modified Harris Hip Score, Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale, Hip Outcome Score-Activities of Daily Living, and visual analogue scale (VAS) score for pain, patient satisfaction, and rates for revision hip arthroscopies and conversion to total hip arthroplasty (THA). During the study period, 1,405 hip arthroscopies were performed with 1,017 eligible for matching. A total of 873 (85.8%) patients had a minimum 2-year follow-up. Fifty-seven patients were matched in each group. Both groups demonstrated significant improvement in patient-reported outcome (PRO) and VAS scores. The LSS group had a lower mean for all preoperative PRO scores. There was no significant difference for the postoperative mean PRO score and change in the PRO score compared with the control group except for NAHS. The mean change in the NAHS demonstrated a greater magnitude of improvement in the LSS group. There was no significant difference between mean VAS scores, patient satisfaction, and rates for revision arthroscopy and conversion to THA between the groups. Prior LSS does not adversely affect outcomes of hip arthroscopy at a minimum 2-year follow-up. These patients have lower preoperative scores but similar magnitude of improvement and revision/THA rates compared with a matched comparative group of patients without prior LSS. Level II, retrospective analysis of prospectively collected data.

Assessment of Glycosaminoglycan Content of Lumbar Intervertebral Discs in Patients with Radiculopathy

Objective: To assess glycosaminoglycan (GAG) content of lumbar intervertebral discs (IVDs) in patients with radiculopathy compared with healthy volunteers with glycosaminoglycan chemical exchange saturation transfer (gagCEST). Methods: The lumbar spines of 15 patients with radiculopathy (9 women, 6 men; mean age 45 years; range: 19 - 80 years) and 13 healthy controls (10 women, 3 men; mean age 29 years; range: 19 - 38 years) without lumbar back pain or previous spine surgery were examined at a 3 Tesla (T) magnetic resonance imaging (MRI) scanner in this prospective study. The MRI protocol included standard morphological, sagittal, and transverse T2-weighted (T2w) images of the five lumbar IVDs (L1-S1) to assess Pfirrmann score and to detect disc disorders according to the Combined Task Force classification. To analyze biochemically the lumbar IVDs, a gagCEST sequence was applied to measure the GAG content of the nucleus pulposus (NP) and annulus fibrosus (AF). Results: Patients with radiculopathy indicated significantly lower gagCEST values in NP than healthy volunteers (2.82% ± 3.12% vs. 4.09% ± 2.25%, P = 0.017). The GAG content of AF showed no significant difference between volunteers and patients (2.66% ± 2.01% vs. 1.92% ± 2.56%; P = 0.175). Conclusions. Patients with radiculopathy presented with lower GAG values than healthy volunteers in NP, indicating an association between pain and IVD degeneration. gagCEST of lumbar IVDs is a powerful, non-invasive tool to investigate early disc degeneration, which we could demonstrate in the NP in our study collective.

Intrathecal administration of nusinersen in adolescent and adult SMA type 2 and 3 patients

Spinal muscular atrophy is a genetic motor neuron disease that leads to progressive muscular atrophy and muscle weakness. In December 2016, the Food and Drug Administration, and in June 2017, the European Medicines Agency approved the antisense oligonucleotide nusinersen for treatment of spinal muscular atrophy. Nusinersen has to be repeatedly administered intrathecally. Due to the clinical features of SMA, the application of the ASO by lumbar puncture can be challenging in symptomatic patients considering the frequently observed scoliosis, previous spine fusion surgeries, joint contractures, and respiratory insufficiency. To evaluate safety and feasibility of the intrathecal treatment in adolescent and adult SMA type 2 and 3 patients, we analyzed 93 lumbar punctures, monitored number of lumbar puncture attempts, duration of the procedure, injection site, and needle length. Oxygen saturation during the intervention, medication for sedation and local anesthesia, adverse events related to lumbar punctures, and macroscopic analysis of CSF were recorded. Moreover, we analyzed the use of CT-scans for performing lumbar punctures and its associated radiation exposure. Performing lumbar puncture for the intrathecal administration of nusinersen in adolescent and adult patients with later-onset SMA is feasible and safe, even in patients with complex spinal anatomies and respiratory insufficiency. To guarantee the quality of the procedure, we recommend establishing an experienced interdisciplinary team consisting of neurologists and/or neuropediatricians, anesthesiologists, orthopedic surgeons, and/or neuroradiologists.

COMBINED USE OF VIDEO LARYNGOSCOPY AND FIBEROPTIC FOR AIRWAY MANAGEMENT IN A PATIENT WITH FIXED CERVICAL SPINE

Airway management may be difficult in patients with fixed cervical spine who have undergone previous spine surgery. Among the various techniques, fiber-optic intubation is a preferred method for securing the airway in such situation. However, it has some limitations also like identification of landmarks, especially in a case of distorted anatomy of the airway. To overcome this inadequacy, we used video laryngoscopy as a complement, to guide the tip of bronchoscope beneath the epiglottis into the trachea and thus achieving the goal. We present a case of difficult airway of fixed cervical spine with distorted anatomy in which combined use of fiberoptic and video laryngoscopy was performed to secure the airway. In our opinion, this technique can be utilized for other difficult airway case scenario also.

Non-neurologic adverse events after complex adult spinal deformity surgery: results from the prospective, multicenter Scoli-RISK-1 study

PurposeAccurate information regarding the expected complications of complex adult spinal deformity (ASD) is important for shared decision making and informed consent. The purpose of the present study was to investigate the rate and types of non-neurologic adverse events after complex ASD surgeries, and to identify risk factors that affect their occurrence.MethodsThe details and occurrence of all non-neurologic adverse events were reviewed in a prospective cohort of 272 patients after complex ASD surgical correction in a mulitcentre database of the Scoli-RISK-1 study with a planned follow-up of 2 years. Logistic regression analyses were used to identify potential risk factors for non-neurologic adverse events.ResultsOf the 272 patients, 184 experienced a total of 515 non-neurologic adverse events for an incidence of 67.6%. 121 (44.5%) patients suffered from more than one adverse event. The most frequent non-neurologic adverse events were surgically related (27.6%), of which implant failure and dural tear were most common. In the unadjusted analyses, significant factors for non-neurologic adverse events were age, previous spine surgery performed, number of documented non-neurologic comorbidities and ASA grade. On multivariable logistic regression analysis, previous spine surgery was the only independent risk factor for non-neurologic adverse events.ConclusionsThe incidence of non-neurologic adverse events for patients undergoing corrective surgeries for ASD was 67.6%. Previous spinal surgery was the only independent risk factor predicting the occurrence of non-neurologic adverse events. These findings complement the earlier report of neurologic complications after ASD surgeries from the Scoli-RISK-1 study.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Aortic pulsation prevents the development of ossification of anterior longitudinal ligament toward the aorta in patients with diffuse idiopathic skeletal hyperostosis (DISH) in Japanese: Results of chest CT-based cross-sectional study

BackgroundThe development and etiology of diffuse idiopathic skeletal hyperostosis (DISH) were far from complete understanding. Even the precise mechanism of the development of its typical right-sided ossification of the anterior longitudinal ligament (OALL) frequently compared to ‘flowing candle wax’, a hallmark of DISH, remains unknown. MethodsThe participants of this study were 261 individuals (31 females and 230 males) diagnosed as DISH according to the criteria established by Resnick and Niwayama extracted from a consecutive 3013 patients who have undergone chest CT for the examination of pulmonary diseases in our institute. The patients with previous thoracic spine surgery and younger than 15 years old were excluded. Chest CT data were converted to the condition suitable for bone evaluation by the software application. The positional relationship between thoracic aorta and OALL, the morphology of the OALL adjacent to the aorta and the presence of calcification of the aortic wall adjacent to the OALL were studied. ResultsOf 261 individuals with DISH, we found that thoracic aorta was localized adjacent to the OALL (AD-group) in 123 cases (47%), whereas 138 cases (53%) were not (NAD-group). All OALL in AD-group was localized between T6 and T12. The shape of the OALL adjacent to the aorta was either flat or concave except for one. No case showed obvious calcification of the aortic wall adjacent to the OALL in AD-group. ConclusionsThe aortic pulsation might play an important role in inhibit the development of the OALL toward the aorta in DISH. It is likely that establishment of the optimal condition of the pulsation stress simulating aortic pulsation and its delivery system can achieve arresting, slowing the progression and/or changing the morphology of the ossified lesions.

Clinical experiences with a PEEK-based dynamic instrumentation device in lumbar spinal surgery: 2\xa0years and no more

BackgroundDynamic spine implants were developed to prevent adjacent segment degeneration (ASD) and adjacent segment disease (ASDi). Purpose of this study was to investigate the clinical and radiological outcomes of “topping off” devices following lumbar spinal fusion procedure using a PEEK-based dynamic rod system. Moreover, this study focused on the hypothesis that “topping off” devices can prevent ASD.MethodsThis prospective nonrandomized study included patients with indication for single-level lumbar fusion and radiological signs of ASD without instability. The exclusion criteria were previous lumbar spine surgery and no sign of disc degeneration in the adjacent segment according to magnetic resonance imaging. All patients were treated with single-level lumbar interbody fusion and dynamic stabilization of the cranial adjacent segment. Patients underwent a clinical examination and radiographs preoperatively and at 1 and 2 years after surgery. Analyses were performed on clinical data collected with the German Spine Registry using the core outcome measure index (COMI) and visual analogue scale (VAS) scores for back and leg pain.ResultsA total of 22 patients (6 male and 16 female) with an average age of 57.6 years were included in the study; 20 patients completed the follow-up (FU). The average COMI score was 9.0 preoperatively, 4.2 at the 1-year FU, and 4.7 at the 2-year FU. The average preoperative VAS scores for back and leg pain were 7.7 and 7.1, respectively. At the 1-year FU, the scores were 4.25 for back pain and 2.2 for leg pain, and at the 2-year FU, the scores were 4.7 for back pain and 2.3 for leg pain. At FU, failure of the dynamic topping off implant material was verified in four cases, and ASD of the segment cranial to the topping off was confirmed in three cases.ConclusionsThese results demonstrate significant improvements in clinical outcomes and pain reduction after lumbar spinal fusion with topping off at 2 years after surgery. However, the implant failed due to the high rate of implant failure and the development of ASD in the segment cranial to the dynamic stabilized segment.

Wednesday, September 26, 2018 3:35 PM – 5:05 PM Preserving Spinal Motion: 87. Posterior cervical foraminotomy for cervical radiculopathy: should cervical sagittal alignment be considered?

BACKGROUND CONTEXT Despite an increasing trend for anterior approach, microsurgical and endoscopic advances have enabled excellent outcomes by minimally invasive posterior cervical foraminotomy with motion preservation, for managing cervical radiculopathy. On the other hand, the poserior approach inherently compromises posterior column integrity, where roughly two-thirds of cervical load is transmitted. Hence, surgeons often avoid posterior cervical foraminotomy in patients presenting with imaging evidence of kyphosis or straightening to prevent postoperative kyphotic deformity. PURPOSE To determine interval changes in cervical segmental angles after postrior cervical foraminotomy and analyzing factors affecting cervical sagittal re-alignment in the postoperative period. STUDY DESIGN/SETTING In this retrospective study, we reviewed interval change in cervical segmental angles after posterior cervical foraminotomy. analyzing factors affecting cervical sagittal re-alignment in the immediate postoperative period and at 6-months follow-up. PATIENT SAMPLE Between January, 2007 and January, 2013, a total of 289 consecutive patients underwent key-hole post cervical foraminotomy at single center for unilateral radiculopathy due to degenerative cervical disease. Patients with myelopathy, neoplasm, congenital deformity, fracture, or history of previous cervical spine surgery were excluded, as were patients with focal instability at affected levels. Pathology predisposing to radiculopathy was softened disc (n=157), foraminal stenosis (n=116), or both (n=16). OUTCOME MEASURES On admission, prior to postoperative radiographs and 6 months after operation follow-up in outpatient, patients were routinely asked to gauge levels of pain they feeling at that point in time by VAS and it was recorded in medical chart. METHODS Within 2 days and 6 months after posterior cervical foraminotomy, postoperative plain radiographs were obtained to compare the cervical sagittal alignment with preoperative alignment in 289 consecutive patients. Sagittal alignment was evaluated using Cobb's angle between C2 and C7 formed by lines drawn at the base of axis and the superior endplate of the C7 vertebral body on the lateral radiograph. To evaluate the clinical outcomes, patients were routinely asked to gauge levels of pain they experienced by VAS on admission, prior to postoperative radiographs and 6 months after operation follow-up in outpatient. RESULTS More than two-third of the patients presenting with kyphotic or straight curvature improved short-term following operation. On follow-up plain radiographs after 6 months, the improvement of sagittal alignment was well maintained, but rather more prominent. Improvement in sagittal alignment was dominant when radiculopathy was due to softened discs, rather than stenosis, and with shorter symptom duration. Patient age had no significant impact on outcomes. In patients with higher preoperative VAS score, Cobb's angle was significantly lower, and as perioperative VAS score declined, sagittal alignment improved significantly. CONCLUSIONS Overall, our data suggest that loss of preoperative cervical lordotic curvature may be a distorted reflection due to pain. Particularly in acute-onset radiculopathies from softened discs, posterior cervical foraminotomy is thus a valid surgical option, despite preoperative loss of normal lordotic sagittal alignment. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P39. Modic 2 changes and smoking predict vascular adherence during anterior lumbar exposure

BACKGROUND CONTEXT An anterior approach to access lumbar intervertebral discs risk major vascular injury and significant bleeding. We aimed to identify predictive factors for vascular adherence to allow pre-operative planning and technique modification. METHODS Retrospective analysis of a prospectively collected database was performed of consecutive patients undergoing anterior retroperitoneal exposure for lumbar disc surgery from 2009 to 2016. Data collected included demographic factors, smoking status, MRI findings, operative parameters and difficulty of dissection due to vascular adherence (standard or difficult). Smokers were defined as those currently smoking or had ceased smoking within 6 months of operation. Exclusion criteria were morbid obesity, previous anterior spine surgery or radiotherapy. RESULTS Multivariate analysis of 246 patients (mean age 42.5years (21–80), male 50%) demonstrated two statistically significant risk factors – Modic 2 changes on MRI (P=.009) and smoking status (p=.007). Of 57 patients with Modic 2 changes at the operative level, 16 had a difficult dissection due to vascular adherence (28%). Of 189 patients without Modic 2 changes, only 25 patients had a difficult dissection (13%) (p=.014). Patients with Modic 2 changes were 2.1times more likely to have vascular adherence.Of 125 nonsmoking patients, 13 had a difficult dissection (10%). Of 83 ex-smokers, 19 had a difficult dissection (23%) and of 38 current smokers, nine had a difficult dissection (24%). Overall, of the 121 smokers (ex- and current), 28 had a difficult dissection (23%) (p=.01). Patients with any smoking history were 2.2times more likely to have vascular adherence. CONCLUSIONS Modic 2 changes on MRI and any smoking history predicted adherence of the large vessels to the anterior disc annulus leading to a more difficult dissection. These two predictors should alert the surgeon to the potential for a challenging dissection and major vascular injury.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Understanding Lumbar Stenosis/Spondylolisthesis: 9. The relationship between spinopelvic parameters and baseline pain, function or health related quality of life in degenerative lumbar spondylolisthesis

BACKGROUND CONTEXT The importance of sagittal balance and spinopelvic parameters are recognized in the management and outcomes of adult spinal deformity and isthmic spondylolisthesis, but less is known regarding their role in degenerative lumbar spondylolisthesis (DLS). The purpose of this study is to determine the influence of baseline sagittal balance and spinopelvic parameters on pain, function, and health-related quality of life (HRQOL) of patients presenting with DLS. PURPOSE The purpose of this study is to determine the influence of baseline sagittal balance and spinopelvic parameters on pain, function, and health-related quality of life (HRQOL) of patients presenting with DLS. STUDY DESIGN/SETTING Prospective, multi-center study from the Canadian Spine Outcome and Research Network (CSORN). PATIENT SAMPLE Patients with DLS were enrolled in a prospective, multi-center study between 2015 and 2017. Inclusion into this study required DLS at 1 or 2 levels and symptoms of neurogenic claudication or radicular pain with our without back pain. Patients were excluded if they had previous lumbar spine surgery or the presence of another condition which significantly affected function OUTCOME MEASURES Patient-rated outcome measures included the Numeric Pain Rating Scale (NPRS) for back pain and leg pain, Oswestry Disability Index (ODI), SF-12 Physical Component Summary score (PCS) and Mental Component Summary score (MCS), EQ-5D. Pelvic parameter measurements included: sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), lumbar lurdosis (LL), thoracic kyphosis (TK), T1 spino-pelvic inclination (T1 SPI), and T9 spino-pelvic inclination (T9 SPI). METHODS Baseline patient demographics, radiographic spinopelvic parameters, and sagittal alignment were analyzed for possible correlation to HRQOL using Pearson correlations. RESULTS A total of 154 patients were analyzed (mean age: 65.8, BMI: 29.1) with grade I (72%) or II (28%) DLS, of which 95 were females. Primary symptoms were related to neurogenic claudication (80%), radiculopathy (15.3%) or back pain (4.7%). On average, symptom duration was greater than 2 years in 71% of patients. Patients had moderate to severe symptoms and disability (mean NRS back: 7.2, NRS leg: 7.3, ODI: 45.6, PCS-12: 33.2, MCS-12: 49.6, EQ-5D: 0.54). Baseline measurements of radiographic alignment included sacral slope (SS=34.9±16.7°), pelvic tilt (PT=24.8±9.5°), pelvic incidence (PI=57.4±13.8°), sagittal vertical axis (SVA=35.8±40.8mm), lumbar lordosis (LL=45.7±13.6°), thoracic kyphosis (TK=36.8±13.0°), T9-spinopelvic inclination (T9SPI=9.62±4.0°), and T1-spinopelvic inclination (T1SPI=4.43±10.4°). There were 54% of patients who had an insufficient lumbar lordosis based on the relationship between PI and LL (LL CONCLUSIONS Patients with DLS have global sagittal misalignment compared to published normative controls, highlighted by less lumbar lordosis, a PI to LL mismatch, and increased PT. Spinopelvic alignment was not associated with patient outcomes, although positive sagittal balance may also be influenced by spinal stenosis. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Thursday, September 27, 2018 1:05 PM–2:05 PM Understanding Anxiety and Depression when Performing Spine Surgery: 120. Preoperative psychological factors significantly add to the predictability of chronic narcotic use: a two-year prospective study

BACKGROUND CONTEXT Narcotic therapy can be effective for treating chronic pain, but research has established that it is commonly associated with addiction and overdose. Concerns with chronic narcotic use are well established in the literature. Understanding the risk of developing chronic narcotic use in the preoperative period may be aided through investigation of psychological measures. PURPOSE To determine if psychological factors are significant predictors of narcotic use two years following thoracolumbar spine surgery. STUDY DESIGN/SETTING A prospective observational study using Canadian Spine Outcomes and Research Network (CSORN) data alongside validated psychological measures. PATIENT SAMPLE Consecutively enrolled adult patients having undergone thoracolumbar spine surgery (N=191). Those having undergone previous spine surgery were excluded. OUTCOME MEASURES Baseline measures of interest included the Pain Catastrophizing Scale (PCS), Tampa Scale for Kinesiophobia, Multidimensional Scale for Perceived Social Support, Chronic Pain Acceptance Questionnaire (CPAQ-8), Oswestry Disability Index (ODI), Numeric Rating Scales for back and leg pain (NRS-B/L), SF-12’s Mental Component Summary (MCS), narcotic use and demographic variables. The postoperative measure of interest was narcotic use at two-year follow-up. METHODS Baseline measures were collected at initial clinical assessment. Narcotic use was collapsed into binary categories of use and no use. Descriptive statistics were run. Chi Square analysis was used for categorical variables and an ANOVA for continuous variables. Significant variables were built into a binary logistic regression to determine predictors of postoperative narcotic use. Significance was set at α RESULTS A total of 27.23% of the sample were using narcotics two years after surgery. The regression model included ODI, NRS-Leg, time with condition, chief complaint, preoperative drug use, gender, MCS, PCS subscale helplessness and CPAQ subscale pain willingness and was significant χ2 =(13, N=191) 54.99; p=.000. The model accounted for 39.6% of the variance in narcotic use and correctly predicted in 79.7% of cases. Psychological variables accounted for 9.6% of the variance over and above the other predictors. CONCLUSIONS Psychological factors in the preoperative period are significant predictors of narcotic use two years postoperatively. The likelihood of chronic narcotic use following surgery is predictable and therefore may be proactively managed. Identifying predictors of chronic postsurgical narcotic use can enable surgeons to provide their patient with preventative resources. Managing chronic narcotic use is imperative, as it is central to the patient's overall health and quality of life. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Validation of the Neck Disability Index in Serbian Patients With Cervical Radiculopathy

ObjectiveThe purpose of this study was to translate the Neck Disability Index into the Serbian language (NDI-S) and to investigate the validity of this version for use in Serbian population. MethodsFifty patients with cervical radiculopathy were enrolled in the study and completed a multidimensional questionnaire, including NDI-S. Inclusion criteria were ages between 18 and 65 years, Serbian speaking, no cognitive or hearing impairment, sharp and radiating neck and upper extremity pain that has lasted less than 12 months, radiculopathy signs evaluated by electromyoneurography and disc herniation, or spondylotic changes of cervical spine visualized on magnetic resonance imaging. Exclusion criteria were malignancy, previous cervical spine discectomy, trauma of the cervical spine and myelopathy, polyneuropathy, fibromyalgia, and psychiatric disorders. Validity was determined by the correlation of the Neck Disability Index, with pain measured by visual analogue scale, characteristics related to pain, and mental status. Also, factor structure of NDI-S was explored through factor analysis. Reliability was assessed through internal consistency (Cronbach’s α and item-total correlations). ResultsCorrelation analysis between pain and NDI-S showed significant values (P < .01). The NDI-S correlated well with patients mental status (r = 0.421, P < .01). Cronbach’s α of NDI-S was 0.85, denoting excellent internal consistency of the questionnaire. Item-total correlations were significant and ranged from 0.328 to 0.789. Factor analysis demonstrated a 2-factor structure with an explained variance of 55%. ConclusionThe NDI-S is a valid questionnaire to measure neck and arm pain related to disability in Serbian patients with cervical radiculopathy.

Psychometric validation of the adapted Traditional Chinese version of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ)

BackgroundLow back pain is a common health problem encountered by various populations among different countries. This prospective study aimed to translate and cross-culturally adapt the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) into Traditional Chinese and to assess its validity, reliability and sensitivity in Chinese patients experiencing low back pain. MethodsDouble forward and single back translation of the JOABPEQ was performed with cross-cultural adaptation. By convenience sampling, the final version of the translated JOABPEQ was administered to Chinese patients attending a specialty outpatient clinic with a history of back pain, followed by the traditional Chinese versions of Oswestry Disability Index (ODI) and Short Form-12 version 2 (SF-12v2). Construct validity of the domains were assessed using Spearman's correlation test. Internal consistency was assessed by Cronbach's alpha (α). Sensitivity of the adapted JOABPEQ was determined by known group comparisons. ResultsA total of 100 patients were recruited. The translated JOABPEQ demonstrated excellent overall internal consistency (α: 0.912); and good internal consistency for the domains of Lumbar Function, Walking Ability, Social Life Function and Mental Health (α: 0.811, 0.808, 0.788, and 0.827 respectively). Scores of all domains of the translated JOABPEQ had significant correlations (p < 0.01) with ODI at all domains, as well as with almost all domains of SF-12v2 (p < 0.01–0.05). The translated JOABPEQ was sensitive in detecting differences in patients with/without a history of previous spine surgery, and also between patients with acute/acute on chronic versus chronic pain in specific domains. ConclusionsThe Traditional Chinese version of JOABPEQ has satisfactory psychometric properties in general, including adequate clinical and construct validity, and internal consistency in assessing Southern-Chinese patients with low back pain. It is demonstrated as a sensitive outcome measure. The translated JOABPEQ is verified for its use in the local clinical setting for patient assessment and future research.