Addisu Mesfin

Fractures in children with cerebral palsy.

Introduction: We studied the fracture history in a large population of patients with cerebral palsy to determine which children were at the highest risk for fracture. Methods: The International Classification of Diseases (Ninth Revision) coding identified 763 children with cerebral palsy. Patients and caregivers were contacted for information about fracture history and risk factors for low bone density. Of the 763 children identified, 418 children (54.8%) were available for this study; 243 (58%) had quadriplegia, 120 (29%) diplegia, and 55 (13%) hemiplegia. Three hundred sixty-six children were spastic, 23 mixed tone, 13 athetoid, and 16 classified as others. We identified 50 children (12%) who fractured; 15 of these same children had, over time, multiple fractures. Results: The number of fractures showed a normal distribution by age, with a mean of 8.6 (SD, 4.0). Children with cerebral palsy with mixed tone had a higher rate of fracture (&khgr;2 = 14.7, P < 0.01); &khgr;2 analysis indicated that the children who fractured were, as a group, more likely to use a feeding tube, have a seizure disorder, take valproic acid (VPA), and use standing equipment in therapy. Multiple regression analysis demonstrated older age and VPA use as predictive of fracture and gave the following equation: fracture = −0.01 + (VPA × 0.17) + (age × 0.15). The subgroup that sustained multiple fractures were older at the time of first fracture than the children who had only one reported fracture (t = −2.3, P < 0.05). Conclusions: The main finding of our article is that older age at first fracture and use of VPA are predictive of fractures and define a group of children with cerebral palsy who may benefit from treatment interventions to increase bone density.

High-dose rhBMP-2 for adults: major and minor complications: a study of 502 spine cases.

BACKGROUND Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) has increased considerably since its introduction in 2002. The complications associated with high-dose rhBMP-2 (≥ 40 mg) are unknown. The purpose of our study was to determine outcomes and medical and surgical complications associated with high-dose rhBMP-2 at short-term and long-term follow-up evaluations. METHODS Five hundred and two consecutive adult patients who had received high-dose rhBMP-2 as a part of spinal surgery from 2002 to 2009 at one institution were enrolled. Data were entered prospectively and studied and analyzed retrospectively. Surgical procedures in the thoracic and lumbar spine were included. Major and minor complications were documented intraoperatively, perioperatively, and at the latest follow-up examination. Complications potentially associated with rhBMP-2 use were evaluated for correlation with rhBMP-2 dose. Scoliosis Research Society (SRS) and Oswestry Disability Index (ODI) outcome measures were obtained before and after surgery. RESULTS On average, 115 mg (range, 40 to 351 mg) of rhBMP-2 was used. The average age of the patients (410 women and ninety-two men) at the time of the index procedure was 52.4 years (range, eighteen to eighty years). There were 265 primary and 237 revision procedures, and 261 patients had interbody fusion. An average of 11.5 vertebrae were instrumented. The average duration of follow-up was forty-two months (range, fourteen to ninety-two months). The diagnoses included idiopathic scoliosis (41%), degenerative scoliosis (31%), fixed sagittal imbalance (18%), and other diagnoses (10%). The rate of intraoperative complications was 8.2%. The rate of perioperative major surgical complications was 11.6%. The rate of perioperative major medical complications was 11.6%. Minor medical complications occurred in 18.9% of the cases, and minor surgical complications occurred in 2.6%. Logistic regression analysis and Pearson correlation did not identify a significant correlation between rhBMP-2 dosage and radiculopathy (r = -0.006), seroma (r = -0.003), or cancer (r = -0.05). Significant improvements in the ODI score (from a mean of 41 points to a mean of 26 points; p < 0.001) and the SRS total score (from a mean of 3.0 points to a mean of 3.7 points; p < 0.001) were noted at the latest follow-up evaluation. CONCLUSIONS This is the largest study of which we are aware that examines complications associated with high-dose rhBMP-2. Major surgical complications occurred in 11.6% of patients, and 11.6% experienced major medical complications. There was a cancer prevalence of 3.4%, but no correlation between increasing rhBMP-2 dosage and cancer, radiculopathy (seen in 1% of the patients), or seroma (seen in 0.6%) was found.

Clinical Results and Functional Outcomes of Primary and Revision Spinal Deformity Surgery in Adults

BACKGROUND Few studies have examined the postsurgical functional outcomes of adults with spinal deformities, and even fewer have focused on the functional results and complications among older adults who have undergone primary or revision surgery for spinal deformity. Our goal was to compare patient characteristics, surgical characteristics, duration of hospitalization, radiographic results, complications, and functional outcomes between adults forty years of age or older who had undergone primary surgery for spinal deformity and those who had undergone revision surgery for spinal deformity. METHODS We retrospectively reviewed the cases of 167 consecutive patients forty years of age or older who had undergone surgery for spinal deformity performed by the senior author (K.M.K.) from January 2005 through June 2009 and who were followed for a minimum of two years. We divided the patients into two groups: primary surgery (fifty-nine patients) and revision surgery (108 patients). We compared the patient characteristics (number of levels arthrodesed, type of procedure, estimated blood loss, and total operative time), duration of hospitalization, radiographic results (preoperative, six-week postoperative, and most recent follow-up Cobb angle measurements for thoracic and lumbar curves, thoracic kyphosis, and lumbar lordosis), major and minor complications, and functional outcome scores (Scoliosis Research Society-22 Patient Questionnaire and Oswestry Disability Index). RESULTS The groups were comparable with regard to most parameters. However, the revision group had more patients with sagittal plane imbalance and more frequently required pedicle subtraction osteotomies (p < 0.01). Patients in the primary group required more correction in the coronal plane than did patients in the revision group, whereas patients in the revision group required more correction in the sagittal plane. We found no significant difference between the two groups in the rate of major complications or in the Scoliosis Research Society-22 Patient Questionnaire functional outcome scores. There were significant improvements in many functional outcome scores in both groups between the preoperative and early (six-week) postoperative periods and between the early postoperative period and the time of final follow-up. CONCLUSIONS Revision surgery for spinal deformity in adults, although technically challenging and considered to present a higher risk than primary surgery, was shown to have a complication rate and outcomes that were comparable with those of primary spinal deformity surgery in adults. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Lumbar curve response to selective thoracic fusion in adult idiopathic scoliosis

BACKGROUND CONTEXT To date, no study has critically examined the radiographic characteristics of the lumbar curve after selective thoracic fusion for the adult idiopathic scoliosis patient population. PURPOSE To evaluate the radiographic response of the lumbar curve to selective thoracic fusion in the adult scoliosis population with correlative clinical outcomes. STUDY DESIGN Retrospective case series. PATIENT SAMPLE Thirty patients with idiopathic scoliosis surgically treated at a mean age of 40 years (range, 20-66) using a posterior translational technique. OUTCOME MEASURES Radiographic review and functional outcome assessment. METHODS A retrospective, minimum 2-year follow-up, radiographic, and clinical review. All patients underwent selective thoracic posterior fusion with end-instrumented vertebra at T11 (1), T12 (7), L1 (14), and L2 (8). RESULTS At a mean follow-up of 39 (range, 24-87) months, spontaneous lumbar curve Cobb improvement (36 degrees -18 degrees = 50% correction) was less than the bending radiograph (12 degrees , 68% correction). Lowest-instrumented vertebra (LIV) tilt angle improved from 24 to 9 degrees and LIV disc angle improved from 8 to 4 degrees (p < .001). Lumbar apical disc angle improved from 10 to 7 degrees (p < .001). Lumbar apical vertebral translation remained unchanged from pre-op (17 mm) to latest follow-up (17 mm) (p = .23). Lumbar curve rotation increased from 8 to 10 degrees (p = .11). One patient had coronal imbalance of greater than 3 cm and two patients had greater than 3 cm of negative sagittal imbalance. Mean subgroup scores of the Scoliosis Research Society-22 questionnaire improved (p < .01) for pain (3.0-3.8) and self-image (2.5-4.0) but remained the same for function and mental health. Only one patient required extension of fusion to include the lumbar curve 6 years postoperatively. CONCLUSIONS The lumbar curve response in adult, selective thoracic scoliosis surgery is characterized by 1) moderate correction but less than the bending film Cobb; 2) greater change in LIV tilt and disc angle than apical vertebra disc angle; 3) no change in lumbar apical translation or rotation; 4) more significant disc height preservation at the LIV compared with lumbar apex. Good clinical outcomes can be achieved with posterior translational instrumentation in adult scoliosis patients.

Management of metastatic cervical spine tumors

The skeletal system is the third most common site of metastases after the lung and liver. Within the skeletal system, the vertebral column is the most common site of metastases, and 8% to 15% of vertebral metastases are in the cervical spine, consisting, anatomically and biomechanically, of the occipitocervical junction, subaxial spine, and cervicothoracic junction. The vertebral body is more commonly affected than the posterior elements. Nonsurgical management techniques include radiation therapy (stereotactic and conventional), bracing, and chemotherapy. Surgical techniques include percutaneous methods, such as vertebroplasty, and palliative methods, such as decompression and stabilization. Surgical approach depends on the location of the tumor and the goals of the surgery. Appropriate patient selection can lead to successful surgical outcomes by restoring spinal stability and improving quality of life.

Accuracy of intra-articular glenohumeral injections: The anterosuperior technique with arthroscopic documentation

PURPOSE Our objective was to assess the accuracy rate of needle placement with the anterosuperior technique of glenohumeral joint injection that uses familiar palpable superficial landmarks as a guide instead of diagnostic imaging. METHODS Between April 2007 and October 2007 at our institution, 42 patients met the study inclusion criteria of being aged 18 years or older and undergoing shoulder arthroscopy. For the injection (performed by 1 surgeon), anesthetized patients were placed in the beach-chair position with the arm in adduction and internal rotation. The surgeon was allowed to redirect the needle only once without withdrawing the needle from the entry site. After injection, arthroscopic confirmation of needle position in the joint and the presence of backflow from the posterior portal cannula were used to determine accuracy and the relation of the needle to adjacent anatomy. RESULTS Of the 42 injections, 38 needles were inserted accurately into the glenohumeral joint (91% accuracy rate), most through the rotator interval (21) or the long head of the biceps tendon (9). Four needles were placed inaccurately into the anterior synovium and subacromial space. Adhesive capsulitis was the diagnosis in 3 of those 4 shoulders but in only 5 of the 38 shoulders in the group with accurate placement (P < .05). Body mass index was not statistically different between the accurate and inaccurate injection groups (P > .05). CONCLUSIONS Anterosuperior glenohumeral joint injection without image guidance provides an accuracy rate of 91%. The anterosuperior technique for glenohumeral injections yields an accuracy rate higher than that of the standard anterior techniques and comparable to that of posterior injection. LEVEL OF EVIDENCE Level IV, diagnostic study.

National trends in the management of central cord syndrome: an analysis of 16,134 patients

BACKGROUND CONTEXT Central cord syndrome (CCS) is a common cause of incomplete spinal cord injury. However, to date, national trends in the management and mortality after CCS are not fully understood. PURPOSE To analyze how patient, surgical, and institutional factors influence surgical management and mortality after CCS. STUDY DESIGN A retrospective cohort analysis. PATIENT SAMPLE The Nationwide Inpatient Sample (NIS) was queried for records of patients with a diagnosis of CCS from 2003 to 2010. OUTCOME MEASURES They included in hospital mortality and surgical management, including anterior cervical decompression and fusion (ACDF), posterior cervical decompression and fusion (PCDF), and posterior cervical decompression (PCD). METHODS Using International Classification of Diseases, Ninth Revision, Clinical Modification codes, patient records with a diagnosis of CCS from 2003 to 2010 were selected from the NIS database and sorted by inpatient mortality and surgical management. Demographic information (age, gender, and race) and hospital characteristics were evaluated with χ(2)-tests for categorical variables and t tests for continuous variables. Multivariate logistic regression models controlled for confounding. RESULTS In this sample of 16,134 patients, a total of 39.7% of patients (6,351) underwent surgery. ACDF was most common (19.4%), followed by PCDF (7.4%) and PCD (6.8%). From 2003 to 2010, surgical management increased by an average of 40% each year. The overall inpatient mortality rate was 2.6%. Increasing age and comorbidities were associated with higher rates of patient mortality and a decreasing surgical rate (p<.01). Hospitals greater than 249 beds (p<.01) and the south (p<.01) were associated with a higher surgical rate. Rural hospitals (p<.01) and people in the second income quartile (p<.01) were associated with higher inpatient mortality. CONCLUSIONS Elderly patients with medical comorbidities are associated with a lower surgical rate and a higher mortality rate. Surgical management was more prevalent in the south and large hospitals. Mortality was higher in rural hospitals. It is important for surgeons to understand how patient, surgical, and institutional factors influence surgical management and mortality.

Correlation of PROMIS Physical Function and Pain CAT Instruments With Oswestry Disability Index and Neck Disability Index in Spine Patients.

Study Design. A prospective and retrospective cross-sectional cohort analysis. Objective. The aim of this study was to show that Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT) assessments for physical function and pain interference can be efficiently collected in a standard office visit and to evaluate these scores with scores from previously validated Oswestry Disability Index (ODI) and Neck Disability Index (NDI) providing evidence of convergent validity for use in patients with spine pathology. Summary of Background Data. Spinal surgery outcomes are highly variable, and substantial debate continues regarding the role and value of spine surgery. The routine collection of patient-based outcomes instruments in spine surgery patients may inform this debate. Traditionally, the inefficiency associated with collecting standard validated instruments has been a barrier to routine use in outpatient clinics. We utilized several CAT instruments available through PROMIS and correlated these with the results obtained using “gold standard” legacy outcomes measurement instruments. Methods. All measurements were collected at a routine clinical visit. The ODI and the NDI assessments were used as “gold standard” comparisons for patient-reported outcomes. Results. PROMIS CAT instruments required 4.5 ± 1.8 questions and took 35 ± 16 seconds to complete, compared with ODI/NDI requiring 10 questions and taking 188 ± 85 seconds when administered electronically. Linear regression analysis of retrospective scores involving a primary back complaint revealed moderate to strong correlations between ODI and PROMIS physical function with r values ranging from 0.5846 to 0.8907 depending on the specific assessment and patient subsets examined. Conclusion. Routine collection of physical function outcome measures in clinical practice offers the ability to inform and improve patient care. We have shown that several PROMIS CAT instruments can be efficiently administered during routine clinical visits. The moderate to strong correlations found validate the utility of computer adaptive testing when compared with the gold standard “static” legacy assessments. Level of Evidence: 4

Spinal muscular atrophy: manifestations and management.

Abstract Spinal muscular atrophy (SMA) is an autosomal recessive disorder caused by a homozygous deletion in the SMN1 gene and is manifested by loss of the anterior horn cells of the spinal cord. Classifications of the disorder are based on age of onset and the patients level of function. Scoliosis and hip subluxation or dislocation are two musculoskeletal manifestations associated with SMA. Severity of scoliosis correlates with age at presentation. Bracing has been unsuccessful in halting curve progression and may interfere with respiratory effort. Early onset scoliosis associated with SMA has been successfully treated with growing rod constructs, and posterior spinal fusion can be used in older children. Hip subluxations and dislocations are best treated nonsurgically if the patient reports no pain because a high rate of recurrent dislocation has been reported with surgical intervention.

National Trends in the Surgical Management of Adult Lumbar Isthmic Spondylolisthesis: 1998 to 2011.

Study Design. A retrospective review. Objective. Isthmic spondylolisthesis (ISY) is a common orthopedic condition. Our objective was to identify trends in the surgical management of adult ISY in the United States and to evaluate trends in the surgical techniques utilized. Summary of Background Data. Various surgical approaches have been described for ISY but preferred trends are not known. Methods. Using the Nationwide Inpatient Sample (NIS), 47,132 adult patients (≥18 years) with ISY undergoing lumbar spine fusion from 1998 to 2011 were identified. Our primary outcome of interest was the national trend in use of anterior (ASF), posterior (PSF), posterior with interbody (P/TLIF), and combined anterior-posterior fusion (A/PSF) surgeries for ISY patients. Poisson regression, modified Walds test, and linear and logistic regression analysis with P < 0.05 were used for statistical analysis. Results. The annual rate of fusion surgeries for ISY increased 4.33 times—from 28.31 surgeries in 1998 to 122.69 surgeries per million US adults per year in 2011. Over the study period, annual rates of ASFs increased 2.65 times (P < 0.001), PSFs increased 1.03 times (P = 0.24), P/TLIFs increased 4.33 times (P < 0.001), and A/PSF increased 2.93 times (P < 0.001). In 2010 to 2011, the complication rate was significantly higher for A/PSF (18.86%, P < 0.001). PSFs had a higher complication rate of 3.61% and P/TLIFs (2.58%). The risk of complications was lower for females, elective admissions, and in hospitals in the South. Mean hospitalization charges adjusted to 2011 dollars were significantly higher for A/PSF (