Alan H. Daniels

Incidence, risk factors, and outcomes of osteonecrosis of the jaw: integrated analysis from three blinded active-controlled phase III trials in cancer patients with bone metastases

BACKGROUND Osteonecrosis of the jaw (ONJ) has been reported in patients receiving bisphosphonates for metastatic bone disease. ONJ incidence, risk factors, and outcomes were evaluated in a combined analysis of three phase III trials in patients with metastatic bone disease receiving antiresorptive therapies. PATIENTS AND METHODS Patients with bone metastases secondary to solid tumors or myeloma were randomly assigned to receive either s.c. denosumab (120 mg) or i.v. zoledronic acid (4 mg) every 4 weeks. On-study oral examinations were conducted by investigators at baseline and every 6 months. Oral adverse events were adjudicated by an independent blinded committee of dental experts. RESULTS Of 5723 patients enrolled, 89 (1.6%) patients were determined to have ONJ: 37 (1.3%) received zoledronic acid and 52 (1.8%) received denosumab (P = 0.13). Tooth extraction was reported for 61.8% of patients with ONJ. ONJ treatment was conservative in >95% of patients. As of October 2010, ONJ resolved in 36.0% of patients (29.7% for zoledronic acid and 40.4% for denosumab). CONCLUSIONS In this combined analysis of three prospective trials, ONJ was infrequent, management was mostly conservative, and healing occurred in over one-third of the patients. Educating physicians about oral health before and during bone-targeted therapy may help reduce ONJ incidence and improve outcomes.BACKGROUND Osteonecrosis of the jaw (ONJ) has been reported in patients receiving bisphosphonates for metastatic bone disease. ONJ incidence, risk factors, and outcomes were evaluated in a combined analysis of three phase III trials in patients with metastatic bone disease receiving antiresorptive therapies. PATIENTS AND METHODS Patients with bone metastases secondary to solid tumors or myeloma were randomly assigned to receive either s.c. denosumab (120 mg) or i.v. zoledronic acid (4 mg) every 4 weeks. On-study oral examinations were conducted by investigators at baseline and every 6 months. Oral adverse events were adjudicated by an independent blinded committee of dental experts. RESULTS Of 5723 patients enrolled, 89 (1.6%) patients were determined to have ONJ: 37 (1.3%) received zoledronic acid and 52 (1.8%) received denosumab (P = 0.13). Tooth extraction was reported for 61.8% of patients with ONJ. ONJ treatment was conservative in >95% of patients. As of October 2010, ONJ resolved in 36.0% of patients (29.7% for zoledronic acid and 40.4% for denosumab). CONCLUSIONS In this combined analysis of three prospective trials, ONJ was infrequent, management was mostly conservative, and healing occurred in over one-third of the patients. Educating physicians about oral health before and during bone-targeted therapy may help reduce ONJ incidence and improve outcomes.

Adverse events associated with anterior cervical spine surgery.

&NA; Anterior cervical procedures for neurologic decompression and fusion, including cervical diskectomy and cervical corpectomy, are commonly performed by orthopaedic surgeons and spinal neurosurgeons. These procedures are highly successful in treating most patients with persistent pain and neurologic symptoms that have not responded to nonsurgical methods. Adverse events occur infrequently, but several have been described, including esophageal injury, vertebral artery injury, dural tear, postoperative airway compromise, spinal cord injury, hematoma, dysphagia, dysphonia, and graft dislodgement. Newer procedures, such as cervical total disk replacement and the use of bone morphogenetic protein as a supplement to fusion, have raised unique concerns. Appropriate strategies must be utilized to avoid these adverse events, and the treating surgeon should have an understanding of how to detect and manage such events when they do arise.

Airway compromise due to wound hematoma following anterior cervical spine surgery.

One of the most serious adverse events associated with anterior cervical spine surgery is wound hematoma resulting in airway compromise. The reported incidence of this postoperative complication has varied from 0.2% to 1.9%. Obstruction of the airway secondary to bleeding presents a challenging clinical scenario given the rapidity of onset, distorted anatomy of the upper respiratory tract, urgent need to act and potential for catastrophic consequences. This high-risk, life-threatening clinical scenario requires specialized knowledge and a well-designed treatment protocol to achieve a positive outcome. In this review, we report a case of airway compromise secondary to wound hematoma following anterior cervical discectomy and fusion, followed by a review of relevant literature, anatomy, etiologic factors and diagnostic considerations. We also propose guidelines for the prevention and management of postoperative airway obstruction due to wound hematoma.

Benign tumors of the spine.

Benign tumors in the spine include osteoid osteoma, osteoblastoma, aneurysmal bone cyst, osteochondroma, neurofibroma, giant cell tumor of bone, eosinophilic granuloma, and hemangioma. Although some are incidental findings, some cause local pain, radicular symptoms, neurologic compromise, spinal instability, and deformity. The evaluation of spinal tumors includes a thorough history and physical examination, imaging, sometimes laboratory evaluation, and biopsy when indicated. Appropriate treatment may be observational (eg, eosinophilic granuloma) or ablative (eg, osteoid osteoma, neurofibroma, hemangioma), but generally is surgical, depending on the level of pain, instability, neurologic compromise, and natural history of the lesion. Knowledge of the epidemiology, common presentation, imaging, and treatment of benign bone tumors is essential for successful management of these lesions.

Complications associated with prone positioning in elective spinal surgery

Complications associated with prone surgical positioning during elective spine surgery have the potential to cause serious patient morbidity. Although many of these complications remain uncommon, the range of possible morbidities is wide and includes multiple organ systems. Perioperative visual loss (POVL) is a well described, but uncommon complication that may occur due to ischemia to the optic nerve, retina, or cerebral cortex. Closed-angle glaucoma and amaurosis have been reported as additional etiologies for vision loss following spinal surgery. Peripheral nerve injuries, such as those caused by prolonged traction to the brachial plexus, are more commonly encountered postoperative events. Myocutaneous complications including pressure ulcers and compartment syndrome may also occur after prone positioning, albeit rarely. Other uncommon positioning complications such as tongue swelling resulting in airway compromise, femoral artery ischemia, and avascular necrosis of the femoral head have also been reported. Many of these are well-understood and largely avoidable through thoughtful attention to detail. Other complications, such as POVL, remain incompletely understood and thus more difficult to predict or prevent. Here, the current literature on the complications of prone positioning for spine surgery is reviewed to increase awareness of the spectrum of potential complications and to inform spine surgeons of strategies to minimize the risk of prone patient morbidity.

Variability in spine surgery procedures performed during orthopaedic and neurological surgery residency training: an analysis of ACGME case log data.

BACKGROUND Current spine surgeon training in the United States consists of either an orthopaedic or neurological surgery residency, followed by an optional spine surgery fellowship. Resident spine surgery procedure volume may vary between and within specialties. METHODS The Accreditation Council for Graduate Medical Education surgical case logs for graduating orthopaedic surgery and neurosurgery residents from 2009 to 2012 were examined and were compared for spine surgery resident experience. RESULTS The average number of reported spine surgery procedures performed during residency was 160.2 spine surgery procedures performed by orthopaedic surgery residents and 375.0 procedures performed by neurosurgery residents; the mean difference of 214.8 procedures (95% confidence interval, 196.3 to 231.7 procedures) was significant (p = 0.002). From 2009 to 2012, the average total spinal surgery procedures logged by orthopaedic surgery residents increased 24.3% from 141.1 to 175.4 procedures, and those logged by neurosurgery residents increased 6.5% from 367.9 to 391.8 procedures. There was a significant difference (p < 0.002) in the average number of spinal deformity procedures between graduating orthopaedic surgery residents (9.5 procedures) and graduating neurosurgery residents (2.0 procedures). There was substantial variability in spine surgery exposure within both specialties; when comparing the top 10% and bottom 10% of 2012 graduates for spinal instrumentation or arthrodesis procedures, there was a 13.1-fold difference for orthopaedic surgery residents and an 8.3-fold difference for neurosurgery residents. CONCLUSIONS Spine surgery procedure volumes in orthopaedic and neurosurgery residency training programs vary greatly both within and between specialties. Although orthopaedic surgery residents had an increase in the number of spine procedures that they performed from 2009 to 2012, they averaged less than half of the number of spine procedures performed by neurological surgery residents. However, orthopaedic surgery residents appear to have greater exposure to spinal deformity than neurosurgery residents. Furthermore, orthopaedic spine fellowship training provides additional spine surgery case exposure of approximately 300 to 500 procedures; thus, before entering independent practice, when compared with neurosurgery residents, most orthopaedic spine surgeons complete as many spinal procedures or more. Although case volume is not the sole determinant of surgical skills or clinical decision making, variability in spine surgery procedure volume does exist among residency programs in the United States.

Pediatric thoracolumbar spine trauma.

Abstract Thoracolumbar spine trauma is an important cause of morbidity and mortality in pediatric patients. Special attention to this population is necessary because several unique features of the growing pediatric spine separate these patients from adult patients. These injuries are frequently associated with high‐energy trauma and concurrent thoracic or abdominal injuries that require coordinated multidisciplinary care. Thoracolumbar spine trauma in pediatric patients may lead to compression fractures, burst fractures, flexion‐distraction injuries (ie, Chance fracture), fracturedislocation injuries, apophyseal fractures/herniations, and spinous process and transverse process fractures. Depending on the nature of the injury and the patients level of skeletal maturity, thoracolumbar spinal injuries may have substantial ability to heal and remodel. Because the impact of thoracolumbar spinal injury on pediatric patients can be devastating, appropriate early diagnosis and management, as well as long‐term follow‐up, are imperative.

Incidence and cost of treating axis fractures in the United States from 2000 to 2010.

Study Design. Retrospective database analysis. Objective. To examine the incidence of hospitalization, treatment, and cost of caring for patients with axis (C2) fractures. Summary of Background Data. The incidence of C2 fractures in the elderly seems to be increasing, however, a comprehensive analysis of the incidence, treatment, and cost of treating C2 fractures has not been previously reported. Methods. The Nationwide Inpatient Sample from 2000 to 2010 was used to identify patients with C2 fracture without neurological injury (International Classification of Disease, Ninth Revision, Clinical Modification code 805.02). Examined variables included age, International Classification of Disease, Ninth Revision, Clinical Modification injury severity score, comorbidities, mortality, hospital length of stay, treatments, and total inpatient hospitalization charge. Charges were adjusted for inflation to 2010 US dollars as well as for cost-to-charge ratios. Results. In total, 31,129 patients with C2 fracture were identified. From 2000 to 2010 the incidence of C2 fracture hospitalization increased in all age groups (P < 0.0001). The most rapid increase was in patients older than 84 years, who experienced a 3-fold increase from 3.18 to 9.77 hospitalizations per 10,000 individuals per year (P < 0.0001). From 2000 to 2010, the rate of halo vest placement decreased from 25.2% to 10.4% (P < 0.0001), whereas the rate of surgical intervention increased from 13.1% to 16.5% (P = 0.029). For nonoperatively treated patients, the mean hospitalization charge per patient increased from

Is Subspecialty Fellowship Training Emerging as a Necessary Component of Contemporary Orthopaedic Surgery Education

39,346 in 2000 to

Airway compromise due to laryngopharyngeal edema after anterior cervical spine surgery

63,222 in 2010, and for surgically treated patients, it increased from