Amandeep Bhalla

Surgical Management of Civilian Gunshot-induced Spinal Cord Injury: Is It Overutilized?

Study Design. Retrospective chart review. Objective. Assess appropriate utilization of surgery for civilian gunshot-induced spinal cord injuries (CGSWSCI) according to literature standards in a large cohort. Summary of Background Data. CGSWSCI are mechanically stable injuries that rarely require surgery. Nonetheless, we continue to see high numbers of these patients undergo surgical treatment. This study compares indications for surgeries performed in a large cohort of CGSWSCI patients to established indications for surgical management of such injuries. The rate of over-utilization of surgical management was calculated. Methods. Four hundred eighty-nine CGSWSCI patients transferred for rehabilitation to our institution between 2000 and 2014 were identified. Retrospective chart review was performed to identify patients who underwent initial surgical treatment, the specific surgeries performed, and indications given. We assessed appropriateness of surgery according to literature standards. Patients treated surgically were followed to assess for complications and the need for additional intervention and compared to nonsurgical patients. Secondarily, visual analog scale pain scores (0–10) and patient perceived improvement were compared between surgical and nonsurgical patients after telephone survey of both groups. Results. Of 489 patients, 91 (18%) underwent initial surgery. Of 91 surgeries, 69 (75%) were not indicated by literature standards. Five of 91 (5.5%) of initially operated patients required a secondary surgery compared with two of 398 (0.5%) of the nonoperative group (P = 0.003). Over-utilization rate of the entire cohort was 14.1%. No difference was seen for pain scores or patient perceived improvement between operative and nonoperative patients. Conclusion. We report a high overutilization rate (14%) of surgery for CGSWSCI in our cohort. Surgical management was associated with higher infection and secondary surgery rates compared to nonsurgical management. Surgery done without a clear, demonstrable benefit poses unnecessary risk to patients and accumulates unwarranted healthcare costs. Level of Evidence: 3

The influence of subgroup diagnosis on radiographic and clinical outcomes after lumbar fusion for degenerative disc disorders revisited: a systematic review of the literature

BACKGROUND CONTEXT Understanding the influence of preoperative diagnosis on outcomes for lumbar fusion surgery improves the quality of research and outcomes data, and helps guide treatment decisions. PURPOSE We sought to perform a systematic review of the literature published between 2000 and 2014 regarding lumbar fusion outcomes for degenerative disorders. An assessment of the influence of subgroup diagnosis on outcomes as well as the quality of this body of literature was performed. STUDY DESIGN Systematic review PATIENT SAMPLE: The 100 studies ultimately included involved adult patients (n=8,706) undergoing fusion surgery for degenerative disorders of the lumbar spine. OUTCOME MEASURES Visual analog scale (VAS) pain scores, complication rates, and determination of successful fusion METHODS: With adherence to the PRISMA guidelines, electronic searches were performed through PubMed, Scopus, and Web of Science to identify all studies involving lumbar fusion for degenerative disc disorders from January 2000 to August 2014. Studies were eligible for inclusion if they addressed adult patients treated with lumbar fusion for one of the following: stable degenerative disc disease, unstable degenerative disc disease, degenerative disc disease not specified (DDDns), herniated disc (DH), degenerative spondylolisthesis (DDDsp), and adult degenerative scoliosis (DDDsc). Abstracted data included the number of patients, preoperative diagnosis, fusion technique, complications, fusion rate, and clinical outcomes. RESULTS One hundred articles met inclusion criteria and yielded data for 8,706 patients. Forty-three studies included data for clinical improvement (VAS scores). The mean clinical improvement in VAS scores was significantly different among the diagnoses (p<.001), with DDDsp demonstrating the highest improvement (60%) and DDDns having the lowest (45%). Eighty-five studies included data for complication rates. Complication rates differed significantly (p<.001), with the highest rate seen in the DDDsc group (18%), followed by DDDsp (14%). Seventy-eight studies included data for fusion. The pooled odds of fusion for prospective studies were 6.93 (95% CI 4.75, 10.13). There was no evidence of publication bias. CONCLUSIONS A relationship between outcomes and subgroup diagnosis was demonstrated. This review demonstrated a higher quality of evidence in the literature, and greater overall fusion rates compared to similar studies published in the 1980s and 1990s.

Neck Pain from a Spine Surgeon’s Perspective

Through the myriad of abnormalities encountered by spine surgeons, neck pain is one of the most perplexing. The nature, onset, and location of the pain all provide information as to what the potential pain generator may be. By synthesizing data garnered from the physical examination, imaging studies, and history, a spine surgeon must formulate a differential diagnosis and treatment plan. The surgeon must determine whether the patient has cervical radiculopathy, myelopathy, or simply cervical spondylosis because the treatment of each of these is vastly different.

Cervical Radiculopathy and Myelopathy

Cervical radiculopathy is a symptomatic root dysfunction that is most often self-limiting. Familiarity with cervical spine anatomy and the clinical presentation of root dysfunction help to make the diagnosis. Activity modification, anti-inflammatory medications, and physical therapy are often adequate in managing symptoms. Surgical consultation is warranted for persistent or debilitating symptoms and in the setting of motor weakness. Cervical myelopathy is the result of spinal cord dysfunction, most commonly due to compressive, degenerative pathology. A detailed history, physical examination, and appropriate neuroradiographic imaging are used to make the diagnosis. An understanding of its stepwise, progressive natural history, and the offending structural abnormality, is key to helping patients make informed care decisions.

Critical analysis of trends in lumbar fusion for degenerative disorders revisited: influence of technique on fusion rate and clinical outcomes

AbstractPurposeLumbar fusion for degenerative disorders is among the most common spine surgical procedures performed. The purpose of this study was to analyze fusion, complications, and clinical success for lumbar fusion performed with various surgical techniques as reported in the literature from 2000 to 2015 and compare with previous critical analysis of outcomes from 1980 to 2000.MethodsA systematic review of the literature to identify all studies of adult lumbar fusion for degenerative disorders published between January 1, 2000, and August 31, 2015, was performed adhering to PRISMA guidelines. Studies were included if they enabled analysis of outcomes of individual fusion techniques.ResultsData from 8599 patients extracted from 160 studies were recorded. Posterior and transforaminal lumbar interbody fusion (PLIF and TLIF) had significantly higher fusion rates compared to instrumented posterolateral fusion (PLF) (OR 3.20 and 2.46, respectively). Clinical success rate was statistically higher with MIS versus non-MIS fusion (OR 2.44). While methodological quality was higher in studies from 2000 to 2015 than prior decades, the outcomes of comparable procedures were about the same.ConclusionsLumbar fusions for degenerative disorders from 2000 to 2015 demonstrate a trend toward more interbody fusions and MIS techniques than prior decades. Clinical success with MIS appears more likely than with non-MIS fusions, despite equivalent fusion and complication rates. While these data are intriguing, they should be interpreted cautiously considering the level of heterogeneity of the studies available. Further, high-quality comparative studies are warranted to better understand the relative benefits of more complex interbody and MIS fusions for these conditions.Graphical abstract These slides can be retrieved under Electronic Supplementary Material.

Inadequate Surgical Decompression in Patients with Cervical Myelopathy: A Retrospective Review

Study Design Retrospective study. Objective We reviewed cases of surgically treated cervical spondylotic myelopathy (CSM) or chronic, degenerative myelopathy of the subaxial cervical spine to study the incidence of inadequate surgical decompression. Methods We included all persons treated at our institution after a first surgical decompression for CSM over a 3-year period. Inadequate original surgical decompression was defined as neurologic decline within 12 months postoperatively and ongoing impingement of the spinal cord with <1-mm change in anteroposterior canal dimension from pre- to postoperative magnetic resonance imaging (MRI) leading to revision decompressive surgery. Revisions for other reasons were not counted as inadequate. Results Of 50 patients, 5 (10%) required revision decompression for neurologic decline and inadequate change in space available for the cord on postoperative imaging; 4 patients declined within the first 6 months and 1 patient at 8 months postoperatively. None of the 5 declined further after posterior revision, but none recovered from the interval loss. All 5 had undergone anterior approaches, for an anterior inadequacy rate of 23% (5 of 22). None of the 28 patients having posterior or combined approach declined at 2 years or had <1-mm change on postoperative MRI. The difference between anterior and posterior approaches was statistically significant (p = 0.018). Conclusions The rate of inadequate surgical decompression for CSM was greater than expected in this series and directly associated with an anterior approach. No cases of inadequacy occurred for posterior or combined approaches. Postoperative neuroradiographic imaging such as MRI should be entertained routinely for this entity or at least for anterior-only approaches.

Spinal Column Injury at T11-T12 Causing C8 Tetraplegia Misdiagnosed as Spinal Cord Injury without Radiographic Abnormality in an Adult: A Case Report

Traumatic spinal cord injury is often assumed to occur locally as a result of an adjacent osteoligamentous disruption of the spinal column. When the spinal cord injury and the spinal column disruption are noncontiguous in location, without any imaging evidence of spinal column disruption near the cord injury, a diagnosis of spinal cord injury without radiographic abnormality (SCIWORA) or the more modern spinal cord injury without neuroradiographic abnormality (SCIWONA)1 often is made. The imaging component of SCIWONA includes magnetic resonance imaging (MRI) or other imaging beyond computed tomography (CT) or radiographs. Distraction injury mechanisms occurring without substantial local translation may cause these types of nonlocal injuries, thereby providing an adequate explanation without uncertainty. Misapplication of the SCIWORA or SCIWONA designation may lead to improper treatment. We report a case of violent osteoligamentous distraction at T11-T12 that caused spinal cord injury up to T1, resulting in complete tetraplegia at C8. An incorrect diagnosis of SCIWORA initially was applied, and, as a result, the treatment was incorrect. We present a review of the literature and mechanism, including a “taffy distraction” mechanism. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A sixty-five-year-old man was involved in a high-speed, sudden deceleration motor vehicle accident. He was extracted from the vehicle and transported to a level-I trauma center with a Glasgow Coma Score of 3. Resuscitative measures were immediately undertaken per the Advanced Trauma Life Support protocol, and full spine precautions were also taken. Complete neural-axis imaging with use of CT and MRI revealed a T11-T12 three-column distraction injury (Figs. 1-A and 1-B). Additional clinical findings included a nondisplaced left occipital condyle fracture, a hemothorax on the right, bilateral pulmonary emboli, multiple rib fractures, superior and inferior pubic rami fractures, a left acetabulum fracture, …