Bryan Swaim

Prospective study of iliac crest bone graft harvest site pain and morbidity

BACKGROUND CONTEXT Morbidity associated with autologous bone graft harvest is an important factor in determining the utility of expensive alternatives such as recombinant bone morphogenic protein. The most frequently reported complication associated with graft harvest is chronic pain. PURPOSE To prospectively determine the degree of pain and morbidity associated with autologous iliac crest bone graft harvest and its effect on activities of daily living. STUDY DESIGN Prospective observational cohort study. PATIENT SAMPLE One hundred ten adult patients undergoing elective posterior lumbar spinal fusion surgery involving autologous iliac crest bone graft harvest. OUTCOME MEASURES Patient self-reported Visual Analog Scale (VAS) scores for pain and a study-specific questionnaire regarding activities of daily living. METHODS One hundred ten patients were prospectively enrolled. Postoperative VAS scores (0-100) for harvest site pain were obtained at 6-week, 6- and 12-month follow-up. Patients completed a 12-month questionnaire regarding the persistence of specific symptoms and resulting limitation of specific activities. RESULTS One hundred four patients were available for 1-year follow-up. Mean VAS pain scores (scale 0-100) at 6 weeks, 6 and 12 months were 22.7 (standard deviation [SD], 25.9), 15.9 (SD, 21.5), and 16.1 (SD, 24.6), respectively. At 12 months, 16.5% reported more severe pain from the harvest site than the primary surgical site, 29.1% reported numbness, and 11.3% found the degree of numbness bothersome, whereas 3.9% were bothered by scar appearance. With respect to activity limitations resulting from harvest site pain at 1 year, 15.1% reported some difficulty walking, 5.2% with employment, 12.9% with recreation, 14.1% with household chores, 7.6% with sexual activity, and 5.9% irritation from clothing. CONCLUSIONS There is a significant rate of persistent pain and morbidity from iliac crest bone graft harvest when associated with elective spine surgery. Mean pain scores progressively decline over the first postoperative year. Nevertheless, harvest site pain remains functionally limiting in a significant percentage of patients 1 year after surgery. Rates of functional limitation are higher than previously reported and may be because of increased sensitivity of the prospective study design and targeted investigation of these specific symptoms. Validity of these findings is necessarily limited by patient ability to discriminate harvest site pain from alternative sources of back and buttock pain.

Synovial inflammation in patients undergoing arthroscopic meniscectomy: molecular characterization and relationship to symptoms.

OBJECTIVE Traumatic and degenerative meniscal tears have different anatomic features and different proposed etiologies, yet both are associated with the development or progression of osteoarthritis (OA). In established OA, synovitis is associated with pain and progression, but a relationship between synovitis and symptoms in isolated meniscal disease has not been reported. Accordingly, we sought to characterize synovial pathology in patients with traumatic meniscal injuries and determine the relationships between inflammation, meniscal and cartilage pathology, and symptoms. METHODS Thirty-three patients without evidence of OA who were undergoing arthroscopic meniscectomy for meniscal injuries were recruited. Pain and function were assessed preoperatively; meniscal and cartilage abnormalities were documented at the time of surgery. Inflammation in synovial biopsy specimens was scored, and associations between inflammation and clinical outcomes were determined. Microarray analysis of synovial tissue was performed, and gene expression patterns in patients with and those without inflammation were compared. RESULTS Synovial inflammation was present in 43% of the patients and was associated with worse preoperative pain and function scores, independent of age, sex, or cartilage pathology. Microarray analysis and real-time polymerase chain reaction revealed a chemokine signature in synovial biopsy specimens with increased inflammation scores. CONCLUSION Our findings indicate that in patients with traumatic meniscal injury undergoing arthroscopic meniscectomy without radiographic evidence of OA, synovial inflammation occurs frequently and is associated with increased pain and dysfunction. Synovia with increased inflammation scores exhibit a unique chemokine signature. Chemokines may contribute to the development of synovial inflammation in patients with meniscal pathology; they also represent potential therapeutic targets for reducing inflammatory symptoms.

Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients

BACKGROUND CONTEXT Lumbar facet joint synovial cysts are benign degenerative abnormalities of the lumbar spine. Previous reports have supported operative and nonoperative management. Facet joint steroid injection with cyst rupture is occasionally performed, but there has been no systematic evaluation of this treatment option. PURPOSE To profile the role of facet joint steroid injections with cyst rupture in the treatment of lumbar facet joint synovial cysts. STUDY DESIGN/SETTING Retrospective chart review and long-term follow-up of patients treated for lumbar facet joint synovial cysts. PATIENT SAMPLE One hundred one patients treated for lumbar facet joint synovial cysts with fluoroscopically guided corticosteroid facet joint injection and attempted cyst rupture. OUTCOME MEASURES Oswestry Disability Index and numeric rating scale score for back and leg pain. METHODS A retrospective review and a subsequent interview were conducted to collect pretreatment and posttreatment pain and disability scores along with details of subsequent treatment interventions. Group differences in pain and disability scores were assessed using paired t test. Multiple clinical factors were analyzed in terms of risk for surgical intervention using logistic regression modeling and Cox proportional hazards modeling. RESULTS Successful cyst rupture was confirmed fluoroscopically in 81% of cases. Fifty-five patients (54%) required subsequent surgery over a period averaging 8.4 months because of inadequate symptom relief. All patients reported significant improvement in back pain, leg pain, and disability at 3.2 years postinjection, regardless of their subsequent treatment course (p<.0001 in all groups). There was no significant difference in current pain between patients who received injections only and those who underwent subsequent surgery. CONCLUSIONS This study presents the largest clinical series of nonsurgical treatment for lumbar facet joint synovial cysts. Lumbar facet joint steroid injection with attempted cyst rupture is correlated with avoiding subsequent surgery in half of treated patients. Successful cyst rupture does not appear to have added benefit, and it was associated with worse disability 3 years postinjection. Long-term outcomes are similar, regardless of subsequent surgery.

The Accuracy of the Physical Examination for the Diagnosis of Midlumbar and Low Lumbar Nerve Root Impingement

Study Design. Cross-sectional study with prospective recruitment. Objective. To determine the accuracy of the physical examination for the diagnosis of midlumbar nerve root impingement (L2, L3, or L4), low lumbar nerve root impingement (L5 or S1) and level-specific lumbar nerve root impingement on magnetic resonance imaging, using individual tests and combinations of tests. Summary of Background Data. The sensitivity and specificity of the physical examination for the localization of nerve root impingement has not been previously studied. Methods. Sensitivities, specificities, and likelihood ratios (LRs) were calculated for the ability of individual tests and test combinations to predict the presence or absence of nerve root impingement at midlumbar, low lumbar, and specific nerve root levels. Results. LRs ≥5.0 indicate moderate to large changes from pre-test probability of nerve root impingement to post-test probability. For the diagnosis of midlumbar impingement, the femoral stretch test (FST), crossed FST, medial ankle pinprick sensation, and patellar reflex testing demonstrated LRs ≥5.0 (LR ∞). LRs ≥5.0 were observed with the combinations of FST and either patellar reflex testing (LR 7.0; 95% confidence interval [CI] 2.3–21) or the sit-to-stand test (LR ∞). For the diagnosis of low lumbar impingement, the Achilles reflex test demonstrated an LR ≥5.0 (LR 7.1; 95% CI 0.96–53); test combinations did not increase LRs. For the diagnosis of level-specific impingement, LRs ≥5.0 were observed for anterior thigh sensation at L2 (LR 13; 95% CI 1.8–87); FST at L3 (LR 5.7; 95% CI 2.3–4.4); patellar reflex testing (LR 7.7; 95% CI 1.7–35), medial ankle sensation (LR ∞), or crossed FST (LR 13; 95% CI 1.8–87) at L4; and hip abductor strength at L5 (LR 11; 95% CI 1.3–84). Test combinations increased LRs for level-specific root impingement at the L4 level only. Conclusion. Individual physical examination tests may provide clinical information that substantially alters the likelihood that midlumbar impingement, low lumbar impingement, or level-specific impingement is present. Test combinations improve diagnostic accuracy for midlum-bar impingement.

Inciting events associated with lumbar disc herniation.

BACKGROUND CONTEXT No prior study has investigated the frequency of patient-identified inciting events in lumbar disc herniation (LDH) or their clinical significance. PURPOSE To examine the clinical frequency of patient-identified inciting events in LDH, and to identify associations between the presence of inciting events and the severity of the clinical presentation. STUDY DESIGN/SETTING Cross-sectional analysis of data from a cohort study with prospective recruitment, with retrospective data collection on inciting events. The setting was a hospital-based specialty spine clinic. PATIENT SAMPLE One hundred fifty-four adults with lumbosacral radicular pain and LDH confirmed by magnetic resonance imaging. OUTCOME MEASURES Self-report measures of disability measured by the Oswestry Disability Index (ODI), the visual analog scale (VAS) for leg pain, and the VAS for back pain. METHODS Dependent variables included the presence of a patient-identified inciting event, which were categorized as spontaneous onset, nonlifting physical activity, heavy lifting (>35 lbs), light lifting (<35 lbs), nonexertional occurrence, or physical trauma. We examined the association of an inciting event, or a lifting-related event, with each outcome, first using univariate analyses, and second using multivariate modeling, accounting for important adjustment variables. RESULTS Sixty-two percent of LDH did not have a specific patient-identified event associated with onset of symptoms. Nonlifting activities were the most common inciting event, comprising 26% of all LDH. Heavy lifting (6.5%), light lifting (2%), nonexertional occurrences (2%), and physical trauma (1.3%) accounted for relatively small proportions of all LDH. Patient-identified inciting events were not significantly associated with a more severe clinical presentation in crude analyses. Spontaneous LDH was significantly associated with higher baseline ODI scores in multivariate analysis, although the magnitude of this effect was small. There were no significant associations (p< or =.05) between the presence of a lifting-associated event and the outcomes of ODI, VAS leg pain, or VAS back pain. CONCLUSIONS The majority of LDH occurred without specific inciting events. A history of an inciting event was not significantly associated with a more severe clinical presentation. There was no significant association between the occurrence of a lifting-related event and the severity of the clinical presentation. This information may be useful in the counseling of patients recovering from acute LDH.

The effect of paraformaldehyde fixation on the delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) measurement.

The delayed Gadolinium‐Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) method allows for both qualitative and quantitative measurement of the spatial distribution of glycosaminoglycan [GAG] in excised cartilage. The objective of this study was to determine the effect of paraformaldehyde fixation on dGEMRIC measurements. Five bovine and seven human cartilage pieces were punched into 5‐mm plugs, fixed for 18 h in 4% paraformaldehyde solution, and washed. The magnetic resonance imaging (MRI) parameter T1 was measured prior and post fixation in cartilage without (T10) and with (T1Gd), the ionically charged MRI contrast agent Gd(DTPA)2−. Images of tissue before and after fixation were qualitatively very similar. The ratios of T10, T1Gd, and calculated [GAG] after fixation, relative to before fixation, were near or slightly higher than 1 for both bovine cartilage (1.01 ± 0.01, 1.04 ± 0.02, 1.05 ± 0.03, respectively) and for human cartilage (0.96 ± 0.11, 1.03 ± 0.05, 1.09 ± 0.13). Thus, these data suggest that dGEMRIC can be used on previously fixed samples to assess the three dimensional spatial distribution of GAG.

Dual proline labeling protocol for individual “baseline” and “response” biosynthesis measurements in human articular cartilage

OBJECTIVE The heterogeneity of biosynthesis in human-derived cartilage explants poses a challenge to its use in experiments. The aim of this study was to determine the consistency with which two consecutive measures of biosynthesis could be made in individual human articular cartilage explants using a dual proline radiolabeling protocol. METHODS Full-thickness cartilage explants were harvested from young bovine or human (total knee replacement) tibial plateaus. Two consecutive measurements of biosynthesis were obtained by measuring (3)H-proline and (14)C-proline incorporation. Each samples ratio of (14)C-/(3)H-proline incorporation was computed. For comparison to traditional experimental designs, the (14)C-proline incorporation ratio was computed for adjacent cartilage samples. The number of samples needed to observe a change in the proline incorporation ratio of 10, 20, and 50% was determined for both methods. RESULTS The dual-label ratio was consistent across samples from the same plateau [95% confidence interval (CI): +/-20% (human) and +/-30% (bovine) of median]. Adjacent human sample pairs had much greater variability in their (14)C-proline incorporation (95% CI: +/-50% of median). Adjacent bovine sample pairs had CIs that were similar in magnitude to those for the dual-label approach. In the human plateaus, ratio changes of 10, 20 and 50% could be detected using dramatically fewer samples than the adjacent pair method. For bovine samples, the two methods required a similar number of samples per group. CONCLUSION The consistency of the dual-label approach may overcome the difficulties in studying the effects of interventions on biosynthesis in human cartilage in vitro.