David B. Bumpass

Major Complications and Comparison Between 3-column Osteotomy Techniques in 105 Consecutive Spinal Deformity Procedures

Study Design. A retrospective review. Objective. To characterize the risk factors for the development of major complications in 3-column osteotomies and determine whether the presence of a major complication affects ultimate clinical outcomes. Summary of Background Data. Three-column spinal osteotomies, including pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR), are common techniques to correct severe and/or rigid spinal deformities. Methods. Two hundred forty consecutive PSO (n = 156) and VCR (n = 84) procedures in 237 patients were performed at a single institution between 1995 and 2008. Of these, 105 patients (87 PSOs, 18 VCRs) had complete preoperative and minimum 2-year postoperative clinical outcomes data available for analysis. Using established criteria, we reported complications as major or minor and further stratified complications as surgical versus medical and permanent versus transient. Risk factors for complications and their effect on Scoliosis Research Society (SRS) clinical outcomes at baseline and at 2 years or more were assessed. Results. Major medical and surgical complications occurred at similar rates in both PSOs and VCRs (38%, 33 of 87 vs. 22%, 4 of 18; P = 0.28). Overall, 24.8% (26 of 105) experienced major surgical complications (3 permanent) and 15.2% (16 of 105) experienced major medical complications (4 permanent). Patients with PSO were older (53 vs. 29 yr; P < 0.001), had greater estimated blood loss (1867 vs. 1278 mL; P = 0.02), and showed a trend toward fewer fused levels (10.1 vs. 12.2; P = 0.06). Risk factors for major complications included preoperative sagittal imbalance of 40 mm or more (P = 0.01), age 60 years and older (P = 0.01), and the presence of 3 or more medical comorbidities (P = 0.04). Both groups improved significantly from baseline in SRS subscores; however, patients with PSO started off worse but improved more than VCRs in both the pain (+1.0 vs. +0.1; P < 0.001) and function (+0.6 vs. +0.2; P = 0.01) domains, with no differences in final satisfaction (4.1 vs. 4.3; P = 0.54). PSO and VCR patients with no complications had slightly higher satisfaction scores than patients with minor-only complications, major transient complications, and major permanent complications. There were no significant differences among the groups with respect to change in SRS subscores from baseline, and all complication groups improved significantly from baseline (P = 0.04). Conclusion. Major complications occurred in 35% of 3-column osteotomies and at similar rates for both PSO (38%) and VCR (22%) procedures. The presence of a major complication did not affect the ultimate clinical outcomes at 2 years or more.

Assessing the value of a total joint replacement.

Total joint arthroplasty (TJA) continues to be one of the most successful surgical interventions in medicine. Demand is growing rapidly, placing an increasingly heavy cost burden on national health systems. Despite the popularity of these surgeries, high-quality cost-effectiveness studies evaluating TJA are few in number. This article summarizes the current literature on value in arthroplasty, identifying the various factors affecting costs and outcomes, and suggesting how policy makers can influence utilization of TJA to further improve value to society.

Pulmonary Function Improvement After Vertebral Column Resection for Severe Spinal Deformity

Study Design. Retrospective review of prospectively accrued cohorts. Objective. We hypothesized that posterior-only vertebral column resection (PVCR) would result in improved postoperative pulmonary function, avoiding pulmonary insults from combined anterior/posterior approaches. Summary of Background Data. Pulmonary function after PVCR for severe spinal deformity has not been previously studied. Previous studies have demonstrated impaired pulmonary performance after combined anterior/posterior fusions. Methods. Serial pulmonary function testing (PFTs) in 49 patients (27 pediatric, 22 adult) who underwent PVCR at a single institution was reviewed. Mean age at surgery was 28.7 years (range, 8–74 yr), and mean follow-up was 32 months (range, 23–64 mo). Thoracic PVCRs (T5–T11) were performed in 31 patients and thoracolumbar PVCRs (T12–L5) in 18 patients. Results. Pediatric patients who underwent PVCR experienced both increased mean forced vital capacity (FVC) (2.10–2.43 L, P = 0.0005) and forced expiratory volume in 1 second (FEV1) (1.71–1.98 L, P = 0.001). There were no significant differences in percent-predicted values for FVC (69%–66%, P = 0.51) or FEV1 (64%–63%, P = 0.77). In adult patients, there were no significant changes in FVC (2.73–2.61 L, P = 0.35) or FEV1 (2.22–2.07 L, P = 0.51) after PVCR; also, changes in adult percent-predicted values for FVC (79%–76%, P = 0.47) and FEV1 (78%–74%, P = 0.40) were not significant. In pediatric patients who underwent PVCR, improved PFTs were correlated with younger age (P = 0.02), diagnosis of angular kyphosis (P ⩽ 0.0001), no previous spine surgery (P = 0.04), and preoperative halo-gravity traction (P = 0.02). Comparison of PFT changes between patients who underwent PVCR and a control group who underwent combined anterior/posterior approaches revealed no significant differences. Conclusion. In pediatric patients, PVCR resulted in small but significant improvements in postoperative FVC and FEV1. In adult patients, no significant increases in PFTs were found. Patients who have the greatest potential for lung and thoracic cage growth after spinal correction are most likely to have improved pulmonary function after PVCR. Level of Evidence: 3

SRS22R Appearance Domain Correlates Most With Patient Satisfaction After Adult Deformity Surgery to the Sacrum at 5-year Follow-up.

Study Design. Longitudinal cohort. Objective. To evaluate the relationship between Scoliosis Research Society-22R (SRS22-R) domains and satisfaction with management in patients who underwent surgical correction for adult spine deformity. Summary of Background Data. The SRS-22R is used to measure clinical outcomes in adult spine deformity patients. The relationship between patient satisfaction and SRS-22R domain scores, the Oswestry Disability Index (ODI) and radiographical parameters has not been reported at 5-year follow-up. Methods. 135 patients with adult spinal deformity at a single institution who underwent a posterior spinal fusion of 5 levels or more to the sacrum and had complete SRS-22R pre- and minimum 5-year postoperative were identified. Wilcoxon tests were used to compare preoperative and 5-year postoperative scores. Spearman correlations were used to evaluate associations between the 5-year SRS-22R Satisfaction score and changes in SRS-22R domain scores, SubScore (SRS-22R Total—Satisfaction), ODI, and radiographical parameters. Results. There were 125 females and 10 males with a mean BMI of 26.6 kg/m2 and mean age of 53.6 years. There were 74 primary and 61 revision surgeries with a mean 9.9 levels fused and mean follow-up of 67 months. There was a statistically significant improvement between paired pre- and 5-year postop SRS-22R domain scores and most radiographical parameters, commonly P ⩽ 0.001. The majority of patients had an SRS-22R Satisfaction score of 3.0 or more (88%) or 4.0 or more (67%), consistent with a moderate ceiling effect. Correlations for SRS-22R domain scores were all statistically significant and either weak [Mental (0.26), Activity (0.27), Pain (0.35), or moderate (Appearance (0.59))]. SRS-22R SubScore (0.54) and ODI (0.43) also had a moderate correlation. Correlations for all radiographical and operative parameters were either very weak or weak. Conclusion. SRS-22R Appearance, SubScore, and ODI correlate most with patient satisfaction in adult deformity patients undergoing 5 or more level fusion to the sacrum at 5-year follow-up. Level of Evidence: 2

Disc herniations in the National Football League

Study Design. Retrospective analysis of a prospectively collected database. Objective. To determine the overall incidence, location, and type of disc herniations in professional football players to target treatment issues and prevention. Summary of Background Data. Disc herniations represent a common and debilitating injury to the professional athlete. The NFLs (National Football Leagues) Sports Injury Monitoring System is a surveillance database created to monitor the league for all injuries, including injuries to the cervical, thoracic, and lumbar spine. Methods. A retrospective analysis was performed on all disc herniations to the cervical, thoracic, and lumbar spine during a 12-season period (2000–2012) using the NFLs surveillance database. The primary data points included the location of the injury, player position, activity at time of injury, and playing time lost due to injury. Results. During the 12 seasons, 275 disc herniations occurred in the spine. In regard to location, 76% occurred in the lumbar spine and most frequently affected the L5–S1 disc. The offensive linemen were most frequently injured. As expected, blocking was the activity that caused most injuries. Lumbar disc herniations rose in prevalence and had a mean loss of playing time of more than half the season (11 games). Thoracic disc herniations led to the largest mean number of days lost overall, whereas players with cervical disc herniations missed the most practices. Conclusion. Disc herniations represent a significant cause of morbidity in the NFL. Although much attention is placed on spinal cord injuries, preventive measures targeting the cervical, thoracic, and lumbar spine may help to reduce the overall incidence of these debilitating injuries. Level of Evidence: N/A

A prospective study of pain reduction and knee dysfunction comparing femoral skeletal traction and splinting in adult trauma patients.

Objectives: To determine if distal femoral traction pins result in knee dysfunction in patients with femoral or pelvic fracture, and to determine if skeletal traction relieves pain more effectively than splinting for femoral shaft fractures. Design: Prospective cohort trial. Setting: Level I urban trauma center. Patients/Participants: One hundred twenty adult patients with femoral shaft, acetabular, and unstable pelvic fractures. Intervention: Patients with femoral shaft fractures were placed into distal femoral skeletal traction or a long-leg splint, based on an attending-specific protocol. Patients with pelvic or acetabular fractures with instability or intraarticular bone fragments were placed into skeletal traction. Main Outcome Measurements: An initial Lysholm knee survey was administered to assess preinjury knee pain and function; the survey was repeated at 3- and 6-month follow-up visits. Also, a 10-point visual analog scale was used to document pain immediately before, during, and immediately after fracture immobilization with traction or splinting. Results: Thirty-five patients (29%) were immobilized with a long-leg splint, and 85 (71%) were immobilized with a distal femoral traction pin. Eighty-four patients (70%) completed a 6-month follow-up. Lysholm scores decreased by a mean 9.3 points from preinjury baseline to 6 months postinjury in the entire cohort (P < 0.01); no significant differences were found between the splint and traction pin groups. During application of immobilization, visual analog scale pain scores were significantly lower in traction patients as compared with splinted patients (mean, 1.9 points less, P < 0.01). Traction pins caused no infections, neurovascular injuries, or iatrogenic fractures. Conclusions: Distal femoral skeletal traction does not result in detectable knee dysfunction at 6 months after insertion, and results in less pain during and after immobilization than long-leg splinting. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

An update on civilian spinal gunshot wounds: treatment, neurological recovery, and complications

Study Design. Retrospective analysis of inpatient and outpatient data from a single academic trauma center. Objective. To test the effectiveness of a conservative treatment algorithm for civilian spinal gunshot wounds (CSGSWs) by comprehensively evaluating neurological status and recovery, fracture type, concomitant injuries, indications for surgery, and complications. Summary of Background Data. Few large studies exist to guide treatment of CSGSWs, and none have been published in nearly 20 years. Methods. A search of International Classification of Diseases, Ninth Revision (ICD-9) codes was performed for all hospital patients treated from 2003 to 2011 by either neurosurgery or orthopedic surgery to identify 159 consecutive patients who sustained CSGSWs. Mean follow-up was 13.6 months. American Spinal Injury Association grading was used to assess neurological injury. Results. Fifty percent of patients had neurological deficits from CSGSW. Complete spinal injury was the most common injury grade; thoracic injuries had the most risk of complete injury (P < 0.001). Nearly 80% of patients had concomitant injuries to other organs. Operative treatment was more likely in patients with severe neurological injuries (P = 0.008) but was not associated with improved neurological outcomes (P = 1.00). Nonoperative treatment did not lead to any cases of late spinal instability or neurological deterioration. Overall, 31% of patients had an improvement of at least 1 American Spinal Injury Association grade by final follow-up. Nearly half of patients experienced at least 1 GSW-related complication; risk of complications was associated with neurological injury grade (P < 0.001) and operative treatment (P = 0.04). Conclusion. The vast majority of CSGSWs should be managed nonoperatively, regardless of neurological grade or number of spinal columns injured. Indications for surgery include spinal infection and persistent cerebrospinal fluid leaks. Level of Evidence: 3

Does Planned Staging for Posterior-Only Vertebral Column Resections in Spinal Deformity Surgery Increase Perioperative Complications?

STUDY DESIGN Propensity-matched case control. OBJECTIVES To compare the perioperative complication rate between single- and two-stage posterior-only VCRs (2-pVCR). A vertebral column resection (VCR) for severe spinal deformity is a technically challenging and lengthy procedure with a potentially high complication rate. Planned staging has an advantage of distributing operative time into 2 smaller, more manageable, intervals. METHODS Adult and pediatric spinal deformity patients undergoing a VCR were retrospectively identified from a single institutions surgical database from 1985 to 2013. Propensity scoring was used to match 2-pVCR and single-staged patients. Each group was matched for 15 preoperative risk factors including demographic, operative, and radiographic characteristics. Perioperative complications were defined as occurring within 2 months of initial surgery. Additionally, a binary logistic regression analysis was performed with complications as the outcome. RESULTS A total of 183 consecutive patients were identified as undergoing a VCR, with 172 meeting the inclusion criteria (posterior-only). Forty-four patients underwent planned 2-pVCR whereas 124 had a single-staged VCR. Consistent with propensity-matching, no statistically significant difference between the single- and 2-pVCR cohorts existed for all matching parameters, except pulmonary function tests. There was no significant difference (p =.290) between complication rates for single-stage (12/35; 34%) and 2-pVCR (8/35; 23%) patients. Stepwise binary logistic regression analysis showed that age (p =.014; OR = 0.94, CI = 0.89-0.99) and body mass index (p =.030; OR = 1.13 CI = 1.01-1.26) influenced the occurrence of a complication. CONCLUSION Planned staging of posterior-only VCRs does not increase the occurrence of perioperative complications in adult and pediatric spinal deformity patients. LEVEL OF EVIDENCE III (Propensity-matched case control).STUDY DESIGN Propensity-matched case control. OBJECTIVES To compare the perioperative complication rate between single- and two-stage posterior-only VCRs (2-pVCR). SUMMARY OF BACKGROUND DATA A vertebral column resection (VCR) for severe spinal deformity is a technically challenging and lengthy procedure with a potentially high complication rate. Planned staging has an advantage of distributing operative time into 2 smaller, more manageable, intervals. METHODS Adult and pediatric spinal deformity patients undergoing a VCR were retrospectively identified from a single institutions surgical database from 1985 to 2013. Propensity scoring was used to match 2-pVCR and single-staged patients. Each group was matched for 15 preoperative risk factors including demographic, operative, and radiographic characteristics. Perioperative complications were defined as occurring within 2 months of initial surgery. Additionally, a binary logistic regression analysis was performed with complications as the outcome. RESULTS A total of 183 consecutive patients were identified as undergoing a VCR, with 172 meeting the inclusion criteria (posterior-only). Forty-four patients underwent planned 2-pVCR whereas 124 had a single-staged VCR. Consistent with propensity-matching, no statistically significant difference between the single- and 2-pVCR cohorts existed for all matching parameters, except pulmonary function tests. There was no significant difference (p = .290) between complication rates for single-stage (12/35; 34%) and 2-pVCR (8/35; 23%) patients. Stepwise binary logistic regression analysis showed that age (p = .014; OR = 0.94, CI = 0.89-0.99) and body mass index (p = .030; OR = 1.13 CI = 1.01-1.26) influenced the occurrence of a complication. CONCLUSION Planned staging of posterior-only VCRs does not increase the occurrence of perioperative complications in adult and pediatric spinal deformity patients. LEVEL OF EVIDENCE III (Propensity-matched case control).

Results of Revision Surgery for Proximal Junctional Kyphosis Following Posterior Segmental Instrumentation: Minimum 2-Year Postrevision Follow-Up

Study Design. A retrospective cohort study. Objectives. The aim of this study was to evaluate radiographic and patient-reported outcomes at minimum 2 years after revision surgery for proximal junctional kyphosis (PJK), correlating these results with PJK etiology. Summary of Background Data. There are no studies detailing the results of revision surgery for PJK following posterior segmental instrumentation. Methods. Thirty-two consecutive patients treated with revision surgery after PJK above posterior fusions (25 women/7 men, average age at surgery 60.6 yrs) were reviewed for radiographic and patient-reported outcomes (mean follow-up, 4.5 yrs; range, 2–10 yrs). Patients were subdivided into fracture (F) and nonfracture (NF) groups on the basis of PJK etiology. Results. Radiographic severity of PJK improved significantly with revision surgery and was maintained at ultimate follow-up (P < 0.001). However, initial sagittal vertical axis (SVA) correction was not maintained through ultimate follow-up (P = 0.04). There were significant postrevision improvements in mean Oswestry scores (P < 0.001) and SRS total scores (P < 0.001) in all patients. In patients with pelvic incidence-lumbar lordosis (PI-LL) mismatch < 11°, final PJK measurement was smaller than in patients with mismatch ≥11° (9.4° vs. 19.8°, P = 0.009). Six patients (19%) developed new postrevision PJK, with two (6%) requiring additional surgery. Patients who sustained PJK through a fracture had greater improvements in Oswestry (P = 0.004), total SRS (P = 0.04), pain (P < 0.001), and satisfaction (P = 0.05) scores, although the fracture patients had less maintained SVA correction (P = 0.002). Conclusion. Revision surgery for PJK following posterior instrumentation achieved acceptable radiographic and clinical outcomes at minimum 2-year follow-up. Patients with PI-LL mismatch <11° experienced more ultimate PJK correction than patients with mismatch ≥11°. Although the NF group experienced more sustained correction of sagittal balance, the F group reported greater improvements in patient-reported outcomes. Ultimate clinical outcomes after revision surgery for PJK were similar between patients with and without compression fractures. Level of Evidence: 3

Implications of lumbar plexus anatomy for removal of total disc replacements through a posterior approach.

Study Design. An anatomic study in which the lumbar plexuses of 14 embalmed cadavers were dissected bilaterally and measured using a posterior approach. Objective. To determine the cephalocaudal (root-to-root) distances and the mediolateral (root-to-tether) distances within the lumbar plexus and determine the feasibility for removal of a lumbar total disc replacement (TDR) through these anatomic spaces using a posterior approach. Summary of Background Data. Currently, lumbar TDRs are implanted primarily through an anterior retroperitoneal or transperitoneal approach. However, revision surgeries through these approaches can be complicated by significant adhesions, with potential injuries to intra- and retroperitoneal contents. Advancements in accessing anterior column structures through a posterior lumbar extracavitary approach suggest that posterior removal of TDRs may be an alternative. Unlike the thoracic extracavitary approach in which ligation of the thoracic nerve rarely leaves significant morbidity, the lumbar extracavitary approach cannot rely on the analogous ligation of the lumbar root to achieve access. Therefore, feasibility of the lumbar extracavitary approach depends on the presence of sufficient anatomic space between the tethered nerves of the lumbar plexus. Methods. Fourteen adult cadavers (5 M/9F) were dissected through a posterior approach to expose the lumbar plexus bilaterally. The root-to-root distances at levels L2–S1 and corresponding root-to-tether distances at levels L3–L5 were measured bilaterally. Results. Root-to-root distance was smallest at the male L5–S1 interval (11.7 ± standard deviations 4.1 mm). Root-to-tether distance was smallest at the female L5 (43.1 ± standard deviations 8.4 mm). These plexus measurements compare favorably with the CHARITÉ TDR components, in which the thickest sliding core is 11.0 mm in height and the largest endplate is 42.0 mm in width. Conclusion. This anatomic study suggests that posterior TDR removal is possible in the lumbar spine without undue risk to the surrounding nervous structures.