Elizabeth Yu

Outcomes of slipped capital femoral epiphysis treated with in situ pinning.

Background: Previous long-term studies have shown good outcomes for most patients after in situ pinning of slipped capital femoral epiphyses (SCFE). However, concern is growing about the effects of leaving the epiphysis in a nonanatomic position. We undertook a retrospective study to carefully document patient-reported outcomes and need for additional surgery after in situ pinning of SCFE. Further, we sought to determine the risk factors for persistent pain and dysfunction after in situ pinning. Methods: Between 1965 and 2005, 146 patients (176 hips) with SCFE underwent in situ pinning at a tertiary referral center. Medical records and radiographs were reviewed for slip characteristics and need for subsequent surgery. Patient-reported outcome measures were collected by mailed survey. Mean follow-up was 16 years (range, 2 to 43 y). Results: Twenty-one hips (12%) underwent reconstructive surgery for persistent symptoms, including femoral osteotomy (11), surgical hip dislocation (2), and total hip arthroplasty (8). Mild slips, as well as moderate and severe slips, were treated with reconstructive surgery, including total hip arthroplasty. Of the remaining hips, 33% were painful with a mean overall visual analog score of 2.4 (range, 0 to 10). Mean outcome scores were as follows: Harris Hip Score 90 (max. 100); Hip Dysfunction Osteoarthritis Outcome score 411 (max. 500); UCLA Activity Score 8 (max. 10); and Marx Activity Score 5 (max. 16). Conclusions: Reconstructive surgery was performed in 12% of hips. Patients with mild, moderate, and severe slips underwent arthroplasty for degenerative changes. Persistent mild pain was common in one third of patients treated with in situ pinning. Level of Evidence: Level IV, therapeutic study, case series.

Arthroscopy and the Dramatic Increase in Frequency of Anterior Acromioplasty from 1980 to 2005: An Epidemiologic Study

PURPOSE The purposes of this study was to better understand the utilization of anterior acromioplasty over time, in the absence of rotator cuff repair; to examine the relation to patient characteristics (age, sex) and types of rotator cuff pathology (inflammation or fibrosis, partial-thickness tearing, full-thickness tearing undergoing debridement); and to assess the utilization of arthroscopy in this procedure. METHODS Using the resources of the Rochester Epidemiology Project, cataloging medical records of residents in Olmsted County, Minnesota, we identified 246 patients who underwent anterior acromioplasty between 1980 and 2005. It has previously been shown that rarely does a resident of Olmsted County undergo an orthopaedic procedure at a facility outside the county. RESULTS The incidence of anterior acromioplasty increased over time (P < .001), with crude rates of 3.3 per 100,000 persons in 1980 to 1985 and 19.0 per 100,000 persons in 2000 to 2005. Sex, age, and types of rotator cuff pathology did not significantly change over the 26-year period. There was a dramatic shift from use of the open approach to the arthroscopic approach over this time period (P < .001) and a decrease in the concomitant performance of distal clavicle resection (P < .001). CONCLUSIONS The frequency of anterior acromioplasty has dramatically increased over time. Increasing knowledge about this syndrome, including better imaging, has facilitated patient treatment for a stable spectrum of rotator cuff pathology (inflammation or fibrosis, partial-thickness tearing, full-thickness tearing undergoing debridement), as has the application of endoscopic surgery. LEVEL OF EVIDENCE Level III, epidemiologic study.

Adjacent Segment Disease

EDUCATIONAL OBJECTIVES As a result of reading this article, physicians should be able to: 1. Understand the forces that predispose adjacent cervical segments to degeneration. 2. Understand the challenges of radiographic evaluation in the diagnosis of cervical and lumbar adjacent segment disease. 3. Describe the changes in biomechanical forces applied to adjacent segments of lumbar vertebrae with fusion. 4. Know the risk factors for adjacent segment disease in spinal fusion. Adjacent segment disease (ASD) is a broad term encompassing many complications of spinal fusion, including listhesis, instability, herniated nucleus pulposus, stenosis, hypertrophic facet arthritis, scoliosis, and vertebral compression fracture. The area of the cervical spine where most fusions occur (C3-C7) is adjacent to a highly mobile upper cervical region, and this contributes to the biomechanical stress put on the adjacent cervical segments postfusion. Studies have shown that after fusion surgery, there is increased load on adjacent segments. Definitive treatment of ASD is a topic of continuing research, but in general, treatment choices are dictated by patient age and degree of debilitation. Investigators have also studied the risk factors associated with spinal fusion that may predispose certain patients to ASD postfusion, and these data are invaluable for properly counseling patients considering spinal fusion surgery. Biomechanical studies have confirmed the added stress on adjacent segments in the cervical and lumbar spine. The diagnosis of cervical ASD is complicated given the imprecise correlation of radiographic and clinical findings. Although radiological and clinical diagnoses do not always correlate, radiographs and clinical examination dictate how a patient with prolonged pain is treated. Options for both cervical and lumbar spine ASD include fusion and/or decompression. Current studies are encouraging regarding the adoption of arthroplasty in spinal surgery, but more long-term data are required for full adoption of arthroplasty as the standard of care for prevention of ASD.

Does Less Invasive Spine Surgery Result in Increased Radiation Exposure? A Systematic Review

BackgroundRadiation exposure to patients and spine surgeons during spine surgery is expected. The risks of radiation exposure include thyroid cancer, cataracts, and lymphoma. Although imaging techniques facilitate less invasive approaches and improve intraoperative accuracy, they may increase radiation exposure.Questions/purposesWe performed a systematic review to determine whether (1) radiation exposure differs in open spine procedures compared with less invasive spine procedures; (2) radiation exposure differs in where the surgeon is positioned in relation to the C-arm; and (3) if radiation exposure differs using standard C-arm fluoroscopy or fluoroscopy with computer-assisted navigation.MethodsA PubMed search was performed from January 1980 to July 2013 for English language articles relating to radiation exposure in spine surgery. Twenty-two relevant articles met inclusion criteria. Level of evidence was assigned on clinical studies. Traditional study quality evaluation of nonclinical studies was not applicable.ResultsThere are important risks of radiation exposure in spine surgery to both the surgeon and patient. There is increased radiation exposure in less invasive spine procedures, but the use of protective barriers decreases radiation exposure. Where the surgeon stands in relation to the image source is important. Increasing the distance between the location of the C-arm radiation source and the surgeon, and standing contralateral from the C-arm radiation source, decreases radiation exposure. The use of advanced imaging modalities such as CT or three-dimensional computer-assisted navigation can potentially decrease radiation exposure.ConclusionsThere is increased radiation exposure during less invasive spine surgery, which affects the surgeon, patient, and operating room personnel. Being cognizant of radiation exposure risks, the spine surgeon can potentially minimize radiation risks by optimizing variables such as the use of barriers, knowledge of position, distance from the radiation source, and use of advanced image guidance navigation-assisted technology to minimize radiation exposure. Continued research is important to study the long-term risk of radiation exposure and its relationship to cancer, which remains a major concern and needs further study as the popularity of less invasive spine surgery increases.

Incidence of slipped capital femoral epiphysis: a population-based study.

The incidence of slipped capital femoral epiphysis (SCFE) remains controversial. A population-based database was used to identify all residents of a Midwestern American county treated for a new diagnosis of SCFE. Between 1965 and 2005, 49 patients (aged 9–16 years) underwent treatment of SCFE. This represents an annual incidence of 8.3 unilateral cases and 0.5 bilateral cases per 100 000 children. In patients with unilateral disease, mild slips developed in nine contralateral hips (19%) at a mean of 166 days (range: 6–432 days). As all contralateral slips were mild, we recommend careful follow-up rather than prophylactic pinning of the contralateral hip.

A systematic review of the need for MRI for the clearance of cervical spine injury in obtunded blunt trauma patients after normal cervical spine CT

Clearance of cervical spine injury (CSI) in the obtunded or comatose blunt trauma patient remains controversial. In patients with unreliable physical examination and no evidence of CSI on computed tomography (CT), magnetic resonance imaging of the cervical spine (CS-MRI) is the typical follow-up study. There is a growing body of evidence suggesting that CS-MRI is unnecessary with negative findings on a multi-detector CT (MDCT) scan. This review article systematically analyzes current literature to address the controversies surrounding clearance of CSI in obtunded blunt trauma patients. A literature search through MEDLINE database was conducted using all databases on the National Center for Biotechnology Information (NCBI) website (www.ncbi.nlm.nih.gov) for keywords: “cervical spine injury,” “obtunded,” and “MRI.” The search was limited to studies published within the last 10 years and with populations of patients older than 18 years old. Eleven studies were included in the analysis yielding data on 1535 patients. CS-MRI detected abnormalities in 256 patients (16.6%). The abnormalities reported on CS-MRI resulted in prolonged rigid c-collar immobilization in 74 patients (4.9%). Eleven patients (0.7%) had unstable injury detected on CS-MRI alone that required surgical intervention. In the obtunded blunt trauma patient with unreliable clinical examination and a normal CT scan, there is still a role for CS-MRI in detecting clinically significant injuries when MRI resources are available. However, when a reliable clinical exam reveals intact gross motor function, CS-MRI may be unnecessary.

The top 50 Articles on Minimally Invasive Spine Surgery.

Study Design. Bibliometric study of current literature. Objective. To catalog the most important minimally invasive spine (MIS) surgery articles using the amount of citations as a marker of relevance. Summary of Background Data. MIS surgery is a relatively new tool used by spinal surgeons. There is a dynamic and evolving field of research related to MIS techniques, clinical outcomes, and basic science research. To date, there is no comprehensive review of the most cited articles related to MIS surgery. Methods. A systematic search was performed over three widely used literature databases: Web of Science, Scopus, and Google Scholar. There were four searches performed using the terms “minimally invasive spine surgery,” “endoscopic spine surgery,” “percutaneous spinal surgery,” and “lateral interbody surgery.” The amount of citations included was averaged amongst the three databases to rank each article. The query of the three databases was performed in November 2015. Results. Fifty articles were selected based upon the amount of citations each averaged amongst the three databases. The most cited article was titled “Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion” by Ozgur et al and was credited with 447, 239, and 279 citations in Google Scholar, Web of Science, and Scopus, respectively. Citations ranged from 27 to 239 for Web of Science, 60 to 279 for Scopus, and 104 to 462 for Google Scholar. There was a large variety of articles written spanning over 14 different topics with the majority dealing with clinical outcomes related to MIS surgery. Conclusion. The majority of the most cited articles were level III and level IV studies. This is likely due to the relatively recent nature of technological advances in the field. Furthermore level I and level II studies are required in MIS surgery in the years ahead. Level of Evidence: 5

The Morel-Lavallée lesion revisited: management in spinopelvic dissociation

BACKGROUND CONTEXT The Morel-Lavallée lesion occurs from a compression and shear force that usually separates the skin and subcutaneous tissue from the underlying muscular fascia. A dead space is created that becomes filled with blood, liquefied fat, and lymphatic fluid from the shearing of vasculature and lymphatics. If not treated appropriately, these lesions can become infected, cause tissue necrosis, or form chronic seromas. PURPOSE To review appropriate identification and treatment of Morel-Lavallée lesions in spinopelvic dissociation patients. STUDY DESIGN Uncontrolled case series. METHODS Retrospective review of medical records. No funding was received in support of this study. The authors report no conflicts of interest. RESULTS We present four cases of patients with traumatic spinopelvic dissociation. All had concomitant lumbosacral Morel-Lavallée lesions. All four trauma patients suffered traumatic spinopelvic dissociation with concomitant lumbosacral Morel-Lavallée lesions. Appropriate treatment included irrigation and debridement, drainage, antibiotics, and vacuum-assisted wound closure. CONCLUSIONS Our series reflects an association of Morel-Lavallée lesion in spinopelvic dissociation trauma patients. Possibly, the rotatory injury that occurs at the spinopelvic junction creates a shear force to form the Morel-Lavallée lesion. When presented with a spinopelvic dissociation patient, one should be prepared to treat a Morel-Lavallée lesion.

The Pedicles Are Not the Densest Regions of the Lumbar Vertebrae: Implications for Bone Quality Assessment and Surgical Treatment Strategy

Study Design: Cadaver study. Objective: To determine the bone density of lumbar vertebral anatomic subregions. Bone mineral density (BMD) is a major factor in osseous fixation construct strength. The standard region for implant fixation of the spine is the pedicle; however, other regions may be more viable options with higher bone quality. Methods: Using computed tomography images, the spine was digitally isolated by applying a filter for adult bone. The spine model was separated into 5 lumbar vertebrae, followed by segmentation of each vertebra into 7 regions and determination of average Hounsfield units (HU). HU was converted to BMD with calibration phantoms of known BMD. Results: Overall mean BMD in vertebral regions ranged from 172 to 393 mg/cm3 with the highest and lowest BMD in the lamina and vertebral body, respectively. Vertebral regions formed 3 distinct groups (P < .03). The vertebral body and transverse processes represent one group with significantly lower BMD than other regions. Spinous process, pedicles, and superior articular processes represent a second group with moderate BMD. Finally, inferior articular process (IAP) and lamina represent a third group with significantly higher BMD than other regions. Conclusions: Standard lumbar fusion currently uses the vertebral body and pedicles as primary locations for fixation despite their relatively low BMD. Utilization of posterior elements, especially the lamina and IAP, may be advantageous as a supplement to modern constructs or the primary site for fixation, possibly mitigating construct failures due to loosening or pullout.

Dyspnea as the Presenting Symptom of Cervical Spondylotic Myelopathy

Background  A case report of acute unilateral hemidiaphragm paralysis and resultant dyspnea due to cervical spondylotic myelopathy (CSM) is described. Case Report  An 82-year-old man presented with a nonproductive cough, chest congestion, hoarseness, and shortness of breath on ambulation. The patient underwent cardiac catheterization, which revealed extensive stenosis of the major cardiac arteries. Subsequently, he underwent triple coronary artery bypass grafting. Despite the cardiac surgery, the patients dyspnea did not improve. In addition, he developed new complaints of generalized weakness. Magnetic resonance and radiographic imaging of the cervical spine revealed extensive multilevel degenerative spondylosis with moderate to severe central canal narrowing from C2 to C7 and myelomalacia. The patient underwent C2–C6 laminectomy and instrumented fusion with local autograft. After surgery, the patient had gradual relief of dyspnea as well as improvement of strength. The dyspnea completely resolved. Conclusion  The diagnosis of CSM as the cause of dyspnea is difficult to make. When unrelated cardiac or pulmonary disease coexists, the presenting symptoms of CSM may be subtle and must be actively sought. Signs and symptoms can vary widely and may include symptoms of intermittent neck pain or headache. Dyspnea may be related to unilateral diaphragm paralysis caused by CSM. This etiology of dyspnea should be considered in elderly patients who have other comorbidities that often obscure the diagnosis.