Frank P. Castro

Anterior/posterior lumbar fusion versus transforaminal lumbar interbody fusion: analysis of complications and predictive factors.

No previous study has compared the complications between anterior/posterior and transforaminal interbody fusions. We performed a retrospective analysis of 164 patients to compare the complications and associated predictive factors of the two techniques of circumferential lumbar fusion. Fifty-three had same-day anterior/posterior fusion (group 1), and 111 had transforaminal interbody fusion (group 2). Mean operating time (p < 0.0001) and hospital stay (p < 0.0001) was significantly longer for group 1 patients. Average blood loss was greater for group 1 patients (p < 0.01). Higher complication rates were found in group 1 patients (p < 0.004). Wound infection occurred more frequently in patients with adjunctive treatment (p < 0.04). Hospital stay was an independent predictor of complications in both groups. In group 1, body mass index was independently associated with complications. In group 2, both hospital stay and adjunctive treatment were predictive of complications. Transforaminal lumbar interbody fusion is the preferred technique because it is associated with shorter operating time, less blood loss, shorter hospital stay, and lower incidence of complications.

Role of activated growth factors in lumbar spinal fusions

Background The concentration of platelets into an activated growth factor (AGF) gel may stimulate graft consolidation into a fusion mass. Preoperative hemodilution and intraoperative clot activation may also reduce the overall blood loss. Consequently, the need for postoperative transfusions may also be reduced. Objective The objective of this work was to report our experience with AGF platelet gels in transforaminal lumbar interbody fusion (TLIF) procedures. Methods A consecutive series of patients between 1996 and 1999 undergoing one- and two-level TLIFs with AGF were compared with a consecutive series of TLIF patients who did not receive AGF. Sixty-two control subjects who did not receive AGF and 22 patients who received an AGF platelet gel were compared after 41 and 34 months of follow-up, respectively. Results On average, the AGF group required 18 minutes of additional preincision anesthesia (P = 0.0001). No statistical differences in the operative times, estimated blood loss, postoperative drainage, percentage of patients requiring a transfusion, or length of hospitalization were appreciated between the two groups. The 19% decrease in the arthrodesis rate of the AGF group, as compared with the control group, did not reach statistical significance. Platelet counts from the AGF platelet concentrates demonstrated an average 3.5-fold increase compared with preoperative serum levels. Conclusions The theoretical benefits of AGF platelet gel technology were not clinically appreciated. The cost of implementing this technology may therefore outweigh its theoretical benefits.

Degenerative conditions of the lumbar spine treated with intervertebral titanium cages and posterior instrumentation for circumferential fusion.

Thirty-five consecutive patients were evaluated at an average follow-up time of 20 months after circumferential lumbar spinal fusion. All patients had degenerative conditions of the lumbar spine and same-day anterior spinal fusion by using titanium cages packed with autograft bone and posterior instrumentation combined with a posterolateral autogenous bone graft. The purpose of this study was to determine whether anterior titanium cage placement and posterior instrumentation with autologous bone graft was a safe and efficacious procedure in patients with degenerative disease of the lumbar spine. Fusion rates, complications, pain relief, medication use, and work status were specifically analyzed. Although previous reports documented the use of this technique for trauma and tumor cases, few studies assessed clinical and radiographic results in patients with degenerative conditions of the lumbar spine. Plain radiographs were used to determine spinal fusion at each spinal level. All patients were administered preoperative and postoperative questionnaires regarding three specific clinical-outcome parameters. These consisted of pain level, medication use, and work status. Intraoperative and postoperative complications were also documented. Radiographic results showed that 61 (97%) of 63 lumbar levels undergoing an arthrodesis procedure fused either anteriorly, posteriorly, or both. Of the 35 patients in this series, 33 (94%) fused at all levels, and two did not. Substantial pain relief was reported in 46% of all patients. Thirteen (37%) patients had one or more surgical complications. Circumferential spinal fusion in patients with degenerative etiologies yields excellent radiographic fusion rates and good pain relief. The procedure is technically demanding and is associated with a high rate of complications.

A cost analysis of two anterior cervical fusion procedures.

Multilevel anterior cervical discectomy and fusion (ACDF) remains a difficult problem. A recently described surgical technique for multilevel ACDF has eliminated the morbid complications associated with harvesting iliac crest bone graft (ICBG) while maintaining the advantages of using autologous bone graft. A matched-pairs t test was used to compare the estimated costs of 27 ACDFs using titanium surgical mesh, local autologous bone graft, and anterior plate instrumentation with 27 ACDFs using ICBG and plate fixation. The three variables considered were cage cost, operating time (cost), and hospitalization cost. The estimated costs for the two surgical procedures were not significantly different. Thus, the time saved by not harvesting an ICBG was comparable to the cost of the cage. Harvesting ICBG also increased the morbidity rate by 22%.

Stingers, the Torg Ratio, and the Cervical Spine:

We prospectively determined the risk of initial stinger experience in a group of college football players while considering the presence of cervical canal stenosis and each players position, playing time, and body type. Prospective analysis revealed a 7.7% incidence of initial stinger experience. The average Torg ratio for all players was 0.924 ± 0.122, with the seventh cervi cal level being the narrowest. Initial stinger experience depended on position played and body type. The Torg ratio did not influence initial stinger occurrence. Play ers who experienced multiple stingers, however, had significantly smaller Torg ratios than players experi encing only one stinger (0.75 versus 0.87). A Torg ratio of 0.70 may be a more statistically and clinically appro priate threshold for determining significant cervical ste nosis and advising collegiate athletes of their risk of experiencing recurrent stingers.

An analysis of food and drug administration medical device reports relating to total joint components

A total of 1,717 total hip and 2,769 total knee medical device reports submitted to the U.S. Food and Drug Administration (FDA) from 1984 through 1993 were reviewed. A large percentage of total hip complications could be attributed to some aspect of component modularity. Cementless modular acetabular components were the single largest source of device-related complications. Fifty-six percent of total knee medical device reports (MDRs) were associated with accelerated polyethylene wear. By location, MDRs identified patellar (46%), tibial (33%), and femoral (5%) component complications. It was estimated that less than 5% of device-related complications were reported to the FDA. Based on the reports received, it was apparent that mechanical failure of components was a common and increasing cause of total joint revision.

Stingers, cervical cord neurapraxia, and stenosis

The risk of sustaining a stinger, CCN, or a more serious catastrophic injury to the cervical spine increases with increasing stenosis. The RR of a player sustaining a second stinger or CCN increases exponentially when compared with the risk of a player sustaining an initial stinger or CCN. Intravenous steroids have no role in the management of stingers or CCN. Players who remain symptomatic after a stinger, players with persistently abnormal diagnostic studies after a stinger, and any player who experiences a CCN should be excluded from further participation in contact sports.

Cost of implanting a cemented versus cementless femoral stem.

Fifty stratified unselected cases of primary uncomplicated total hip arthroplasty performed at the total joint service of a university teaching hospital were examined. In 25 cases, the femoral stem was implanted with cement, and in the other 25, a cementless stem was implanted. For cemented stems, third-generation cement technique was used, including centrifugation. The average cost to the hospital for a cementless stem was

The efficacy of anterior spine exposure by an orthopedic surgeon

900 greater than for a cemented stem. The total cost to the hospital for accessories used to achieve modern cement technique was over

Analysis of retrieved uncemented porous-coated acetabular components in patients with and without pelvic osteolysis.

700. The operative time for implanting a cemented stem averaged 20 minutes longer, which resulted in an additional operating time charge of