Georgia Stobbs

Adult spinal deformity surgery : Complications and outcomes in patients over age 60

Study Design. A retrospective analysis, including prospectively collected patient outcomes data. Objective. To determine the rate of complications and outcomes in patients ≥60 years of age who underwent major spinal deformity surgery requiring a minimum 5-level arthrodesis procedure. Summary of Background Data. As the population ages, an increasing number of older patients are presenting with spinal deformity disorders that may require major reconstructive procedures. Previous studies have reported complication rates as high as 80% in this age group for 1- and 2-level fusion procedures. The prevalence of complications was found to increase with the greater number of levels fused. Methods. Forty-six patients who were 60 years of age or older underwent a thoracic or lumbar arthrodesis procedure consisting of 5 levels or greater. Diagnosis, comorbidities, operative data, hospital data, major and minor complications, and deaths were recorded. Oswestry Disability Index (ODI) Scores were used to evaluate clinical outcomes. Results. Thirty-eight females and 8 males with a mean age of 67 years (range, 60–85 years) and a mean follow-up of 4.2 years (range, 2–11 years) had complete records. Thirty-six (78%) patients had at least 1 comorbidity. Twenty-nine (63%) patients had at least 1 prior spinal surgery. A mean of 9 levels (range, 5–16 levels) were fused in each patient. The overall complication rate was 37%. The major complication rate was 20%. ODI improved from 49 to 25 for a mean improvement of 24 (49%) (P < 0.0001). Conclusion. The overall complication rate was 37% and the major complication rate was 20%. Increasing age was a significant factor (P < 0.05) in predicting the presence of a complication. Patients older than 69 years had more complications. The presence of a comorbidity had no association with complication rates and neither had an effect on final patient reported outcomes, which showed significant improvement (ODI preoperative, 49; postoperative, 25) (P < 0.0001).

Symptomatic progression of asymptomatic rotator cuff tears a prospective study of clinical and sonographic variables

BACKGROUND The purposes of this study were to identify changes in tear dimensions, shoulder function, and glenohumeral kinematics when an asymptomatic rotator cuff tear becomes painful and to identify characteristics of individuals who develop pain compared with those who remain asymptomatic. METHODS A cohort of 195 subjects with an asymptomatic rotator cuff tear was prospectively monitored for pain development and examined annually for changes in various parameters such as tear size, fatty degeneration of the rotator cuff muscle, glenohumeral kinematics, and shoulder function. Forty-four subjects were found to have developed new pain, and the parameters before and after pain development were compared. The forty-four subjects were then compared with a group of fifty-five subjects who remained asymptomatic over a two-year period. RESULTS With pain development, the size of a full-thickness rotator cuff tear increased significantly, with 18% of the full-thickness tears showing an increase of >5 mm, and 40% of the partial-thickness tears had progressed to a full-thickness tear. In comparison with the assessments made before the onset of pain, the American Shoulder and Elbow Surgeons scores for shoulder function were significantly decreased and all measures of shoulder range of motion were decreased except for external rotation at 90° of abduction. There was an increase in compensatory scapulothoracic motion in relation to the glenohumeral motion during early shoulder abduction with pain development. No significant changes were found in external rotation strength or muscular fatty degeneration. Compared with the subjects who remained asymptomatic, the subjects who developed pain were found to have significantly larger tears at the time of initial enrollment. CONCLUSIONS Pain development in shoulders with an asymptomatic rotator cuff tear is associated with an increase in tear size. Larger tears are more likely to develop pain in the short term than are smaller tears. Further research is warranted to investigate the role of prophylactic treatment of asymptomatic shoulders to avoid the development of pain and loss of shoulder function.

Location and initiation of degenerative rotator cuff tears: An analysis of three hundred and sixty shoulders

BACKGROUND It has been theorized that degenerative rotator cuff tears most commonly involve the supraspinatus tendon, initiating at the anterior portion of the supraspinatus insertion and propagating posteriorly. The purposes of this study were to determine the most common location of degenerative rotator cuff tears and to examine tear location patterns associated with various tear sizes. METHODS Ultrasonograms of 360 shoulders with either a full-thickness rotator cuff tear (272) or a partial-thickness rotator cuff tear (eighty-eight) were obtained to measure the width and length of the tear and the distance from the biceps tendon to the anterior margin of the tear. Tears were grouped on the basis of their size (anteroposterior width) and extent (partial or full-thickness). Each tear was represented numerically as a column of consecutive numbers representing the tear width and distance posterior to the biceps tendon. All tears were pooled to graphically represent the width and location of the tears within groups. Frequency histograms of the pooled data were generated, and the mode was determined for each histogram representing various tear groups. RESULTS The mean age (and standard deviation) of the 233 subjects (360 shoulders) was 64.7 +/- 10.2 years. The mean width and length of the tears were 16.3 +/- 12.1 mm and 17.0 +/- 13.0 mm, respectively. The mean distance from the biceps tendon to the anterior tear margin was 7.8 +/- 5.7 mm (range, 0 to 26 mm). Histograms of the various tear groups invariably showed the location of 15 to 16 mm posterior to the biceps tendon to be the most commonly torn location within the posterior cuff tendons. The histograms of small tears (a width of <10 mm) and partial-thickness tears showed similar distributions of tear locations, indicating that the region approximately 15 mm posterior to the biceps tendon may be where rotator cuff tears most commonly initiate. CONCLUSIONS Degenerative rotator cuff tears most commonly involve a posterior location, near the junction of the supraspinatus and infraspinatus. The patterns of tear location across multiple tear sizes suggest that degenerative cuff tears may initiate in a region 13 to 17 mm posterior to the biceps tendon.

Loss of spinal cord monitoring signals in children during thoracic kyphosis correction with spinal osteotomy: why does it occur and what should you do?

Study Design. A retrospective review of pediatric kyphosis patients undergoing a spinal cord-level osteotomy for correction. Objective. To evaluate the prevalence, etiology, timing, and intervention related to loss of spinal cord monitoring data during surgical correction of pediatric kyphosis in the spinal cord region. Summary of Background Data. Although much has been written regarding the risks inherent to scoliosis surgery, there is less literature available regarding the neurologic outcomes of pediatric kyphosis surgery. As more surgeons contemplate posterior-only kyphosis correction with spinal cord-level osteotomies, the importance of maintaining spinal cord neurologic function is paramount. Methods. Forty-two patients with pediatric kyphosis undergoing a posterior-only spinal reconstruction with a spinal cord level osteotomy or posterior-based vertebral column resection performed were reviewed. Patients were categorized by diagnosis, type and incidence of osteotomies, and loss of neurogenic mixed-evoked potential (NMEP) data. Interventions required to regain data and postoperative neurologic outcomes were also reviewed. Results. Of the 42 patients, 9 (21.4%) demonstrated a complete loss of NMEP data sometime during surgery while concomitant somatosensory sensory-evoked potentials (SSEP) remained within acceptable limits of baseline values. All 9 patients had intraoperative intervention including: blood pressure elevation (n = 1), release of corrective forces (n = 2), blood pressure elevation and correction release (n = 3), malalignment/subluxation adjustment (n = 1), further bony decompression (n = 1), or restoration of anterior column height via a titanium cage along with further posterior decompression (n = 1). In all cases, SSEPs were unchanged and NMEPs returned varying from 8 to 20 minutes after loss, with all patients having a normal wake-up test intraoperatively and a normal neurologic examination after surgery. Conclusion. Intraoperative multimodality monitoring with some form of motor tract assessment is a fundamental component of kyphosis correction surgery in the spinal cord region in order to create a safer, optimal environment and to minimize neurologic deficit. The surgeon must be able to trust the information monitoring provides and act on it accordingly.

Relationship of Radiographic Acromial Characteristics and Rotator Cuff Disease: A Prospective Investigation of Clinical, Radiographic, and Sonographic Findings

BACKGROUND Many studies have attempted to correlate radiographic acromial characteristics with rotator cuff tears, but the results have not been conclusive. Therefore, the purpose of this study was to determine the relationship between rotator cuff disease and the development of symptoms with different radiographic acromial characteristics, including shape, index, and presence of a spur. MATERIALS AND METHODS The records of 216 patients enrolled in an ongoing prospective, longitudinal study investigating asymptomatic rotator cuff tears were reviewed. All patients underwent standardized radiographic evaluation, clinical evaluation, and shoulder ultrasonography at regularly scheduled surveillance visits. Three blinded observers reviewed all radiographs to determine the acromial morphology, presence, and size of an acromial spur, as well as the acromial index. These findings were analyzed to determine an association with the presence of a full-thickness rotator cuff tear. RESULTS The 3 observers demonstrated poor agreement for acromial morphology (κ = 0.41), substantial agreement for the presence of an acromial spur (κ = 0.65), and excellent agreement for the acromial index (κ = 0.86). The presence of an acromial spur was highly associated with the presence of a full-thickness rotator cuff tear (P = .003), even after adjusting for age. No association was found between the acromial index and rotator cuff disease (P = .92). CONCLUSION The presence of an acromial spur is highly associated with the presence of a full-thickness rotator cuff tear in symptomatic and asymptomatic patients. The acromial morphology classification system is an unreliable method to assess the acromion. The acromial index shows no association with the presence of rotator cuff disease.

Comparison of Radiographic Outcomes for the Treatment of Scoliotic Curves Greater Than 100 Degrees : Wires Versus Hooks Versus Screws

Study Design. A retrospective comparative study. Objective. To compare the efficacy and safety of several different anchors in the apical levels of scoliotic curves ≥100° using radiographic outcomes and clinical complications. Summary of Background Data. To the best of our knowledge, no reports have compared various anchors at the apical level for correction of scoliosis curves ≥100°. Methods. Sixty-eight scoliosis patients (44 neuromuscular, 21 idiopathic, and 3 congenital) with major curves ≥100° (mean, 112.7°; range, 100°-159°) who underwent segmental spinal instrumentation and fusion with different anchors in the apical level were analyzed. All patients had a minimum 2-year follow-up (mean, 4.0 years; range, 2.0–10.5) and were divided into Group W (sublaminar wires n = 26), Group H (hooks n = 18), Group A (anterior vertebral screws n = 7), and Group PS (pedicle screws n = 17) based on the type of apical anchor used. Radiographic parameters and complications were investigated. Results. The 4 groups did not demonstrate any significant differences in gender, age at surgery, preoperative major Cobb angle, or curve flexibility (all P > 0.05). However, the PS group demonstrated a shorter follow-up period compared with the other 3 groups (P < 0.05). The PS group demonstrated the greatest correction rate, smallest loss of correction (P < 0.05), and greatest amount of correction of the apical vertebral translation (P < 0.0005) at ultimate follow-up. There were 4 cases (5.9%) of pseudarthrosis (3 in Group W, 1 in Group H; P > 0.05), 6 cases (8.8%) of implant failure (4 in Group W, 2 in Group H; P > 0.05). Despite one (1.5%) intraoperative neurologic complication (differences among groups, P > 0.05), there was no permanent neurologic deficit. Conclusion. All 4 constructs were able to achieve and maintain acceptable correction safely without permanent neurologic deficit and all demonstrated acceptable implant failure rate. Pedicle screw constructs in the apical levels demonstrated the best coronal correction, smallest loss of correction, and greatest amount of apical vertebral translation correction of the major Cobb angle compared with the other constructs without neurologic complications.

Is Spine Deformity Surgery in Patients With Spastic Cerebral Palsy Truly Beneficial?: A Patient/Parent Evaluation

Study Design. Retrospective clinical outcome study. Objective. To evaluate the clinical outcomes and satisfaction associated with the surgical treatment of neuromuscular spinal deformity secondary to cerebral palsy. Summary of Background Data. Controversy still exists regarding whether spinal deformity surgery is truly a beneficial surgery for patients with cerebral palsy (CP) since there is limited functional benefit and higher perioperative complications rates in this patient population. Methods. Neuromuscular patient evaluation questionnaires were answered retrospectively by 84 patients/families of spastic CP patients undergoing spinal fusion. The average follow-up was 6.2 years (range: 2–16). The questionnaires were designed to assess expectation, cosmesis, function, patient care, quality of life, pulmonary function, pain, health status, self-image, and satisfaction. Questionnaire results, complications, and radiographic data were divided into “satisfied group” and “less satisfied group” and we analyzed reasons of satisfaction and dissatisfaction. Results. The overall satisfaction rate was 92%. Ninety-three percent reported improvement with sitting balance, 94% with cosmesis, and 71% in patients quality of life. Functional improvements seemed limited, but 8% to 40% of the patients still perceived the surgical results as improvement. The postoperative complication rate was 27%. The mean preoperative Cobb angle of the major curve was 88° (range: 53°–141°), which corrected to 39° (range: 5°–88°) after surgery. The less satisfied group had a significantly higher late complication rate, less correction of the major curve, greater residual major curve, and hyperlordosis of the lumbar spine after surgery. Conclusion. Despite the perioperative difficulties seen with CP patients, the majority of the patient/parents were satisfied with the results of the spinal deformity surgery. Functional improvements were limited but 8% to 40% of the patients still perceived the results as improved. The reason for less than optimal satisfaction appears to be due to less correction of the major curve, greater residual major Cobb angle, hyperlordosis of the lumbar spine after surgery, and late postoperative complications.

The Morbidity of an Anterior Thoracolumbar Approach : Adult Spinal Deformity Patients With Greater Than Five-Year Follow-up

Study Design. Retrospective study. Objective. To analyze the complications and patient satisfaction related to an anterior thoracolumbar approach in the treatment of adult spinal deformity. Summary of Background Data. There is no long-term follow-up data on the effects of an anterior thoracolumbar approach on adult spinal deformity patients. Methods. A specific questionnaire was used to evaluate long-term follow-up (average, 10.3 years; range, 5–20.6) of 62 adult patients who underwent spinal deformity surgery performed through an anterior thoracolumbar approach. Twenty-six patients had over 10 years follow-up and 36 were between 5 and 10 years follow-up. The questionnaire was composed of detailed scar-related subquestions for pain, appearance, bulging, daily life, and patient’s personal opinion of surgery. Postoperative Oswestry Disability Index (scores) were also obtained. Results. The average age and number of anterior fusion levels were 47.9 (range, 20–74) and 5.6 (range, 2–12), respectively. Although 82.2% patients were satisfied with the results of their surgery, in general, many of the patients were dissatisfied with aspects related to their anterior incision. For the pain domain, 20 patients (32.3%, 6 with >10 years follow-up, 14 patients with 5 years follow-up) had pain over their thoracolumbar scar, which they rated as moderate to severe. Twenty-seven patients (43.5%) had bulging of their scar region, 4 were surgically indicated for repair, and 1 had multiple surgical repairs. Twelve patients (19.4%) felt they had a poor outcome related to the postoperative appearance of their anterior wound. Fifteen patients (24.2%) showed limitations in activities of daily living due to their anterior incision. Three patients with >10 years of follow-up and 4 with >5 years of follow-up felt they were getting worse. The average Oswestry Disability Index score was 25.0 ± 16.3 (range, 0–52) postoperative. Conclusion. This is the first long-term (minimum 5 years) follow-up study focusing on patient outcomes after an anterior thoracolumbar approach for adult spinal deformity treatment. This approach appears to be associated with an appreciable high rate of postoperative pain (32.3%), bulging (43.5%), and functional disturbance (24.2%). Therefore, surgeons should use caution when recommending this approach to future adult spinal deformity patients.

Surgical Treatment of Adult Scoliosis : Is Anterior Apical Release and Fusion Necessary for the Lumbar Curve?

Study Design. A retrospective study. Objectives. To analyze radiographic and functional outcomes after posterior segmental spinal instrumentation and fusion (PSSIF) with and without an anterior apical release of the lumbar curve in adult scoliosis patients. Summary of Background Data. No comparison study on PSSIF of adult lumbar scoliosis with apical release versus without has been published. Methods. Forty-eight adult patients with lumbar scoliosis (average age at surgery 49.6 years, average follow-up 3.7 years) who underwent PSSIF were analyzed with respect to radiographic change, perioperative and postoperative complications, and Scoliosis Research Society (SRS) outcome scores. Twenty-three patients underwent an anterior apical release of the lumbar curve via a thoracoabdominal approach followed by PSSIF (Group I). The remaining 25 patients underwent a PSSIF of the lumbar curve followed by anterior column support at the lumbosacral region through an anterior paramedian retroperitoneal or posterior transforaminal approach (Group II). Results. Before surgery, Group I showed a somewhat larger lumbar major Cobb angle (63.2° vs. 55.9°, P = 0.07), and both groups demonstrated significant differences in lumbar curve flexibility (26.9% vs. 37.2%, P = 0.02) and thoracolumbar kyphosis (27.0° vs. 15.0°, P = 0.03). After surgery, at the ultimate follow-up, there were no significant differences in major Cobb angle, C7 plumbline to the center sacral vertical line (P = 0.17), C7 plumbline to the posterior superior endplate of S1 (P = 0.44), and sagittal Cobb angles at the proximal junction (P = 0.57), T10–L2 (P = 0.24) and T12–S1 (P = 0.51). There were 4 pseudarthroses in Group I and one in Group II (P = 0.02). Postoperative total normalized SRS outcome scores at ultimate follow-up were significantly higher in Group II (69% vs. 79%, P = 0.01). Conclusion. Posterior segmental spinal instrumentation and fusion without anterior apical release of lumbar curves in adult scoliosis demonstrated better total SRS outcome scores and no differences in radiographic parameters without differences in clinical complications. However, the use of BMP in some of these patients (44%) may have also contributed to these differences.

Cross-cultural comparison of the Scoliosis Research Society Outcomes Instrument between American and Japanese idiopathic scoliosis patients: are there differences?

Study Design. A comparative study. Objective. To report a preliminary evaluation of the Scoliosis Research Society Outcomes Instrument (SRS-24) and determine whether differences in baseline scores exist between American and Japanese patients with idiopathic scoliosis. Summary of Background Data. Because the SRS outcomes instrument was primarily introduced for the American population, baseline scores in the Japanese population might differ from the American population. A comparative study using the SRS instrument between American and Japanese patients with idiopathic scoliosis has not been reported. Methods. Two comparable groups of 100 idiopathic scoliosis patients before spinal fusion were separated into American (A) and Japanese (J). There were no statistically significant differences between the groups for gender (A: 9 men/91 women vs. J: 13 men/87 women), age (A: 15.0 ± 2.4 vs. J: 14.9 ± 3.8), main curve location (A: 77 thoracic/23 lumbar, J: 76 thoracic/24 lumbar), main curve Cobb angle (A: 50.5 ± 5.2 vs. J: 51.1 ± 8.7), and thoracic kyphosis (A: 20.9 ± 14.3 vs. J: 19.9 ± 12.1) (P > 0.05, for all comparisons). Patients were evaluated using the first section of the SRS-24 which was divided into 4 domains: total pain, general self-image, general function, and activity. SRS-24 scores were statistical compared in individual domains and questions using the Mann-Whitney U test. Results. American patients had significantly lower scores in pain (P < 0.0001, A: 3.7 ± 0.8 vs. J: 4.3 ± 0.4), function (P < 0.01, A: 3.9 ± 0.6 vs. J: 4.2 ± 0.5), and activity (P < 0.0001, A: 4.5 ± 0.8 vs. J: 4.9 ± 0.3) domains compared with Japanese patients. Japanese patients had significantly lower scores in the self-image (P < 0.0001, A: 4.0 ± 0.7 vs. J: 3.5 ± 0.5) domain. With regard to individual questions, there were significant differences in the scores between the 2 groups for all questions except 5 and 13 (P < 0.05, for all comparisons). Conclusion. SRS-24 scores in the Japanese idiopathic scoliosis population differed from that of the American population. Japanese patients had less back pain, a negative self-image regarding back deformity, higher general physical function, and daily activity. It is highly probable that patient’s perceptions differ due to cultural differences, which affect SRS-24 scores so a cross-cultural comparison of the SRS instrument content is necessary in the future.