Jérôme Paquet

Sagittal spino-pelvic alignment in chronic low back pain

IntroductionThe differences in sagittal spino-pelvic alignment between adults with chronic low back pain (LBP) and the normal population are still poorly understood. In particular, it is still unknown if particular patterns of sagittal spino-pelvic alignment are more prevalent in chronic LBP. The current study helps to better understand the relationship between sagittal alignment and low back pain.Materials and methodsTo compare the sagittal spino-pelvic alignment of patients with chronic LBP with a cohort of asymptomatic adults. Sagittal spino-pelvic alignment was evaluated in prospective cohorts of 198 patients with chronic LBP and 709 normal subjects. The two cohorts were compared with respect to the sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), lumbar tilt (LT), lordotic levels, thoracic kyphosis (TK), thoracic tilt (TT), kyphotic levels, and lumbosacral joint angle (LSA). Correlations between parameters were also assessed.ResultsSagittal spino-pelvic alignment is significantly different in chronic LBP with respect to SS, PI, LT, lordotic levels, TK, TT and LSA, but not PT, LL, and kyphotic levels. Correlations between parameters were similar for the two cohorts. As compared to normal adults, a greater proportion of patients with LBP presented low SS and LL associated with a small PI, while a greater proportion of normal subjects presented normal or high SS associated with normal or high PI.ConclusionSagittal spino-pelvic alignment was different between patients with chronic LBP and controls. In particular, there was a greater proportion of chronic LBP patients with low SS, low LL and small PI, suggesting the relationship between this specific pattern and the presence of chronic LBP.

The Influence of Time from Injury to Surgery on Motor Recovery and Length of Hospital Stay in Acute Traumatic Spinal Cord Injury: An Observational Canadian Cohort Study

To determine the influence of time from injury to surgery on neurological recovery and length of stay (LOS) in an observational cohort of individuals with traumatic spinal cord injury (tSCI), we analyzed the baseline and follow-up motor scores of participants in the Rick Hansen Spinal Cord Injury Registry to specifically assess the effect of an early (less than 24 h from injury) surgical procedure on motor recovery and on LOS. One thousand four hundred and ten patients who sustained acute tSCIs with baseline American Spinal Injury Association Impairment Scale (AIS) grades A, B, C, or D and were treated surgically were analyzed to determine the effect of the timing of surgery (24, 48, or 72 h from injury) on motor recovery and LOS. Depending on the distribution of data, we used different types of generalized linear models, including multiple linear regression, gamma regression, and negative binomial regression. Persons with incomplete AIS B, C, and D injuries from C2 to L2 demonstrated motor recovery improvement of an additional 6.3 motor points (SE=2.8 p<0.03) when they underwent surgical treatment within 24 h from the time of injury, compared with those who had surgery later than 24 h post-injury. This beneficial effect of early surgery on motor recovery was not seen in the patients with AIS A complete SCI. AIS A and B patients who received early surgery experienced shorter hospital LOS. While the issues of when to perform surgery and what specific operation to perform remain controversial, this work provides evidence that for an incomplete acute tSCI in the cervical, thoracic, or thoracolumbar spine, surgery performed within 24 h from injury improves motor neurological recovery. Early surgery also reduces LOS.

Minimizing Errors in Acute Traumatic Spinal Cord Injury Trials by Acknowledging the Heterogeneity of Spinal Cord Anatomy and Injury Severity: An Observational Canadian Cohort Analysis

Clinical trials of therapies for acute traumatic spinal cord injury (tSCI) have failed to convincingly demonstrate efficacy in improving neurologic function. Failing to acknowledge the heterogeneity of these injuries and under-appreciating the impact of the most important baseline prognostic variables likely contributes to this translational failure. Our hypothesis was that neurological level and severity of initial injury (measured by the American Spinal Injury Association Impairment Scale [AIS]) act jointly and are the major determinants of motor recovery. Our objective was to quantify the influence of these variables when considered together on early motor score recovery following acute tSCI. Eight hundred thirty-six participants from the Rick Hansen Spinal Cord Injury Registry were analyzed for motor score improvement from baseline to follow-up. In AIS A, B, and C patients, cervical and thoracic injuries displayed significantly different motor score recovery. AIS A patients with thoracic (T2-T10) and thoracolumbar (T11-L2) injuries had significantly different motor improvement. High (C1-C4) and low (C5-T1) cervical injuries demonstrated differences in upper extremity motor recovery in AIS B, C, and D. A hypothetical clinical trial example demonstrated the benefits of stratifying on neurological level and severity of injury. Clinically meaningful motor score recovery is predictably related to the neurological level of injury and the severity of the baseline neurological impairment. Stratifying clinical trial cohorts using a joint distribution of these two variables will enhance a studys chance of identifying a true treatment effect and minimize the risk of misattributed treatment effects. Clinical studies should stratify participants based on these factors and record the number of participants and their mean baseline motor scores for each category of this joint distribution as part of the reporting of participant characteristics. Improved clinical trial design is a high priority as new therapies and interventions for tSCI emerge.

Health Conditions: Effect on Function, Health-Related Quality of Life, and Life Satisfaction After Traumatic Spinal Cord Injury. A Prospective Observational Registry Cohort Study

OBJECTIVE To analyze relations among injury, demographic, and environmental factors on function, health-related quality of life (HRQoL), and life satisfaction in individuals with traumatic spinal cord injury (SCI). DESIGN Prospective observational registry cohort study. SETTING Specialized acute and rehabilitation SCI centers. PARTICIPANTS Participants (N=340) from the Rick Hansen Spinal Cord Injury Registry (RHSCIR) who were prospectively recruited from 2004 to 2014 were included. The model cohort participants were 79.1% men, with a mean age of 41.6±17.3 years. Of the participants, 34.7% were motor/sensory complete (ASIA Impairment Scale [AIS] grade A). INTERVENTIONS None. MAIN OUTCOME MEASURES Path analysis was used to determine relations among SCI severity (AIS grade and anatomic level [cervical/thoracolumbar]), age at injury, education, number of health conditions, functional independence (FIM motor score), HRQoL (Medical Outcomes Study 36-Item Short-Form Health Survey [Version 2] Physical Component Score [PCS] and Mental Component Score [MCS]), and life satisfaction (Life Satisfaction-11 [LiSat-11]). Model fit was assessed using recommended published indices. RESULTS Goodness of fit of the model was supported by all indices, indicating the model results closely matched the RHSCIR data. Higher age, higher severity injuries, cervical injuries, and more health conditions negatively affected FIM motor score, whereas employment had a positive effect. Higher age, less education, more severe injuries (AIS grades A-C), and more health conditions negatively correlated with PCS (worse physical health). More health conditions were negatively correlated with a lower MCS (worse mental health), however were positively associated with reduced function. Being married and having higher function positively affected Lisat-11, but more health conditions had a negative effect. CONCLUSIONS Complex interactions and enduring effects of health conditions after SCI have a negative effect on function, HRQoL, and life satisfaction. Modeling relations among these types of concepts will inform clinicians how to positively effect outcomes after SCI (eg, development of screening tools and protocols for managing individuals with traumatic SCI who have multiple health conditions).

Predictors of Blood Transfusion in Posterior Lumbar Spinal Fusion: A Canadian Spine Outcome and Research Network Study

Study Design. Retrospective cohort study. Objective. To identify patient or procedure related predictors of postoperative blood transfusions in posterior lumbar fusion (PSF). Summary of Background Data. The rate of PSF surgery has increased significantly. It remains the most common surgical procedure used to stabilize the spine; however, the impact of blood loss requiring blood transfusions remains a significant concern. Methods. Analysis of data from the Canadian Spine Outcomes and Research Network. Patients who underwent PSF between 2008 and 2015 were identified. Multivariate analysis was used to identify predictors of blood transfusion from the collected information. Results. Seven hundred seventy two patients have undergone PSF, 18% required blood transfusion, 54.8% were females and the mean age was 60 years. The analysis revealed five significant predictors: American Society of Anesthesiologist class (ASA), operative time, multilevel fusion, sacrum involvement, and open posterior approach. The odds of transfusion for those with ASA >1 were 6 times those with ASA1 (odds ratio [OR] 6.1, 95% confidence interval [CI] 1.4–27.1, P < 0.018). For each 60-minute increase in operative time, the odds of transfusion increased by 4.2% (OR 1.007, 95% CI 1.004–1.009, P < 0.001). The odds of transfusion were 6 times higher for multilevel fusion (OR 5.8, 95% CI 2.6–13.2, P < 0.001). Extending fusion to the sacrum showed 3 times higher odds for blood transfusion (OR 3.2, 95% CI 1.8–5.8, P < 0.001). The odds of transfusion for patients undergoing open approach were 12 times those who had minimal invasive surgery (OR 12.5, 95% CI 1.6–97.4, P < 0.016). Finally, patients receiving transfusions were more likely to have extended hospital stay. Conclusion. ASA >1, prolonged operative time, multilevel fusion, sacrum involvement, and open posterior approach were significant predictors of blood transfusion in PSF. Level of Evidence: 3

Complications following hospital admission for traumatic brain injury: A multicenter cohort study

Purpose: To evaluate the incidence, determinants and impact on outcome of in‐hospital complications in adults with traumatic brain injury (TBI). Materials and methods: We conducted a multicenter cohort study of TBI patients admitted between 2007 and 2012 in an inclusive Canadian trauma system. Risk ratios of complications, odds ratios of mortality and geometric mean ratios of length of stay (LOS) were calculated using generalized linear models with adjustment for prognostic indicators and hospital cluster effects. Results: Of 12,887 patients, 3.2% had at least one neurological complication and 22.6% a non‐neurological complication. Mechanical ventilation, head injury severity, blood transfusion and neurosurgical intervention had the strongest correlation with neurological complications. Mechanical ventilation, the Glasgow Coma Scale, blood transfusion and concomitant injuries had the strongest correlation with non‐neurological complications. Neurological and non‐neurological complications were associated with a 85% and 53% increase in the odds of mortality, and a 60% and two‐fold increases in LOS, respectively. Conclusions: More than 20% of patients with TBI developed a complication. Many of these complications were associated with increased mortality and LOS. Results highlight the importance of prevention strategies adapted to treatment decisions and underline the need to improve knowledge on the underuse and overuse of clinical interventions. HIGHLIGHTS1/33 and 1/5 TBI admissions develop neurological and non‐neurological complications.50% increase in mortality and 100% increase in LOSTreatments explain more variation in complications rates than patient risk factors.Highlights the importance of prevention strategies adapted to treatment decisionsUnderlines the need to improve knowledge on intervention underuse and overuse

Prognostication in critically ill patients with severe traumatic brain injury: the TBI-Prognosis multicentre feasibility study

Objective Severe traumatic brain injury is a significant cause of morbidity and mortality in young adults. Assessing long-term neurological outcome after such injury is difficult and often characterised by uncertainty. The objective of this feasibility study was to establish the feasibility of conducting a large, multicentre prospective study to develop a prognostic model of long-term neurological outcome in critically ill patients with severe traumatic brain injury. Design A prospective cohort study. Setting 9 Canadian intensive care units enrolled patients suffering from acute severe traumatic brain injury. Clinical, biological, radiological and electrophysiological data were systematically collected during the first week in the intensive care unit. Mortality and functional outcome (Glasgow Outcome Scale extended) were assessed on hospital discharge, and then 3, 6 and 12 months following injury. Outcomes The compliance to protocolised test procedures was the primary outcome. Secondary outcomes were enrolment rate and compliance to follow-up. Results We successfully enrolled 50 patients over a 12-month period. Most patients were male (80%), with a median age of 45 years (IQR 29.0–60.0), a median Injury Severity Score of 38 (IQR 25–50) and a Glasgow Coma Scale of 6 (IQR 3–7). Mortality was 38% (19/50) and most deaths occurred following a decision to withdraw life-sustaining therapies (18/19). The main reasons for non-enrolment were the time window for inclusion being after regular working hours (35%, n=23) and oversight (24%, n=16). Compliance with protocolised test procedures ranged from 92% to 100% and enrolment rate was 43%. No patients were lost to follow-up at 6 months and 2 were at 12 months. Conclusions In this multicentre prospective feasibility study, we achieved feasibility objectives pertaining to compliance to test, enrolment and follow-up. We conclude that the TBI-Prognosis prospective multicentre study in severe traumatic brain injury patients in Canada is feasible.

An analysis of ideal and actual time to surgery after traumatic spinal cord injury in Canada

Study design:Retrospective analysis of a prospective registry and surgeon survey.Objectives:To identify surgeon opinion on ideal practice regarding the timing of decompression/stabilization for spinal cord injury and actual practice. Discrepancies in surgical timing and barriers to ideal timing of surgery were explored.Setting:Canada.Methods:Patients from the Rick Hansen Spinal Cord Registry (RHSCIR, 2004-2014) were reviewed to determine actual timing of surgical management. Following data collection, a survey was distributed to Canadian surgeons, asking for perceived to be the optimal and actual timings of surgery. Discrepancies between actual data and surgeon survey responses were then compared using χ2 tests and logistic regression.Results:The majority of injury patterns identified in the registry were treated operatively. ASIA Impairment Scale (AIS) C/D injuries were treated surgically less frequently in the RHSCIR data and surgeon survey (odds ratio (OR)= 0.39 and 0.26). Significant disparities between what surgeons identified as ideal, actual current practice and RHSCIR data were demonstrated. A great majority of surgeons (93.0%) believed surgery under 24 h was ideal for cervical AIS A/B injuries and 91.0% for thoracic AIS A/B/C/D injuries. Definitive surgical management within 24 h was actually accomplished in 39.0% of cervical and 45.0% of thoracic cases.Conclusion:Ideal surgical timing for traumatic spinal cord injury (tSCI) within 24 h of injury was identified, but not accomplished. Discrepancies between the opinions on the optimal and actual timing of surgery in tSCI patients suggest the need for strategies for knowledge translation and reduction of administrative barriers to early surgery.

Development of a Competence-Based Spine Surgery Fellowship Curriculum Set of Learning Objectives in Canada.

Study Design. Modified-Delphi expert consensus method. Objective. The aim of this study was to develop competence-based spine fellowship curricula as a set of learning goals through expert consensus methodology in order to provide an educational tool for surgical educators and trainees. Secondarily, we aimed to determine potential differences among specialties in their rating of learning objectives to defined curriculum documents. Summary of Background Data. There has been recent interest in competence-based education in the training of future surgeons. Current spine fellowships often work on a preceptor-based model, and recent studies have demonstrated that graduating spine fellows may not necessarily be exposed to key cognitive and procedural competencies throughout their training that are expected of a practicing spine surgeon. Methods. A consensus group of 32 spine surgeons from across Canada was assembled. A modified-Delphi approach refined an initial fellowship-level curriculum set of learning objectives (108 cognitive and 84 procedural competencies obtained from open sources). A consensus threshold of 70% was chosen with up to 5 rounds of blinded voting performed. Members were asked to ratify objectives into either a general comprehensive or focused/advanced curriculum. Results. Twenty-eight of 32 consultants (88%) responded and participated in voting rounds. Seventy-eight (72%) cognitive and 63 (75%) procedural competency objectives reached 70% consensus in the first round. This increased to 82 cognitive and 73 procedural objectives by round 4. The final curriculum document evolved to include a general comprehensive curriculum (91 cognitive and 53 procedural objectives), a focused/advanced curriculum (22 procedural objectives), and a pediatrics curriculum (22 cognitive and 9 procedural objectives). Conclusion. Through a consensus-building approach, the study authors have developed a competence-based curriculum set of learning objectives anticipated to be of educational value to spine surgery fellowship educators and trainees. To our knowledge, this is one of the first nationally based efforts of its kind that is also anticipated to be of interest by international colleagues. Level of Evidence: N/A

Patient Reported Outcomes Following Surgery for Degenerative Spondylolitshtesis: Comparison of a Universal and Multi-Tier Health Care System

STUDY DESIGN Retrospective review of results from a prospectively collected Canadian cohort in comparison to published literature. OBJECTIVES (1) To investigate whether patients in a universal health care system have different outcomes than those in a multitier health care system in surgical management of degenerative spondylolisthesis (DS). (2) To identify independent factors predictive of outcome in surgical DS patients. SUMMARY OF BACKGROUND DATA Canada has a national health insurance program with unique properties. It is a single-payer system, coverage is universal, and access to specialist care requires referral by the primary care physician. The United States on the other hand is a multitier public/private payer system with more rapid access for insured patients to specialist care. METHODS Surgical DS patients treated between 2013 and 2016 in Canada were identified through the Canadian Spine Outcome Research Network (CSORN) database, a national registry that prospectively enrolls consecutive patients with spinal pathology from 16 tertiary care academic hospitals. This population was compared with the surgical DS arm of patients treated in the Spine Patients Outcome Research Trial (SPORT) study. We compared baseline demographics, spine-related, and health-related quality of life (HRQOL) outcomes at 3 months and 1 year. Multivariate analysis was used to identify factors predictive of outcome in surgical DS patients. RESULTS The CSORN cohort of 213 patients was compared with the SPORT cohort of 248 patients. Patients in the CSORN cohort were younger (mean age 60.1 vs. 65.2; p<.001), comprised fewer females (60.1% vs. 67.7%; p=.09), and had a higher proportion of smokers (23.3% vs. 8.9%; p<.001). The SPORT cohort had more patients receiving compensation (14.6% vs. 7.7%; p<.001). The CSORN cohort consisted of patients with slightly greater baseline disability (Oswestry disability index scores: 47.7 vs. 44.0; p=.008) and had more patients with symptom duration of greater than 6 months (93.7% vs. 62.1%; p<.001). The CSORN cohort showed greater satisfaction with surgical results at 3 months (91.1% vs. 66.1% somewhat or very satisfied; p<.01) and 1 year (88.2% vs. 71.0%, p<.01). Improvements in back and leg pain were similar comparing the two cohorts. On multivariate analysis, duration of symptoms, treatment group (CSORN vs. SPORT) or insurance type (public/Medicare/Medicaid vs. Private/Employer) predicted higher level of postoperative satisfaction. Baseline depression was also associated with worse Oswestry disability index at 1-year postoperative follow-up in both cohorts. CONCLUSIONS Surgical DS patients treated in Canada (CSORN cohort) reported higher levels of satisfaction than those treated in the United States (SPORT cohort) despite similar to slightly worse baseline HRQOL measures. Symptom duration and insurance type appeared to impact satisfaction levels. Improvements in other patient-reported health-related quality of life measures were similar between the cohorts.