John A. Sielatycki

Is more lordosis associated with improved outcomes in cervical laminectomy and fusion when baseline alignment is lordotic

BACKGROUND CONTEXT In cervical spondylotic myelopathy (CSM), cervical sagittal alignment (CSA) is associated with disease severity. Increased kyphosis and C2-C7 sagittal vertical axis (SVA) correlate with worse myelopathy and poor outcomes. However, when alignment is lordotic, it is unknown whether these associations persist. PURPOSE The study aimed to investigate the associations between CSA parameters and patient-reported outcomes (PROs) following posterior decompression and fusion for CSM when baseline lordosis is maintained. STUDY DESIGN/SETTING This is an analysis of a prospective surgical cohort at a single academic institution. PATIENT SAMPLE The sample includes adult patients undergoing primary cervical laminectomy and fusion for CSM over a 3-year period. OUTCOME MEASURES The PROs included EuroQol-5D, Short-Form-12 (SF-12) physical composite (PCS) and mental composite scales (MCS), Neck Disability Index, and the modified Japanese Orthopaedic Association scores. Radiographic CSA parameters measured included C1-C2 Cobb, C2-C7 Cobb, C1-C7 Cobb, C2-C7 SVA, C1-C7 SVA, and T1 slope. METHODS The PROs were recorded at baseline and at 3 and 12 months postoperatively. The CSA parameters were measured on standing radiographs in the neutral position at baseline and 3 months. Wilcoxon rank test was used to test for changes in PROs and CSA parameters, and Pearson correlation coefficients were calculated for CSA parameters and PROs preoperatively and at 12 months. No external sources of funding were used for this work. RESULTS There were 45 patients included with an average age of 63 years who underwent posterior decompression and fusion of 3.7±1.3 levels. Significant improvements were found in all PROs except SF-12 MCS (p=.06). Small but statistically significant changes were found in C2-C7 Cobb (mean change: +3.6°; p=.03) and C2-C7 SVA (mean change: +3 mm; p=.01). At baseline, only C2-C7 SVA associated with worse SF-12 PCS scores (r=-0.34, p=.02). Postoperatively, there were no associations found between PROs and any CSA parameters. Similarly, no CSA parameters were associated with changes in PROs. CONCLUSIONS Although creating more lordosis and decreasing SVA are associated with improved myelopathy and outcomes in patients with kyphosis, our study did not find such associationsin patients with lordosis undergoing posterior laminectomy and fusion for CSM. This suggests that any amount of lordosis may be sufficient.

Does Obesity Correlate With Worse Patient-Reported Outcomes Following Elective Anterior Cervical Discectomy and Fusion?

BACKGROUND Studies have investigated the impact of obesity in thoracolumbar surgery; however, the effect of obesity on patient-reported outcomes (PROs) following anterior cervical discectomy and fusion (ACDF) is unknown. OBJECTIVE To examine the relationship between obesity and PROs following elective ACDF. METHODS Consecutive patients undergoing ACDF for degenerative conditions were evaluated. Patients were divided into groups with a body mass index ≥35. The EuroQol-5D, Short-Form 12 (SF-12), modified Japanese Orthopaedic Association score, and Neck Disability Index were used. Correlations between PROs and obesity were calculated at baseline and 1 year. RESULTS A total of 299 patients were included, with 80 obese (27%) and 219 nonobese (73%). patients At baseline, obesity was associated with worse myelopathy (modified Japanese Orthopaedic Association score: 10.7 vs 12.2, P = .01), general physical health (SF-12 physical component scale score: 28.7 vs 31.8, P = .02), and general mental health (SF-12 mental component scale score: 38.9 vs 42.3, P = .04). All PROs improved significantly following surgery in both groups. There was no difference in absolute scores and change scores for any PRO at 12 months following surgery. Furthermore, there was no difference in the percentage of patients achieving a minimal clinically important difference for the Neck Disability Index (52% vs 56%, P = .51) and no difference in patient satisfaction (85% vs 85%, P = .85) between groups. CONCLUSION Obesity was not associated with less improvement in PROs following ACDF. There was no difference in the proportion of patients satisfied with surgery and those achieving a minimal clinically important difference across all PROs. Obese patients may therefore achieve meaningful improvement following elective ACDF. ABBREVIATIONS ACDF, anterior cervical discectomy and fusionBMI, body mass indexEQ-5D, EuroQol-5DMCID, minimal clinically important differenceMCS, mental component scalemJOA, modified Japanese Orthopaedic AssociationNDI, Neck Disability IndexNRS, Numerical Rating ScalePCS, physical component scalePROs, patient-reported outcomesSF-12, Short Form 12.

Arthroscopy-Associated Complications in Osteosarcoma

Iatrogenic seeding of sarcoma cells into a joint is a feared, although uncommon, phenomenon. In 1983, Joyce and Mankin described twelve patients who had undergone arthroscopy for suspected intra-articular pathology and were later determined to have extra-articular malignancies. Failure to appreciate the extra-articular lesion in eight of these patients led to delays in definitive treatment as well as the introduction of diseased tissue into the joint space1. In 2003, Musculo et al. reported a similar series of twenty-five patients with suspected athletic injuries who were operated on first and only later diagnosed with benign or malignant bone tumors2. Microscopic seeding of a joint with tumor cells from an undiagnosed malignancy is a risk in treating bone and soft-tissue tumors3-5. Iatrogenic spread of a tumor by arthroscopy is a rare complication that can substantially alter surgical outcomes for patients, leading to more aggressive surgical treatment when conservative therapy may have initially been possible6-8. In a busy clinical practice, orthopaedic surgeons must remain vigilant in assessing all patients with musculoskeletal pain, particularly patients with an equivocal etiology. We report the case of a young man with osteosarcoma who had arthroscopy-related complications. The patient’s family was informed that data concerning this case would be submitted for publication, and they provided consent. A previously healthy nineteen-year-old man presented to his primary physician with knee pain, swelling, and limited weight-bearing. The patient offered a reportedly “vague” history of trauma to the knee, sustained while playing with the family dog. After evaluation, the physician decided on empiric treatment with rest and nonsteroidal anti-inflammatory drugs. Despite the medication, the pain continued to worsen, and the patient was subsequently referred for orthopaedic evaluation. The patient presented to the orthopaedist with poorly localized pain about the knee …