Kristen Radcliff

Contributing factors to surgical site infections.

&NA; Surgical site infections (SSIs) are the most common nosocomial infections. These complications lead to revision surgery, delayed wound healing, increased use of antibiotics, and increased length of hospital stay, all of which have a significant impact on patients and the cost of health care. Such intraoperative factors as proper skin preparation, adherence to sterile technique, surgical duration, and traffic in the operating room contribute more to SSIs than do patient‐related risk factors such as diabetes mellitus, obesity, and preexisting colonization with methicillin‐resistant Staphylococcus aureus. Surgeons have a responsibility to understand the current evidence regarding the factors that affect the rates of SSIs so as to provide the highest level of patient care.

Adjacent segment disease in the lumbar spine following different treatment interventions.

BACKGROUND CONTEXT Adjacent segment disease (ASD) is symptomatic deterioration of spinal levels adjacent to the site of a previous fusion. A critical issue related to ASD is whether deterioration of spinal segments adjacent to a fusion is due to the spinal intervention or due to the natural history of spinal degenerative disease. PURPOSE The purpose of this review is to summarize the recent clinical literature on adjacent segment disease in light of the natural history, patient-modifiable risk factors, surgical risk factors, sagittal balance, and new technology. STUDY DESIGN This review will evaluate the recent literature on genetic and hereditary components of spinal degenerative disease and potential links to the development of ASD. METHODS After a meticulous search of Medline for relevant articles pertaining to our review, we summarized the recent literature on the rate of ASD and the effect of various interventions, including motion preservation, sagittal imbalance, arthroplasty, and minimally invasive surgery. RESULTS The reported rate of ASD after decompression and stabilization procedures is approximately 2% to 3% per year. The factors that are consistently associated with adjacent segment disease include laminectomy adjacent to a fusion and a sagittal imbalance. CONCLUSIONS Spinal surgical interventions have been associated with ASD. However, whether such interventions may lead to an acceleration of the natural history of the disease remains questionable.

Does obesity affect outcomes of treatment for lumbar stenosis and degenerative spondylolisthesis? Analysis of the Spine Patient Outcomes Research Trial (SPORT)

Study Design. Retrospective subgroup analysis of prospectively collected data according to treatment received. Objective. The purpose of this study was to determine whether obesity affects treatment outcomes for lumbar stenosis (SpS) and degenerative spondylolisthesis (DS). Summary of Background Data. Obesity is thought to be associated with increased complications and potentially less favorable outcomes after the treatment of degenerative conditions of the lumbar spine. This, however, remains a matter of debate in the existing literature. Methods. An as-treated analysis was performed on patients enrolled in the Spine Patient Outcomes Research Trial for the treatment of SpS or DS. A comparison was made between patients with a body mass index (BMI) of less than 30 (“nonobese,” n = 373 SpS and 376 DS) and those with a BMI of 30 or more (“obese,” n = 261 SpS and 225 DS). Baseline patient characteristics, intraoperative data, and complications were documented. Primary and secondary outcomes were measured at baseline and regular follow-up time intervals up to 4 years. The difference in improvement over baseline between surgical and nonsurgical treatment (i.e., treatment effect) was determined at each follow-up interval for the obese and nonobese groups. Results. At 4-year follow-up, operative and nonoperative treatment provided improvement in all primary outcome measures over baseline in patients with BMI of less than 30 and 30 or more. For patients with SpS, there were no differences in the surgical complication or reoperation rates between groups. Patients with DS with BMI of 30 or more had a higher postoperative infection rate (5% vs. 1%, P = 0.05) and twice the reoperation rate at 4-year follow-up (20% vs. 11%, P = 0.01) than those with BMI of less than 30. At 4 years, surgical treatment of SpS and DS was equally effective in both BMI groups in terms of the primary outcome measures, with the exception that obese patients with DS had less improvement from baseline in the 36-Item Short Form Health Survey (SF-36) physical function score than nonobese patients (22.6 vs. 27.9, P = 0.022). With nonoperative treatment, patients with SpS with BMI of 30 or more did worse in regard to all 3 primary outcome measures, and patients with DS with BMI of 30 or more had similar SF-36 bodily pain scores but less improvement over baseline in the SF-36 physical function and Oswestry Disability Index scores. Treatment effects for SpS and DS were significant within each BMI group for all primary outcome measures in favor of surgery. Obese patients had a significantly greater treatment effect than nonobese patients with SpS (Oswestry Disability Index, P = 0.037) and DS (SF-36 PF, P = 0.004) largely due to the relatively poor outcome of nonoperative treatment in obese patients. Conclusion. Obesity does not affect the clinical outcome of operative treatment of SpS. There are higher rates of infection and reoperation and less improvement from baseline in the SF-36 physical function score in obese patients after surgery for DS. Nonoperative treatment may not be as effective in obese patients with SpS or DS.

Duration of symptoms resulting from lumbar disc herniation: effect on treatment outcomes: analysis of the Spine Patient Outcomes Research Trial (SPORT).

BACKGROUND The purpose of the present study was to determine if the duration of symptoms affects outcomes following the treatment of intervertebral lumbar disc herniation. METHODS An as-treated analysis was performed on patients enrolled in the Spine Patient Outcomes Research Trial (SPORT) for the treatment of intervertebral lumbar disc herniation. Randomized and observational cohorts were combined. A comparison was made between patients who had had symptoms for six months or less (n = 927) and those who had had symptoms for more than six months (n = 265). Primary and secondary outcomes were measured at baseline and at regular follow-up intervals up to four years. The treatment effect for each outcome measure was determined at each follow-up period for the duration of symptoms for both groups. RESULTS At all follow-up intervals, the primary outcome measures were significantly worse in patients who had had symptoms for more than six months prior to treatment, regardless of whether the treatment was operative or nonoperative. When the values at the time of the four-year follow-up were compared with the baseline values, patients in the operative treatment group who had had symptoms for six months or less had a greater increase in the bodily pain domain of the Short Form-36 (SF-36) (mean change, 48.3 compared with 41.9; p < 0.001), a greater increase in the physical function domain of the SF-36 (mean change, 47.7 compared with 41.2; p < 0.001), and a greater decrease in the Oswestry Disability Index score (mean change, -41.1 compared with -34.6; p < 0.001) as compared with those who had had symptoms for more than six months (with higher scores indicating less severe symptoms on the SF-36 and indicating more severe symptoms on the Oswestry Disability Index). When the values at the time of the four-year follow-up were compared with the baseline values, patients in the nonoperative treatment group who had had symptoms for six months or less had a greater increase in the bodily pain domain of the SF-36 (mean change, 31.8 compared with 21.4; p < 0.001), a greater increase in the physical function domain of the SF-36 (mean change, 29.5 compared with 22.6; p = 0.015), and a greater decrease in the Oswestry Disability Index score (mean change, -24.9 compared with -18.5; p = 0.006) as compared with those who had had symptoms for more than six months. Differences in treatment effect between the two groups related to the duration of symptoms were not significant. CONCLUSIONS Increased symptom duration due to lumbar disc herniation is related to worse outcomes following both operative and nonoperative treatment. The relative increased benefit of surgery compared with nonoperative treatment was not dependent on the duration of the symptoms.

Civilian Gunshot Injuries of the Spinal Cord: A Systematic Review of the Current Literature

BackgroundThe principles that guide management of spinal cord injury (SCI) derive from injury resulting from blunt trauma, not gunshot wounds. Civilian gunshot-induced spinal cord injury (CGSWSCI) is a common, potentially serious cause of neurological deficit; there is disagreement about whether the same approaches used for SCI caused by blunt-force trauma should apply to gunshot-induced SCI.Questions/purposesWe reviewed the literature to answer the following questions regarding presentation and outcome of gunshot wound-induced SCI: (1) Are there differences in recovery prognosis between complete SCI and other patterns of SCI in CGSWSCI. (2) Does the use of steroids improve neurological recovery? (3) Does surgery to remove the bullet affect neurological recovery in CGSWSCI? (4) Does surgery result in an increased risk of complications of treatment?MethodsWe performed a systematic literature review of articles related to civilian gunshot injuries to the spine. Information relating to incidence, pattern of neurological injury, associated injuries, treatment, neurological outcome, and associated complications was extracted. Three independent reviewers assessed the strength of evidence present in the literature by examining quality, quantity, and consistency of results.ResultsA total of 15 articles met the predetermined inclusion criteria. Complete SCIs are associated with the worst functional recovery regardless of treatment. Steroids do not appear to have any added benefit in terms of restoring sensory and motor function. There appears to be some neurologic benefit to surgical decompression with intracanalicular bullet retrieval in patients with an incomplete lesion and a cauda equina syndrome. Complication rates are greater in operated patients.ConclusionsThese findings should be interpreted with caution because of considerable heterogeneity among the studies in the literature on gunshot-induced SCI and because of generally poor-quality study design and a high associated risk of selection bias. Supportive management should be the primary method of care, whereas surgery should be an option in case of radiographic evidence of a static compression on the spinal cord. Future studies are necessary to develop better treatment guidelines for patients with gunshot wound-associated SCI.

Correlation of posterior ligamentous complex injury and neurological injury to loss of vertebral body height, kyphosis, and canal compromise.

Study Design. Retrospective, case-control study. Objective. The purpose of this study was to determine if thoracolumbar vertebral body collapse, translation, or canal compromise (CC) is associated with injury to the posterior ligamentous complex (PLC) or neurological elements. Summary of Background Data. Radiographical parameters, including loss of vertebral body height (LOVBH), vertebral body translation, local kyphosis (LK), and CC, are often used as indicators of spinal instability. The hypothesis of this study was that LOVBH greater than 50%, LK greater than 20°, translation greater than 3.5 mm, or CC greater than 50% is associated with ligamentous and neurological injury. Methods. Retrospective review of prospectively collected spinal cord injury database was performed. Inclusion criteria include consecutive patients with thoracolumbar burst fractures. Exclusion criteria include flexion-distraction injuries and pathological fractures. Computed tomographic scan measurements of the spine were performed by 2 experienced spine surgeons blinded to magnetic resonance imaging results. On magnetic resonance imaging, the supraspinous ligament, interspinous ligament, ligamentum flavum, facet joints, and disc were graded as intact, indeterminate, or disrupted. American Spinal Injury Association (ASIA) score and Frankel Scale score were recorded. Spearman correlation coefficients were calculated to evaluate relationships between vertebral body measurements, ligamentous injury, and neurological injury. Results. Forty-six patients were included in the study. Ten patients had kyphosis greater than 20°, 1 patient had kyphosis greater than 30°, and 9 patients had LOVBH greater than 50%. There were 34 patients with vertebral body translation greater than 3.5 mm and 15 patients with CC greater than 50%. Sixteen patients had ligamentous injury. There was a significant correlation between subjacent segment translation greater than 3.5 mm and ligamentous injury (R = 0.323, P = 0.029) and ASIA motor score (R = −0.379, P = 0.009). There was no significant correlation between ligamentous injury or neurological injury and the following threshold parameters: LOVBH greater than 50%, vertebral body kyphosis greater than 20°, caudal or cephalad interspinous widening greater than 7 mm, CC greater than 50%, and sagittal transverse ratio less than 0.48. Conclusion. The results of this study indicate that LOVBH greater than 50% and LK greater than 20° are not predictive of PLC injury in thoracolumbar burst fractures. Translation greater than 3.5 mm was associated with PLC injury. The PLC and neural elements should be directly assessed with magnetic resonance imaging if there is clinical concern.

The Impact of Epidural Steroid Injections on the Outcomes of Patients Treated for Lumbar Disc Herniation: A Subgroup Analysis of the Sport Trial

BACKGROUND The Spine Patient Outcomes Research Trial (SPORT) is a prospective, multicenter study of operative versus nonoperative treatment of lumbar intervertebral disc herniation. It has been suggested that epidural steroid injections may help improve patient outcomes and lower the rate of crossover to surgical treatment. METHODS One hundred and fifty-four patients included in the intervertebral disc herniation arm of the SPORT who had received an epidural steroid injection during the first three months of the study and no injection prior to the study (the ESI group) were compared with 453 patients who had not received an injection during the first three months of the study or prior to the study (the No-ESI group). RESULTS There was a significant difference in the preference for surgery between groups (19% in the ESI group compared with 56% in the No-ESI group, p < 0.001). There was no difference in primary or secondary outcome measures at four years between the groups. A higher percentage of patients changed from surgical to nonsurgical treatment in the ESI group (41% versus 12% in the No-ESI, p < 0.001). CONCLUSIONS Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection. There was a higher prevalence of crossover to nonsurgical treatment among surgically assigned ESI-group patients, although this was confounded by the increased baseline desire to avoid surgery among patients in the ESI group. Given these data, we concluded that more studies are necessary to establish the value of epidural steroid injection for symptomatic lumbar intervertebral disc herniation.

Cervical laminectomy width and spinal cord drift are risk factors for postoperative C5 palsy.

Background: Cervical laminectomy and fusion (CLF) is a treatment option for multilevel cervical spondylotic myelopathy. Postoperative C5 nerve palsy is a possible complication of CLF. It has been suggested that C5 nerve palsy may be due to posterior drift of the spinal cord related to a wide laminectomy trough. Purpose: To test the hypothesis that excessive spinal cord drift into a wide laminectomy trough is associated with C5 palsy. Study Design: Retrospective case-control study. Patient Sample: Seventeen patients with C5 palsy, 8 patients as control group. Outcome Measures: Spinal cord positional measurements on magnetic resonance imaging (MRI). Methods: All patients who underwent elective CLF for cervical spondylotic myelopathy or ossified posterior longitudinal ligament using posterior instrumentation between 2004 and 2008 were included. Patients who underwent CLF for trauma, infection, or tumors were excluded. Clinical and radiographic outcomes were assessed by chart review (minimum of 1 y follow-up). Patients who developed a new postoperative C5 nerve palsy underwent repeat MRI. The control group also underwent CLF, did not develop a neurological deficit, and received a postoperative MRI for evaluation of possible infection. MRI measurements included the width of the laminectomy trough, the distance from the posterior vertebral body or disk to the anterior spinal cord, the width of the spinal cord herniated into the laminectomy defect, and C2–7 sagittal alignment. Preoperative radiographic measurements included preoperative vertebral body diameter, spinal canal diameter, and sagittal vertical offset. Results: There were seventeen patients with C5 nerve root palsy and 8 patients without C5 nerve root palsy. There were no baseline differences in fusion levels, instrumentation used, patient age, or sex. MRI measurements revealed an increase in mean postoperative cord drift in patients with C5 palsy at C3 (4.2 vs. 2.2 mm, P=0.002), C4 (4.6 vs. 2.8 mm, P=0.056), C5 (5.1 vs. 2.4 mm, P=0.011), and C6 (5.2 vs. 2.4 mm, P=0.003). There was a significant increase in C5 laminectomy trough width among patients with postoperative C5 palsy (17.9 vs. 15.2 mm, P=0.032), but there was no difference in sagittal alignment. Conclusions: A wider laminectomy at C5 was associated with an increased risk of postoperative C5 palsy. Increased preoperative spinal canal diameter is also associated with increased risk of C5 palsy. In addition, patients who experienced C5 nerve palsy had a significantly greater posterior spinal cord drift. Strategies to reduce postoperative laminectomy trough width and spinal cord drift may reduce the risk of postoperative C5 palsy.

Surgical management of spondylolysis and spondylolisthesis in athletes: indications and return to play.

Symptomatic isthmic spondylolisthesis is a common problem in the competitive athlete. Presence of this disorder is recognized easily with imaging studies, although a certain index of suspicion is necessary in the face of normal x-rays. Bone scan, CT scan, and MRI may all play a role in diagnosis. Management of this condition, on the other hand, can be more challenging. There are no high level evidence studies with specific recommendations for bracing, rehab, or surgery. Most athletes successfully return to competition with nonoperative treatment. For those that fail, a pars repair or a fusion are potential options. There are a myriad of techniques advocated for both, and no head to head study has ever proven superiority. Even with fusion, many individuals can return to sports after several months of structured rehab, although a significant number of athletes will fail to resume their pre-injury level of activity.

Restoration of lordosis and disk height after single‐level transforaminal lumbar interbody fusion

Objective:  To study radiographic and clinical outcomes after transforaminal lumbar interbody fusion (TLIF) in order to determine the impact of TLIF on lumbar lordosis, intervertebral height and improvement in clinical outcome measures.