Marcelo Gruenberg

Ultraclean air for prevention of postoperative infection after posterior spinal fusion with instrumentation: A comparison between surgeries performed with and without a vertical exponential filtered air-flow system

Study Design. This study retrospectively compared infection rates between adult patients after posterior spinal instrumentation procedures performed in a conventional versus an ultraclean air operating room. Objective. To evaluate if the use of ultraclean air technology could decrease the infection rate after posterior spinal arthrodesis with instrumentation. Summary of Background Data. Postoperative wound infection after posterior arthrodesis remains a feared complication in spinal surgery. Although this frequent complication results in a significant problem, the employment of ultraclean air technology, as it is commonly used for arthroplasty, has not been reported as a possible alternative to reduce the infection rate after complex spine surgery. Methods. One hundred seventy-nine patients having posterior spinal fusion with instrumentation were divided into 2 groups: group I included 139 patients operated in a conventional operating room, and group II included 40 patients operated in a vertical laminar flow operating room. Patient selection was performed favoring ultraclean air technology for elective cases in which high infection risk was considered. A statistical analysis of the infection rate and its associated risk factors between both groups was assessed. Results. We observed 18 wound infections in group I and 0 in group II. Comparison of infection rates using the chi-squared test showed a statistically significant difference (P <0.017). Conclusion. The use of ultraclean air technology reduced the infection rate after complex spinal procedures and appears to be an interesting alternative that still needs to be prospectively studied with a randomized protocol.

Giant sacral schwannoma. A case report.

Study Design Case report. Objectives To present a rare case of a previously operated giant schwannoma located in the sacrum, and to make some considerations regarding diagnostic modalities and treatment options. Summary of Background Data Large sacral schwannomas with anterior cortex erosion and associated intrapelvic extension are uncommon. Only a few case reports and small series have been published. There is no established consensus regarding diagnostic modalities, necessity for histologic diagnosis before surgery, or best surgical option. Methods The patient presented with a 2‐month history of right sciatica and severe low back pain. After a histopathologic diagnosis and a complete set of image studies, the resection of the tumoral mass was planned posteriorly. Results Seventeen months after tumor resection, the patient has a good clinical outcome, and there are no radiologic signs of instability or recurrence. Conclusions Considering the experience of the few cases reported in the world literature, the management of this tumor appears to grant favorable results, recurrence being the most frequent complication.

Clinical Guidelines and Payer Policies on Fusion for the Treatment of Chronic Low Back Pain

Study Design. Systematic review. Objective. The purpose of this review is to provide a critical appraisal of general and fusion–specific clinical practice guidelines on the treatment of chronic nonradicular low back pain and compare the quality and evidence base of fusion guidelines and select payer policies. Summary of Background Data. The treatment of lumbar spondylosis associated with low back pain with lumbar arthrodesis, or fusion, has risen fourfold in the past two decades. Given the significant associated health care costs, there is an increase in clinical guidelines and payer policies influencing patient treatment options. Assessment of the medical necessity of a treatment, such as lumbar fusions, based on medical literature will frequently supersede the determination of the physician in the care of their patient. Concerns regarding the effectiveness and costs of the surgical treatment of spinal disorders presenting with low back pain has placed enormous scrutiny on the value of surgical treatments to our patients. As both clinical guidelines and payer policies have a major impact on the perceived effectiveness, or medical necessity, of lumbar fusions for the treatment of chronic nonradicular low back pain, a review of this topic was undertaken. Methods. An electronic literature search of PubMed, the National Guideline Clearinghouse and the International Network of Agencies for Health Technology Assessment was performed to identify clinical practice guidelines on assessment and treatment of chronic nonradicular low back pain, including those on use of lumbar fusion, as well as relevant technology assessments. A Google search for publicly available private and public payer policies related to fusion was also performed. A hand search was used to identify specific studies cited for support of the recommendations made. A modified Appraisal of Guidelines Research and Evaluation instrument was used to provide a standardized assessment method for evaluating the quality of development of the evidence base and recommendations in guidelines and selected health policies. This was combined with appraisal of the evidence base supporting the recommendations. Results. Three systematic reviews of general guidelines from a PubMed search yielding 94 citations were included. A convenience sample of five guidelines with recommendations on fusion was taken from 182 citations identified by the National Guideline Clearinghouse and the International Network of Agencies for Health Technology Assessment searches. Two guidelines were developed by US professional societies, (neurosurgery and pain management), and three were European-based guidelines (Belgium, United Kingdom, and the European Cooperation in Science and Technology). The general guidelines were consistent with their recommendations for diagnosis, but inconsistent regarding recommendations for treatment. All guidelines and payer policies with recommendations on fusion included some set of the primary randomized controlled trials comparing fusion to other treatment options with the exception of one policy. However, no clear pattern with regard to the quality of development was identified based on the modified Appraisal of Guidelines Research and Evaluation tool. There were differences in specialty society recommendations. Conclusion. Three systematic reviews of evidence-based guidelines that provide general guidance for the assessment and treatment of chronic low back pain described consistent recommendations and guidance for the evaluation of chronic low back pain but inconsistent recommendations and guidance for treatment. Five evidence-based guidelines with recommendations on the use of fusion for the treatment of chronic low back pain were evaluated. There is some consistency across guidelines and policies that are government sponsored with regard to development process and critical evaluation of index studies as well as overall recommendations. There were differences in specialty society recommendations. There is heterogeneity in the medical payer policies reviewed possibly due to variations in the literature cited and transparency of the development process. A description of how recommendations are formulated and disclosure of any potential bias in policy development is important. Three–medical payer policies reviewed are of poor quality with one rated as good with respect to their development based on the modified Appraisal of Guidelines Research and Evaluation tool. Medical payer policies influence patient care by defining medical necessity for approving treatments, and should be held to the same standards for transparency and development as guidelines. Clinical Recommendations. The spine care community needs to develop (or update) high–quality treatment guidelines. The process should be transparent, methodologically rigorous, and consistent with the Appraisal of Guidelines Research and Evaluation and Institute of Medicine recommendations. This effort should be collaborative across specialty/society groups and would benefit from patient and public input. Payer policies and treatment guidelines need to be transparent and based on the highest quality evidence available. Clinicians from specialty/society groups, guideline developers and policy makers should collaborate on their development. This process would also benefit from public and patient input.

Overdistraction of cervical spine injuries with the use of skull traction: a report of two cases.

Two cases in which cervical spine overdistraction occurred with the use of skull traction are described. A summary of the clinical presentations and definitive treatment together with some bibliographic references are discussed. Finally, suggestions regarding how to avoid overdistraction when using skull traction are given.

Fusion versus nonoperative management for chronic low back pain: do sociodemographic factors affect outcome?

Study Design. Systematic review. Objective. The objectives of this systematic review were to determine whether sociologic and demographic factors modify the effect of fusion versus nonoperative management in patients with chronic low back pain. Summary of Background Data. Chronic low back pain is among the most common symptoms leading patients to seek medical care and presents significant challenges in treatment decision making. This is due to the wide array of pathologic conditions causing back pain, the multitude of patient variables (i.e., litigation, psychologic issues, social issues) that are thought to influence the perception of back pain, and the wide variation in treatment response. Sociodemographic factors are thought to play a role in pain perception and treatment response, though this has been poorly assessed in the literature. Methods. Systematic review of the literature, focused on randomized controlled trials to assess the heterogeneity of treatment effect of sociodemographic factors on the outcomes of fusion versus nonoperative care of the treatment of chronic low back pain. Results. The only sociologic factors evaluated in randomized controlled trials adequate to assess heterogeneity of treatment effect are pending litigation, workers compensation, sick leave, and heavy labor job type. Litigation patients, although thought to do poorly with treatment of chronic low back pain in general, responded more favorably to fusion than nonoperative care. Likewise, patients with lighter jobs and those patients who were not on sick leave did better with fusion than nonoperative care. No demographic factors were observed to respond more favorably to one treatment over the other. Conclusion. Sociodemographic factors are not well studied in the literature, but are assumed to affect treatment outcomes. After rigorous review, few studies held up to the standards required for defining the comparative treatment effect of these factors. Pending litigation may negatively impact outcomes of patients with chronic low back pain; however, those who underwent fusion had better outcomes than those with nonoperative management in two European studies. There is no evidence to suggest that sociodemographic factors alone should preclude surgery. Well-constructed prospective randomized studies with predefined subgroup analyses are required to further understand the impact of sociodemographic factors in the treatment of chronic low back pain. Clinical Recommendations. Sociodemographic factors should be considered when making treatment decisions for patients with chronic low back pain, but alone do not preclude fusion for chronic low back pain. Strength of recommendation: Weak.

Use of CT-guided periradicular injection for the treatment of foraminal and extraforaminal disc herniations

Study design: Retrospective case series. Evidence level IV. Objectives: To evaluate surgical candidates with foraminal or extraforaminal lumbar disc herniation treated with CT-guided periradicular injection (CTGPI) as a valid treatment option for avoiding surgery. Methods: We carried out a retrospective evaluation of 46 consecutive patients with foraminal or extraforaminal disc herniation treated with CTGPI. CTGPI was performed only when radicular pain could not be controlled, or in patients who continued requiring pain medication following an acute episode and whose radicular pain precluded them from resuming their daily activities. Forty-six patients with a minimum 2-year follow-up met the inclusion criteria. There were 21 women and 25 men, with a mean age of 47 years. Results: At 1 month after injection, 41 (89%) patients experienced a decrease in radicular pain; 3 experienced no change; and 2 had received surgical treatment. At the final follow-up visit (mean, 74 months) 6 additional patients underwent surgery while 38 (83%) did not require surgery. Pain level comparison between pre-injection and last examination showed that low back pain had decreased a mean of 5 points and radicular pain diminished a mean of 7 points. Twenty-two (58%) of the 38 nonoperated patients had no pain at all and 35 patients had resumed their normal daily activities. No complications were recorded. Conclusion: Based on these results, we consider that the use of CTGPI is a reliable alternative before surgery for patients with foraminal or extraforaminal disc herniation without severe motor deficit but with intractable radicular pain. Final Class of evidence (CoE)-treatment Yes Study design: RCT Cohort Case control Case series • Methods Concealed allocation (RCT) Intention to treat (RCT) Blinded/independent evaluation of primary outcome F/U ≥85% • Adequate sample size • Control for confounding Overall class of evidence IV The definiton of the different classes of evidence is available on page 59.

Percutaneous cement discoplasty for the treatment of advanced degenerative disk disease in elderly patients

PurposeThe authors describe a percutaneous technique to treat advanced degenerative disk disease in elderly patients.MethodA step-by-step technical description based on our experience in selected cases.ResultPostoperative imaging results are presented as well as indications and recommendations.ConclusionPercutaneous discoplasty can result as an alternative minimal invasive strategy for the treatment of advanced degenerative disk disease.

The influence of anatomy (normal versus scoliosis) on the free-hand placement of pedicle screws: Is misplacement more frequent in patients with anatomical deformity?

Study design: Retrospective prognostic study. Objective: To evaluate whether patients with anatomical deformity due to scoliosis have a higher frequency of inaccurate pedicle screw insertion and related complications using the free-hand technique compared with those whose normal anatomy had been impacted by trauma. Methods: Consecutively treated trauma patients with otherwise normal anatomy (48 patients instrumented with 291 screws, group A) and scoliosis patients (24 patients instrumented with 287 screws, group B) were evaluated. Screw position on CT was evaluated using the classification by Gertzbein and Robbins with modification by Karagoz Guzey. (See web appendix at www.aospine.org/ebsj for complete classification description.) Images were examined by two fellows and one junior staff member none of whom participated in patient management. Screw position was determined by consensus. Results: In group A, five (1.7%) out of 289 screws were severely misplaced and 26 (9%) screws caused either medial (3.8%) or lateral (5.2%) cortical breeches. The other 258 (89.3%) screws were fully contained within the cortical boundaries of the pedicle. In group B, seven (2.8%) out of 256 screws were severely misplaced. Thirty-three (13%) screws caused cortical breeches, either medial (9%), lateral (2%), or anterior (2%), and 216 (84.3%) screws were fully contained within the cortical boundaries of the pedicle and the vertebra. Neurological complications were reported in one patient with scoliosis. No vascular complications were reported in either group. Conclusions: The percentage of incorrectly placed screws was similar in both groups, trauma and deformity patients. The presence of vertebral anatomical changes related to adult scoliosis was not associated with an increase in the screw-related neurological or vascular complications. Methods evaluation and class of evidence (CoE) Methodological principle: Study design: Prospective cohort Retrospective cohort • Case control Case series Methods Patients at similar point in course of treatment Follow-up ≥85% • Similarity of treatment protocols for patient groups • Patients followed for long enough for outcomes to occur • Control for extraneous risk factors Evidence class: III The definiton of the different classes of evidence is available on page 73.

Analysis of Risk Factors for New Vertebral Fracture After Percutaneous Vertebroplasty

Study Design: Retrospective analysis. Level of evidence III. Objectives: Low-energy vertebral compression fractures are an increasing socioeconomic problem among elderly patients. Percutaneous vertebroplasty has been extensively used for the treatment of painful fractures because of its effectiveness. However, some complications have been described; among them, new vertebral compression fractures, whether adjacent or not to the treated vertebra, are commonly reported complications (8% to 52%). Methods: We retrospectively analyzed epidemiological and technical variables presumably associated with new vertebral compression fractures. To determine the relationship between new vertebral compression fracture and percutaneous vertebroplasty, 30 patients (study group) with this complication were compared with 60 patients treated with percutaneous vertebroplasty without this condition (control group). Results: A higher cement percentage was found in the study group (40.3%) compared with the control group (30.5%). Initial vertebral kyphosis was significantly higher in the first group (15°) compared with the control group (9°). Epidemiological factors were similar in both groups. Conclusions: In our study, increased cement percentage injected and a higher kyphosis were associated with new vertebral compression fractures.

Factores asociados a recidiva de hernia de disco lumbar luego de una microdiscectomía

INTRODUCTION Lumbar disc hernias are a common cause of spinal surgery. Hernia recurrence is a prevalent complication. OBJECTIVE To analyse the risk factors associated with hernia recurrence in patients undergoing surgery in our institution. MATERIALS AND METHODS Lumbar microdiscectomies between 2010 and 2014 were analysed, patients with previous surgeries, extraforaminales and foraminal hernias were excluded. Patients with recurrent hernia were the case group and those who showed no recurrence were the control group. RESULTS 177 patients with lumbar microdiscectomy, of whom 30 experienced recurrence (16%), and of these 27 were reoperated. Among the risk factors associated with recurrence, we observed a higher rate of disc height, higher percentage of spinal canal occupied by the hernia and presence of degenerative facet joint changes; we observed no differences in sex, body mass index or age. DISCUSSION Previous studies show increased disc height and young patients as possible factors associated with recurrence. CONCLUSION In our series we found that the higher rate of disc height, the percentage of spinal canal occupied by the hernia and degenerative facet joint changes were associated with hernia recurrence.