Maryse Fortin

Predictors of Discharge Destination After Lumbar Spine Fusion Surgery

Study Design. Retrospective cohort study of the prospective collected American College of Surgeons National Surgical Quality Improvement Program database. Objective. The aim of the study was to identify predictive factors for the need of discharging patients to a facility other than home after lumbar spine fusion surgery. Summary of Background Data. Lumbar spine fusion surgery is a common surgical procedure used to treat a variety of lumbar spine conditions. A great number of patients fail to go home after surgery and require admission to a rehabilitation center. Predictive factors for discharging patients to a facility other than home after lumbar fusion surgery do not exist in the literature. Methods. A total of 15,092 patients undergoing lumbar spine fusion were dichotomized based on discharge destination to patients who were discharged home (N = 12,339) and others who were discharged to a facility other than home (N = 2753). Outcomes included patient demographics, comorbidities, and clinical characteristics. A multivariate logistic regression was used to identify whether outcomes studied were predictive factors for discharging patients to a facility other than home after lumbar fusion surgery. Results. Majority of patients were discharged home after lumbar fusion surgery (81.76%), with only some discharged to a facility other than home (18.24%). Multivariate analysis identified age, female sex, comorbidities (diabetes, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and obesity), minor and major complications, hospital length of stay, operative time at least 259 minutes, and multilevel surgery as significant predictive factors of discharging patients to a facility other than home after lumbar fusion surgery. Conclusion. The identified predictive factors can help the health system in developing an algorithm for early recognition of patients requiring postoperative admission to a facility other than home and possibly decreasing their hospital length of stay. This can significantly decrease the hospital costs for such patients. Level of Evidence: 3

Adjacent Segment Degeneration Versus Disease After Lumbar Spine Fusion for Degenerative Pathology: A Systematic Review With Meta-Analysis of the Literature.

Study Design: A systematic review. Objective: The purpose of this study was to review the published literature to estimate rates and identify risk factors for adjacent segment degeneration (ASDeg) and adjacent segment disease (ASDis) after lumbar fusion. Summary of Background Data: Arthrodesis remains a common intervention for the surgical treatment of degenerative spinal disease. Clinical studies have demonstrated variability in the rates of adjacent segment pathology after lumbar fusion. Methods: This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Symptoms of ASDis were distinguished and defined by the need for a revision surgery procedure to address adjacent level pathology. We searched MEDLINE, EMBASE, Cochrane Library, and CINAHL databases. Extracted data included average patient age, average time to follow-up, type of intervention, potential risk factors, and ASDeg and ASDis incidence. Funnel and forest plots were used to describe heterogeneity and meta-regression to estimate pooled incidence of ASDeg and ASDis. Results: A total of 31 articles with 4206 patients were included for analysis. Combining all extractable data, the overall pooled incidence of ASDeg was 5.9% per year (95% CI, 4.8%, 7.2%), and ASDis was 1.8% (95% CI, 1.3%, 2.4%) per year. The incidence of ASDeg is higher with more motion segments. Sex, age, segmental sagittal alignment, fusion methods, and instrumentation were not associated with an increased risk of ASDeg or ASDis. Radiographic ASDeg did not show strong correlation with clinical outcomes. Conclusions: The prevalence of ASDeg and ASDis has been variably reported in the literature, and fusion length is the factor most significantly associated with adjacent segment pathology. In guiding surgical strategies to avoid adjacent segment pathology, limiting the number of levels fused may have a greater impact than changes in fusion strategies.

Association between paraspinal muscle morphology, clinical symptoms and functional status in patients with lumbar spinal stenosis

PurposeLumbar spinal stenosis (LSS) is a disabling condition associated with narrowing of the spinal canal or vertebral foramina. Paraspinal muscle atrophy and fatty infiltration have been reported in patients with chronic LBP and disc herniation. However, very few imaging studies have examined paraspinal muscle morphology and composition in patients with LSS. The purpose of this study was to investigate the association of paraspinal muscle size, composition and asymmetry with functional status in patients with LSS.MethodsThirty-six patients diagnosed with LSS at L4–L5 with neurogenic claudication were included. Paraspinal muscle measurements were obtained from axial T2-weighted MR images, bilaterally, at the level of the superior and inferior vertebral endplates of L5. Muscle measurements of interest included: total cross-sectional area (CSA), functional CSA (FCSA), the ratio of FCSA to CSA (FCSA/CSA) as an indicator of muscle composition, and relative % asymmetry in muscle CSA. The association between muscle parameters and other patient characteristics with function as indicated from Oswestry Disability Index (ODI) scores and pain interference status was investigated.ResultsGreater multifidus muscle fatty infiltration (e.g., lower FCSA/CSA) and lower psoas relative CSA were associated with lower function (higher ODI and pain interference scores) in univariable and multivariable analyses. There was no association between the different muscle parameters and stenosis severity or back or leg pain duration or severity.ConclusionsOur findings suggest an association of multifidus muscle fatty infiltration and psoas muscle size with functional status in patients diagnosed with LSS. Future prospective studies are needed to evaluate whether such muscle parameters are associated with prognosis and functional recovery following surgical treatment.

Association Between Paraspinal Muscle Morphology, Clinical Symptoms, and Functional Status in Patients With Degenerative Cervical Myelopathy

Study Design. A cross-sectional study. Objective. The aim of this study was to assess fatty infiltration and asymmetry of the multifidus (MF), semispinalis cervicis (SCer), semispinalis capitis (SCap), and splenius capitis (SPL) muscles in patients with degenerative cervical myelopathy (DCM), and evaluate their correlations with clinical symptoms and functional scores. Summary of Background Data. Cervical muscle alterations have been reported in patients with chronic neck pain, but the assessment of cervical muscle morphology has been overlooked in patients with DCM. Methods. Thirty-eight patients diagnosed with DCM and spinal cord compression at C4-C5 or C5-C6 (first level of compression) were included. Cervical muscle measurements of cross-sectional area (CSA) and ratio of functional CSA (fat-free area, FCSA) to total CSA were obtained from T2-weighted axial images at the level above, same, and level below the most cranial level of spinal cord compression. Muscle fatty infiltration and asymmetry was assessed at every level and their associations with respect to clinical signs and symptoms and functional scores were investigated. Results. There was a significant increase in fatty infiltration (decrease in FCSA/CSA ratio) of the MF (P = 0.001) and SPL (P < 0.001) muscles at the level below the spinal cord compression. A significant increase in MF CSA asymmetry was also observed at the level below the compression. Lower MF FCSA/CSA ratio was associated with longer 30-m walking test time. Lower SCer FCSA/CSA was associated with corticospinal distribution motor deficits and atrophy of the hands. Greater asymmetry in SCap CSA was associated with higher Neck Disability Index (NDI) scores, whereas lower asymmetry in MF CSA was associated with a positive Hoffman sign and weakness. Conclusion. A significant increase in muscle fatty infiltration and CSA asymmetry at the level below the compression was observed in patients with DCM. Our results also suggest an association between cervical muscle morphology and DCM clinical symptoms and functional status. Level of Evidence: 2

Use of Computer Assistance in Lumbar Fusion Surgery: Analysis of 15 222 Patients in the ACS-NSQIP Database:

Study Design: Retrospective cohort study. Objective: Several studies have shown that the accuracy of pedicle screw placement significantly improves with use of computer-assisted surgery (CAS). Yet few studies have compared the incidence of postoperative complications between CAS and conventional techniques. The objective of this study is to determine the difference in postoperative complication rates between CAS and conventional techniques in spine surgery. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent posterior lumbar fusion from 2011 to 2013. Multivariate analysis was conducted to demonstrate the difference in postoperative complication rates between CAS and conventional techniques in spine surgery. Results: Out of 15 222 patients, 14 382 (95.1%) were operated with conventional techniques and 740 (4.90%) were operated with CAS. Multivariate analysis showed that patients in the CAS group had fewer odds to experience adverse events postoperatively (odds ratio [OR] = 0.57, P < .001). Minor adverse events occurred in 2905 (20.2%) patients in the conventional group and in 98 (13.2%) patients in the CAS group (OR = 0.57, P < .001). Blood transfusion was present in 2488 (17.3%) of the patients in the conventional group compared to 81 (11.0%) of the patients in the CAS group (OR = 0.56, P < .001). The mean operative time in the conventional group was 205.2 ± 106.1 minutes, and it was 227.0 ± 111.9 minutes in the CAS group. This difference was statistically significant (r = 20.14, P < .001). Conclusion: This article examined the complications in lumbar spinal surgery with or without the use of CAS. These results suggest that CAS may provide a safer technique for implant placement in lumbar fusion surgeries.

Relationship between cervical muscle morphology evaluated by MRI, cervical muscle strength and functional outcomes in patients with degenerative cervical myelopathy

BACKGROUND Cervical muscle alterations have been reported in patients with chronic neck pain, but the assessment of muscle morphology and strength has been overlooked in patients with degenerative cervical myelopathy (DCM). OBJECTIVES This study aimed to investigate the relationship between cervical muscle degenerative changes observed on MRI, muscle strength and symptoms severity in patients diagnosed with DCM. DESIGN Observational study. METHODS Cervical muscle measurements of total cross-sectional area (CSA), functional CSA (fat free area, FCSA) and ratio of FCSA/CSA (e.g. fatty infiltration) were obtained from T2-weighted axial MR images from C2-C3 to C6-C7 in 20 patients. Muscle strength was assessed manually using a microFET2 dynamometer. The association between cervical muscle morphology parameters, muscle strength, symptoms severity and functional status was investigated. RESULTS Greater mean CSA and FCSA was associated with greater overall muscle strength. The mean FCSA explained 37%, 76%, 39%, 20% and 65% of the total variance in flexion, extension, right-side bending, left-side bending and overall muscle strength, respectively. The mean ratio of FCSA/CSA was not significantly associated with cervical muscle strength in any direction. However, greater FCSA/CSA ratio (e.g. less fatty infiltration) was associated with lower disability score (p = 0.02, R2 = 0.20). CONCLUSIONS Cervical muscle lean muscle mass was positively associated with cervical muscle strength in patients with DCM. Moreover, greater fatty infiltration in the cervical extensor muscles was associated with lower functional score. Such findings suggest that clinicians should pay greater attention to cervical muscle morphology and function in patients with DCM.

Utility and costs of radiologist interpretation of perioperative imaging in patients with traumatic single-level thoracolumbar fractures

OBJECTIVE The cost of spine management is rising. As diagnostic imaging accounts for approximately 10% of total patient care spending, there is interest in determining if economies could be made with regard to the routine consultation of radiology for image interpretation. In the context of spine trauma, both the spine surgeon and the radiologist interpret perioperative imaging. Authors of the present study investigated the impact of radiologist interpretation of perioperative imaging from patients with traumatic single-level thoracolumbar fractures given that spine surgeons are expected to be comfortable interpreting pathologies of the musculoskeletal system. METHODS The authors conducted a retrospective review of all patients presenting with a single-level thoracolumbar fracture treated at the McGill University Health Centre in the period from January 2003 to December 2010. The time between image capture and radiologist interpretation as well as the number of extraskeletal and/or incidental findings was extracted from the radiology reports on all perioperative images including radiographic, fluoroscopic, and CT images. The cost of interpretation was obtained from the provincial health insurance entity of Quebec. RESULTS Eighty-two patients met the study inclusion criteria. Radiologists took a median of 1 day (IQR 0-5.5 days) to interpret preoperative radiographs. Intraoperative fluoroscopic images and postoperative radiographs were read by the radiologist a median of 19 days (IQR 4-56.75 days) and 34 days (IQR 1-137.5 days) after capture, respectively (p < 0.05). Preoperative radiologist dictations reported extraskeletal and/or incidental findings for 8.1% of radiographs; there were no intraoperative or postoperative extraskeletal findings beyond those previously reported on the preoperative radiographs. Radiologists took a median of 1 day (IQR 0-1 day) to read both preoperative and postoperative CT scans; extraskeletal and/or incidental findings were present in 46.2% of preoperative reports and 4.5% of postoperative reports. There were no intraoperative or postoperative radiological findings that provoked reoperation. A total of 66 intraoperative fluoroscopy images and 225 postoperative radiographs were read for a cost of

Preoperative Computed Tomography Myelography Parameters as Predictors of Outcome in Patients With Degenerative Cervical Myelopathy: Results of a Systematic Review:

1399.20 and

Complications with and without the Use of Computer-Assistance in Lumbar Fusion Surgery: Analysis of 15,222 Patients in ACS-NSQIP Database

1867.50 (Canadian dollars), respectively, for radiologist interpretation. This cost amounted to 40.3% of all perioperative image interpretation spending. CONCLUSIONS In the management of single-level thoracolumbar fractures, radiologists add information to the diagnostic picture when interpreting preoperative radiographs and perioperative CT scans; however, the interpretation of intraoperative fluoroscopic images and postoperative radiographs comes with significant delay, does not add additional information, and represents an area of potential cost and professional-resource reduction.

CT-Myelogram Predictors of Outcome in Patients with Cervical Spondylotic Myelopathy: Results of a Systematic Review

Study Design: Systematic review. Objectives: To determine the preoperative computed tomography (CT) myelogram imaging parameters in patients diagnosed with degenerative cervical myelopathy (DCM) that correlate with severity of DCM and predict postoperative patients’ functional outcome. Methods: An electronic database search was performed using Ovid Medline and Embase. CT myelogram studies investigating the correlation between imaging characteristics and DCM severity or postoperative outcomes were included. Two independent reviewers performed citation screening, selection, qualitative assessment, and data extraction using an objective and blinded protocol. Results: A total of 5 studies (402 patients) were included in this review and investigated the role of preoperative CT myelogram parameters in predicting the functional outcome after surgical treatment of DCM. All studies were retrospective cohort studies. CT myelogram characteristics included the transverse area of the spinal cord at maximum level of compression, spinal canal narrowing, number of blocks, spinal canal diameter, and flattening ratio. There is low evidence suggesting that patients with a preoperative transverse area of the spinal cord >30 mm2 at the level of maximum compression have better postoperative recovery and outcome. We found no studies investigating the correlation between preoperative CT myelogram parameters and DCM severity. Conclusions: Patients with greater transverse area of spinal cord at the level of maximum compression on the preoperative CT myelogram are more likely to have better neurological outcome after surgery. There is insufficient evidence to suggest that any of the other CT myelogram parameters investigated are predictors of postoperative outcomes in patients with DCM.