Michael J. Vives

Readability of Spine-Related Patient Education Materials From Subspecialty Organization and Spine Practitioner Websites

Study Design. Analysis of spine-related websites available to the general public. Objective. To assess the readability of spine-related patient educational materials available on professional society and individual surgeon or practice based websites. Summary of Background Data. The Internet has become a valuable source of patient education material. A significant percentage of patients, however, find this Internet based information confusing. Healthcare experts recommend that the readability of patient education material be less than the sixth grade level. The Flesch-Kincaid grade level is the most widely used method to evaluate the readability score of textual material, with lower scores suggesting easier readability. Methods. We conducted an Internet search of all patient education documents on the North American Spine Society (NASS), American Association of Neurological Surgeons (AANS), the American Academy of Orthopaedic Surgeons (AAOS), and a sample of 10 individual surgeon or practice based websites. The Flesch-Kincaid grade level of each article was calculated using widely available Microsoft Office Word software. The mean grade level of articles on the various professional society and individual/practice based websites were compared. Results. A total of 121 articles from the various websites were available and analyzed. All 4 categories of websites had mean Flesch-Kincaid grade levels greater than 10. Only 3 articles (2.5%) were found to be at or below the sixth grade level, the recommended readability level for adult patients in the United States. There were no significant differences among the mean Flesch-Kincaid grade levels from the AAOS, NASS, AANS, and practice-based web-sites (P = 0.065, ANOVA). Conclusion. Our findings suggest that most of the Spine-related patient education materials on professional society and practice-based websites have readability scores that may be too high, making comprehension difficult for a substantial portion of the United States adult population.

Postoperative Spinal Wound Infections and Postprocedural Diskitis

Abstract Background/Objective: Postprocedural infections are a significant cause of morbidity after spinal interventions. Methods: Literature review. An extensive literature review was conducted on postprocedural spinal infections. Relevant articles were reviewed in detail and additional case images were included. Results: Clinical findings, laboratory markers, and imaging modalities play important roles in the detection of postprocedural spinal infections. Treatment may range from biopsy and antibiotics to multiple operations with complex strategies for soft tissue management. Conclusions: Early detection and aggressive treatment are paramount in managing postprocedural spinal infections and limiting their long-term sequelae.

Soft tissue injuries with the use of safe corridors for transfixion wire placement during external fixation of distal tibia fractures: an anatomic study.

Objectives To determine which soft tissue structures are at risk and when joint violation can occur during small wire placement for hybrid external fixation of distal tibial fractures while adhering to published guidelines. Design Cadaver anatomic experiment. Setting University orthopaedic program. Sujbects Five embalmed cadavers. Intervention Placement of small wire transfixion pins in the distal tibia. Main Outcome Measurements Dissection and measurements. Methods Four orthopaedic surgeons were shown diagrams that have been widely accepted as allowing for placement of transfixion pins in the distal tibia through safe corridors. Each of the orthopaedic surgeons was then asked to place two transfixion pins into each of five cadaver legs in a position that would provide stable external fixation of the metaphysis to the diaphysis with a circular fixator (forty pins total) for a distal tibial fracture within five centimeters of the plafond. The specimens were dissected, and pins impaling neurovascular structures, tendons, or the ankle capsule were recorded. The superior capsular synovial reflections were measured from the anterior joint line and the tip of the medial malleolus. These measurements were also performed on arthrograms of two extremities before their dissection. Results Fifty-five percent of the pins placed impaled at least one tendon that crosses the ankle joint. Neurovascular structures that were impaled included the saphenous vein (±10.5 percent) and the superficial peroneal nerve (±7.5 percent). One pin violated the superior capsular synovial reflection, which was an average of thirty-two millimeters (±1.58 millimeters) from the tip of the medial malleolus and twenty-one millimeters (±1.63 millimeters) from the anteromedial joint line. Conclusions This study shows that tendons and neurovascular structures above the ankle are at risk during small transfixion pin placement, even when using safe corridors. Pins placed within two centimeters of the anterior joint line or three centimeters from the medial malleolus may be intracapsular.

Management of Acute Spinal Fractures in Ankylosing Spondylitis

Ankylosing Spondylitis (AS) is a multifactorial and polygenic rheumatic condition without a well-understood pathophysiology (Braun and Sieper (2007)). It results in chronic pain, deformity, and fracture of the axial skeleton. AS alters the biomechanical properties of the spine through a chronic inflammatory process, yielding a brittle, minimally compliant spinal column. Consequently, this patient population is highly susceptible to unstable spine fractures and associated neurologic devastation even with minimal trauma. Delay in diagnosis is not uncommon, resulting in inappropriate immobilization and treatment. Clinicians must maintain a high index of suspicion for fracture when evaluating this group to avoid morbidity and mortality. Advanced imaging studies in the form of multidetector CT and/or MRI should be employed to confirm the diagnosis. Initial immobilization in the patients preinjury alignment is mandatory to prevent iatrogenic neurologic injury. Both nonoperative and operative treatments can be employed depending on the patients age, comorbidities, and fracture stability. Operative techniques must be individually tailored for this patient population. A multidisciplinary team approach is best with preoperative nutritional assessment and pulmonary evaluation.

The halo vest: principles of application and management of complications.

Abstract Background: The halo skeletal device commonly is used both as primary treatment and as an adjunct to internal fixation in patients with cervical spinal injuries. For optimal outcome, the multidisciplinary team should have a basic understanding of the indications, design rationale, and complications associated with the halo skeletal fixator. Design: Literature review. Findings: The halo device provides the most rigid form of external cervical immobilization. Adherence to established application guidelines is critical to minimize morbidity. Safe zones for pin placement have been delineated. Protocols for management of pin-site infections have been established to appropriately manage these unfortunate complications. Conclusion: Although the halo is an effective form of cervical immobilization, complications with its use are encountered periodically. Familiarity with the design rationale, proper method of application, and potential complications can help to minimize the morbidity of this commonly used device.

Blood loss during posterior spinal fusion for adolescent idiopathic scoliosis.

Study Design. Retrospective uncontrolled case series. Objective. The purpose of this study was to determine the association, if any, between intraoperative blood loss and need for transfusion with the use of periapical (Ponte) osteotomies, as well as other patient and surgical variables among patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumentation and fusion. Summary of Background Data. Blood loss during posterior spinal fusion for AIS can be substantial. Numerous techniques are used to minimize intraoperative blood loss and the need for allogeneic transfusion. However, it is unclear which patient and surgeon variables affect blood loss most significantly. Methods. A review was conducted on consecutive patients with AIS who had undergone posterior spinal fusion from July 1997 to February 2013 by a single primary surgeon at 1 institution. The relationship of estimated blood loss, normalized blood loss (normalized blood loss = estimated blood loss/number of levels fused/patients weight in kilograms), autologous blood retrieved, and allogeneic transfusion received with various patient- and procedure-related variables were analyzed. Results. Estimated blood loss, normalized blood loss, and autologous blood retrieved were higher in patients who underwent periapical Ponte osteotomies (n = 38) (P < 0.0001, P < 0.001, P < 0.01, respectively). The mean major curve correction was 64% in patients without osteotomies, and 65% in patients with osteotomies (P = 0.81). All patients who underwent osteotomies (38/38) received allogeneic transfusion versus 26% (19/73) of those without osteotomies (P < 0.001). The likelihood of transfusion correlated with increasing number of osteotomies and a lower preoperative hemoglobin level (odds ratio, 3.34; P = 0.003; and odds ratio, 0.51; P = 0.02, respectively). Conclusion. In patients with AIS undergoing posterior spinal fusion with instrumentation, performing periapical osteotomies increased all measures of intraoperative blood loss and need for transfusion without substantially improving major curve correction. As expected, a lower preoperative hemoglobin level was observed in patients who received a blood transfusion after posterior instrumentation and fusion. Level of Evidence: 4

The Effects of Local Insulin Application to Lumbar Spinal Fusions in a Rat Model

BACKGROUND CONTEXTnThe rates of pseudoarthrosis after a single-level spinal fusion have been reported up to 35%, and the agents that increase the rate of fusion have an important role in decreasing pseudoarthrosis after spinal fusion. Previous studies have analyzed the effects of local insulin application to an autograft in a rat segmental defect model. Defects treated with a time-released insulin implant had significantly more new bone formation and greater quality of bone compared with controls based on histology and histomorphometry. A time-released insulin implant may have similar effects when applied in a lumbar spinal fusion model.nnnPURPOSEnThis study analyzes the effects of a local time-released insulin implant applied to the fusion bed in a rat posterolateral lumbar spinal fusion model. Our hypothesis was twofold: first, a time-released insulin implant applied to the autograft bed in a rat posterolateral lumbar fusion will increase the rate of successful fusion and second, will alter the local environment of the fusion site by increasing the levels of local growth factors.nnnSTUDY DESIGNnAnimal model (Institutional Animal Care and Use Committee approved) using 40 adult male Sprague-Dawley rats.nnnMETHODSnForty skeletally mature Sprague-Dawley rats weighing approximately 500 g each underwent posterolateral intertransverse lumbar fusions with iliac crest autograft from L4 to L5 using a Wiltse-type approach. After exposure of the transverse processes and high-speed burr decortication, a Linplant (Linshin Canada, Inc., ON, Canada) consisting of 95% microrecrystalized palmitic acid and 5% bovine insulin (experimental group) or a sham implant consisting of only palmitic acid (control group) was implanted on the fusion bed with iliac crest autograft. As per the manufacturer, the Linplant has a release rate of 2 U/day for a minimum of 40 days. The transverse processes and autograft beds of 10 animals from the experimental and 10 from the control group were harvested atxa0Day 4 and analyzed for growth factors. The remaining 20 spines were harvested at 8 weeks andxa0underwent a radiographic examination, manual palpation, and microcomputed tomographic (micro-CT) examination.nnnRESULTSnOne of the 8-week control animals died on postoperative Day 1, likely due to anesthesia. In the groups sacrificed at Day 4, there was a significant increase in insulinlike growth factor-I (IGF-I) in the insulin treatment group compared with the controls (0.185 vs. 0.129; p=.001). No significant differences were demonstrated in the levels of transforming growth factor beta-1, platelet-derived growth factor-AB, and vascular endothelial growth factor between the groups (p=.461, .452, and .767 respectively). Based on the radiographs, 1 of 9 controls had a solid bilateral fusion mass, 2 of 9 had unilateral fusion mass, 3 of 9 had small fusion mass bilaterally, and 3 of 9 had graft resorption. The treatment group had solid bilateral fusion mass in 6 of 10 and unilateral fusion mass in 4 of 10, whereas a small bilateral fusion mass and graft resorption were not observed. The difference between the groups was significant (p=.0067). Based on manual palpation, only 1 of 9 controls was considered fused, 4 of 9 were partially fused, and 4 of 9 were not fused. In the treatment group, there were 6 of 10 fusions, 3 of 10 partial fusions, and 1 of 10 were not fused. The difference between the groups was significant (p=.0084). Based on the micro-CT, the mean bone volume of the control group was 126.7 mm(3) and 203.8 mm(3) in the insulin treatment group. The difference between the groups was significant (p=.0007).nnnCONCLUSIONSnThis study demonstrates the potential role of a time-released insulin implant as a bone graft enhancer using a rat posterolateral intertransverse lumbar fusion model. The insulin-treatment group had significantly higher fusion rates based on the radiographs and manual palpation and had significantly higher levels of IGF-I and significantly more bone volume on micro-CT.

Timing of surgery following spinal cord injury.

Abstract Background: The optimal timing for surgical intervention after traumatic spinal injuries with spinal cord injury remains unclear. Design: Literature review. Findings: Multiple laboratory investigations (in animal models) and many clinical studies suggest better neurological outcomes with early surgical intervention. Conclusive evidence (well-designed randomized, controlled studies), however, is lacking, partly due to the logistics involved in executing such an investigation. Early surgery also appears to decrease the incidence of complications, reduces hospital stay, and helps reduce costs associated with acute management. Conclusion: Early surgical treatment is beneficial in terms of reducing complications, length of stay, and hospital costs. Further studies are needed to clearly demonstrate the impact of operative timing on neurological outcome.

Orthopedic Imaging: A Practical Approach. 4th Ed.

Technological advances in the field of medical imaging have been dramatic over the last half-decade. As such, the title of the latest edition of this classic book has been appropriately modified from Orthopedic Radiology to Orthopedic Imaging, because the subject matter goes far beyond conventional radiography. n nDr Greenspan has once again skillfully organized this text into a single volume, making it a convenient yet comprehensive resource. The initial section serves as a general introduction to orthopedic imaging, discussing the role of the orthopedic radiologist, covering the various imaging techniques currently available, and reviewing the biology of bone formation and growth. These 46 pages establish a firm foundation for the ensuing 30 chapters addressing specific musculoskeletal conditions. The second section of the book is devoted to traumatic conditions of the musculoskeletal system, and its format is particularly suited for the orthopedist-in-training. Most of the radiographs are supplemented by diagrams, which help to clarify the various fracture patterns presented. Illustrations depicting proper positioning of the patient, beam, and cartridge are vital to understanding “adequate views.” Sections on arthritides, tumors, infections, and metabolic and congenital/developmental disorders combine reproductions of the images with explanatory line drawings, making subtle findings apparent even to the untrained eye. n nIn addition to the more than 1,700 superb illustrations, charts and algorithms supplement the text. Each chapter concludes with a section of bulleted “Practical Points to Remember.” As a result of this style, the abundance of information flows as an easy read. The foreword for this text states that it is particularly geared toward residents in orthopedics and radiology. Physiatrists, rheumatologists, emergency physicians, and all practitioners that commonly encounter musculoskeletal disorders should, however, have access to this informative resource.

Residual motion on flexion-extension radiographs after simulated lumbar arthrodesis in human cadavers

Flexion-extension radiographs are commonly used to assess lumbar fusion. Recommended criteria for solid fusion have varied from 1 to 5 degrees of angular motion between vertebrae. Notwithstanding this wide variation, the validity of these criteria have never been biomechanically tested. As a preliminary and initial step, it was the authors purpose to quantify measurable angular motion after simulating solid lumbar fusion in human cadaver spines. Seven cadaveric spines (L1 to L4) were tested in a radiolucent jig fixed to a servohydraulic testing apparatus. Flexion and extension moments of 10u2009Nm were applied. Fusion was simulated using metallic implants spanning the L2-L3 motion segment. These included transverse process plates, a spinous process plate, pedicle screw construct, or an anterior vertebral body plate to simulate an intertransverse, interspinous process, facet, and interbody fusions, respectively. Angular movements were measured on lateral radiographs and statistically compared using a repeated measures analysis of variance. Simulated intertransverse fusion resulted in 13±4 degrees of motion; interspinous fusion, 9±4 degrees; posterior facet fusion, 5±3 degrees; and interbody fusion with plate, 3±2 degrees. Compared with the intact, only posterior facet fusion and interbody fusion with plate had statistically significantly less motion (P=0.006 and 0.0001, respectively). The amount of radiographically detectable flexion-extension motion with simulated fusions varies widely and seems to be influenced by fusion type. This study documents a range of measurable motion on flexion-extension radiographs after several types of simulated lumbar fusion. However, as the degrees of motion seemed to be high, future studies should use a fusion simulation other than metallic implants that more closely resembles bony arthrodesis.