Mohammed A. Khaleel

Effect of psychopathology on patient-perceived outcomes of total knee arthroplasty within an indigent population.

BACKGROUND Factors other than surgical technique and implants impact patient outcomes following a total knee arthroplasty. The purpose of this study was to analyze the effects of psychopathology on the rate of improvement following total knee arthroplasty in an indigent population. METHODS One hundred and fifty-four consecutive indigent patients undergoing a primary total knee arthroplasty for arthritis were enrolled and available for follow-up. Patients were classified as having psychopathology on the basis of the presence of somatization, depression, and/or a panic or anxiety disorder as assessed with the Patient Health Questionnaire. Outcome measures were completed preoperatively and one year postoperatively. Univariate analyses, controlled for sex and age, were used to compare the rates of improvement in patients who exhibited psychopathology with the rates in those without psychopathology. RESULTS Fifty-four patients (35%) were diagnosed with at least one Axis-I psychological disorder. The psychopathology group showed significantly lower Short Form-36 mental component summary scores both at baseline and one year postoperatively (p < 0.001 for both). The psychopathology group also reported significantly higher levels of perceived disability at baseline on the Pain Disability Questionnaire (p < 0.001) and worse scores on the Western Ontario and McMaster Universities Osteoarthritis Index (p = 0.004); however, the improvement on both of these scales did not differ significantly between the two groups (p > 0.05). The Knee Society Score differed significantly between the two groups at both baseline and the one-year follow-up evaluation (p = 0.003 and p = 0.001, respectively), but there was no significant difference in the total rate of improvement between the two comparison groups (p > 0.05). CONCLUSIONS Not only is there a high prevalence of psychopathology in the indigent population, but psychopathology may result in lower patient-perceived outcome scores at one year after a total knee arthroplasty. Even though outcome scores may be worse for patients with psychopathology, our study showed that these patients still benefit, with the same degree of improvement in function.

The effect of high obesity on outcomes of treatment for lumbar spinal conditions: subgroup analysis of the spine patient outcomes research trial.

Study Design. Spine Patient Outcomes Research Trial subgroup analysis. Objective. To evaluate the effect of high obesity on management of lumbar spinal stenosis, degenerative spondylolisthesis (DS), and intervertebral disc herniation (IDH). Summary of Background Data. Prior Spine Patient Outcomes Research Trial analyses compared nonobese and obese patients. This study compares nonobese patients (body mass index <30 kg/m2) with those with class I obesity (body mass index = 30–35 kg/m2) and class II/III high obesity (body mass index ≥35 kg/m2). Methods. For spinal stenosis, 250 of 634 nonobese patients, 104 of 167 obese patients, and 59 of 94 highly obese patients underwent surgery. For DS, 233 of 376 nonobese patients, 90 of 129 obese patients, and 66 of 96 highly obese patients underwent surgery. For IDH, 542 of 854 nonobese patients, 151 of 207 obese patients, and 94 of 129 highly obese patients underwent surgery. Outcomes included Short Form-36, Oswestry Disability Index, stenosis/sciatica bothersomeness index, low back pain bothersomeness index, operative events, complications, and reoperations. Operative and nonoperative outcomes were compared by change from baseline at each follow-up interval using a mixed effects longitudinal regression model. An as-treated analysis was performed because of crossover between surgical and nonoperative groups. Results. Highly obese patients had increased comorbidities. Baseline Short Form-36 physical function scores were lowest for highly obese patients. For spinal stenosis, surgical treatment effect and difference in operative events among groups were not significantly different. For DS, greatest treatment effect for the highly obese group was found in most primary outcome measures, and is attributable to the significantly poorer nonoperative outcomes. Operative times and wound infection rates were greatest for highly obese patients. For IDH, highly obese patients experienced less improvement postoperatively compared with obese and nonobese patients. However, nonoperative treatment for highly obese patients was even worse, resulting in greater treatment effect in almost all measures. Operative time was greatest for highly obese patients. Blood loss and length of stay was greater for both obese cohorts. Conclusion. Highly obese patients with DS experienced longer operative times and increased infection. Operative time was greatest for highly obese patients with IDH. DS and IDH saw greater surgical treatment effect for highly obese patients due to poor outcomes of nonsurgical management. Level of Evidence: 3

Psychosocial Profiles of Indigent Patients with Severe Osteoarthritis Requiring Arthroplasty

This study documents the prevalence of Axis I diagnoses (ie, depression, anxiety, and others) and their effects on preoperative pain, disability, function, and quality of life assessments in an indigent population undergoing total joint arthroplasty. Consecutive indigent patients scheduled for total joint arthroplasty were categorized by psychosocial testing as either psychologically distressed (PD) or nonpsychologically distressed. Of the subjects, 38% were found to be psychologically distressed. The PD group had significantly lower measures on 7 of the 8 components of the Short Form-36, the Harris hip score, and Knee Society score (P < .05). The PD group also scored significantly worse on both the Western Ontario MacMaster (P < .001) and the Pain Disability Questionnaire (P < .001). There is a high prevalence of psychopathology in the indigent population undergoing total joint arthroplasty, exhibiting poorer scores on pain, disability, function, and quality of life measures before surgery.

Psychological factors that may influence outcome after joint replacement surgery

Current research on total joint arthroplasty has identified psychological distress as a predictor of poor treatment outcomes. Most recent studies on total knee or hip arthroplasty that include psychological variables have found that preoperative indicators of depression, anxiety, pain catastrophizing and low self-efficacy relate directly to higher levels of pain and lower levels of function postoperatively. The goal of this review was to emphasize the current research that has focused on the psychological factors associated with outcomes of knee and hip replacement. Routinely identifying, assessing and treating those with psychological distress before surgery may be warranted.

Defining Avoidable and Unavoidable Complications in Spine Surgery: A Survey Based Study of Spine Fellowship Directors

Study Design. A cross-sectional survey of orthopedic spine surgery fellowship directors in the United States. Objective. The aim of this study was to investigate whether consensus exists with respect to spine-related adverse events and certain hospital-acquired conditions (HACs) or “never events.” Summary of Background Data. As part of a broad effort to improve health care outcomes, providers are no longer reimbursed for HACs, which are deemed avoidable. Although some HACs are unquestionably preventable with proper quality control measures, research suggests that even scrupulous adherence to evidence-based guidelines cannot eliminate others. Methods. Surveys were distributed via email and post. Participants rated 27 HACs and selected spine-specific events on an ordinal scale. Interobserver reliability was assessed among all 46 spine directors (respondents) using the intraclass correlation coefficient (ICC), based on a two-way random effects model, assuming that the participants were a representative population sample of spine surgeons. Multivariable linear regression analyses were performed on each of the 27 complications to identify potential demographic factors that could be associated with variation among respondents in their ratings of “avoidable” to “unavoidable.” Results. Forty-six fellowship directors responded, of whom 98% were orthopedic spine surgeons. The majority (80.4%) of respondents had greater than 10 years’ experience as a spine surgeon, and 66.7% had an annual surgical volume >201 cases. The multivariable linear regression analyses found that demographic factors were not predictive of the directors’ ratings. The complications thought to be completely avoidable (median scores 1) included “Incompatible blood,” “Retained foreign object,” and “Wrong level surgery.” The HAC considered least avoidable was “Site infection with risk factors” (median score 8). Among 17 spine-specific complications, “L4-L5 disc re-herniation within 3 months” (median score 9) was considered least avoidable. Conclusion. This survey suggests that orthopedic spine surgeons consider most “never events” neither avoidable nor unavoidable. There is strong consensus only about the HACs resulting from obvious medical error. Level of Evidence: 4

Computed Tomography Guided Subendplate Injection of Pingyangmycin for A Novel Rabbit Model of Slowly Progressive Disc Degeneration

BACKGROUND CONTEXT Different animal models are used in disc degenerative disease research by now. To our knowledge, a functional animal model that mimics ischemic and slowly progressive disc degeneration of humans does not exist. STUDY DESIGN This is an experimental animal study of disc degeneration. PURPOSE The purpose of this study was to establish an ischemic and slowly progressive intervertebral disc (IVD) degeneration model with an injection of pingyangmycin (PYM) into subchondral bone adjacent to the disc, using bone marrow needle guided by computed tomography (CT) scan. METHODS The subchondral bone adjacent to the lumbar IVDs (from L3-L4 to L5-L6) of 18 rabbits was randomly injected with 3 mL PYM solution (1.5 mg/mL PYM), 3 mL phosphate-buffered saline (vehicle control), or exteriorized but not injected with anything (sham), with using bone marrow needle guided by CT scan. The degenerative process was investigated by using radiography and magnetic resonance imaging at 1, 3, and 6 months postoperatively, combined with histological scoring, immunohistochemistry, and real-time polymerase chain reaction analysis. RESULTS Significant disc space narrowing was observed at 6 months in the discs adjacent to the subchondral bone injected with PYM, compared with the control groups (p<.05). The magnetic resonance imaging assessment also demonstrated a progressive loss of T2-weighted signal intensity postoperatively. The histological score increased significantly compared with that of the control groups from 3 months to the end point (p<.05). The bone tissue area of the end plate increased significantly at the end point, compared with that of the control groups (p<.05). The results of molecular analysis showed significant increase of matrix metalloproteinase-3, a disintegrin and metalloproteinase with thrombospondin motif-5, and marked reduction of aggrecan and Type II collagen after 3 months at the messenger RNA levels in the discs of PYM group (p<.05). The von Willebrand factor expression of PYM group also showed a significant reduction after 1 month (p<.05). CONCLUSIONS Percutaneous injection of PYM into the subchondral bone adjacent to the lumbar IVDs of rabbits, using bone marrow needle guided by CT scan, can result in ischemic and slowly progressive disc degeneration model, which mimics the onset of human disc degeneration.

Magnetic Resonance Neurography of the Lumbosacral Plexus in Failed Back Surgery Syndrome

Study Design. Retrospective clinical case series. Objective. To study the role of magnetic resonance neurography (MRN) of the lumbosacral plexus in management of patients with failed back surgery syndrome (FBSS). Summary of Background Data. FBSS is one of the major problems in health care, affecting up to 40% of patients after spine surgery. To date, no imaging modality has been used to effectively classify nerve compression, because nerve injuries are challenging to detect on conventional lumbar spine magnetic resonance imaging (MRI). To our knowledge, no previous studies have addressed the use of MRN in FBSS or compared it to lumbar spine MRI. Methods. From 203 consecutive 3 T MRN studies of lumbosacral plexus in 1 year, 12% (25/203) presented as FBSS. Demographic data, number of previous lumbar MRIs and their findings, MRN findings, interval between MRI and MRN, pre-and post-MRN diagnosis, pain levels, and treatments were recorded. Changes in diagnosis, treatment, and outcomes after MRN were determined. Results. The final sample of 25 patients had a mean age 62 ± 15 and male to female ratio 1:1.08. Approximately 88% (22/25) had previous lumbar MRI, of which 27% had 3 or more. Most common imaging findings were neuroforaminal stenosis 22.6% (7/31) on MRI and neuropathy 22.9% (19/83) on MRN. Mean interval between MRI and MRN was 13.9 ± 28.3 months. Lumbar MRIs were inconclusive in 36% (8/22). MRN detected 63% (52/83) more findings and changed the diagnosis and treatment in 12% and 48% of FBSS cases, respectively. Favorable outcomes were recorded in 40% to 67% of patients following MRN-guided treatments. Conclusion. FBSS is a complex problem and MRN of lumbosacral plexus impacts its management by better directing source of symptoms. Level of Evidence: 4STUDY DESIGN Retrospective clinical case series. OBJECTIVE To study the role of magnetic resonance neurography (MRN) of the lumbosacral plexus in management of patients with failed back surgery syndrome (FBSS). SUMMARY OF BACKGROUND DATA FBSS is one of the major problems in health care, affecting up to 40% of patients after spine surgery. To date, no imaging modality has been used to effectively classify nerve compression, because nerve injuries are challenging to detect on conventional lumbar spine magnetic resonance imaging (MRI). To our knowledge, no previous studies have addressed the use of MRN in FBSS or compared it to lumbar spine MRI. METHODS From 203 consecutive 3 T MRN studies of lumbosacral plexus in 1 year, 12% (25/203) presented as FBSS. Demographic data, number of previous lumbar MRIs and their findings, MRN findings, interval between MRI and MRN, pre-and post-MRN diagnosis, pain levels, and treatments were recorded. Changes in diagnosis, treatment, and outcomes after MRN were determined. RESULTS The final sample of 25 patients had a mean age 62 ± 15 and male to female ratio 1:1.08. Approximately 88% (22/25) had previous lumbar MRI, of which 27% had 3 or more. Most common imaging findings were neuroforaminal stenosis 22.6% (7/31) on MRI and neuropathy 22.9% (19/83) on MRN. Mean interval between MRI and MRN was 13.9 ± 28.3 months. Lumbar MRIs were inconclusive in 36% (8/22). MRN detected 63% (52/83) more findings and changed the diagnosis and treatment in 12% and 48% of FBSS cases, respectively. Favorable outcomes were recorded in 40% to 67% of patients following MRN-guided treatments. CONCLUSION FBSS is a complex problem and MRN of lumbosacral plexus impacts its management by better directing source of symptoms. LEVEL OF EVIDENCE 4.