Nael Shanti

Surfing for scoliosis : The quality of information available on the internet

Study Design. A cross section of Web sites accessible to the general public was surveyed. Objective. To evaluate the quality and accuracy of information on scoliosis that a patient might access on the Internet. Summary of Background Data. The Internet is a rapidly expanding communications network with an estimated 765 million users worldwide by the year 2005. Medical information is one of the most common sources of inquires on the Web. More than 100 million Americans accessed the Internet for medical information in the year 2000. Undoubtedly, the use of the Internet for patient information needs will continue to expand as Internet access becomes more readily available. This expansion combined with the Internet’s poorly regulated format can lead to problems in the quality of information available. Since the Internet operates on a global scale, implementing and enforcing standards have been difficult. The largely uncontrolled information can potentially negatively influence consumer health outcomes. Methods. To identify potential sites, five search engines were selected and the word “scoliosis” was entered into each search engine. A total of 50 Web sites were chosen for review. Each Web site was evaluated according to the type of Web site, quality content, and informational accuracy by three board-certified academic orthopedic surgeons, fellowship trained in spinal surgery, who each has been in practice for a minimum of 8 years. Each Web site was categorized as academic, commercial, physician, nonphysician health professional, and unidentified. In addition, each Web site was evaluated according to scoliosis-specific content using a point value system of 32 disease-specific key words pertinent to the care of scoliosis on an ordinal scale. A list of these words is given. Point values were given for the use of key words related to disease summary, classifications, treatment options, and complications. The accuracy of the individual Web site was evaluated by each spine surgeon using a scale of 1 to 4. A score of 1 represents that the examiner agreed with less than 25% of the information while a score of 4 represents greater than 75% agreement. Results. Of the total 50 Web sites evaluated, 44% were academic, 18% were physician based, 16% were commercial, 12% were unidentified, and 10% were nonphysician health professionals. The quality content score (maximum, 32 points) for academic sites was 12.6 ± 3.8, physician sites 11.3 ± 4.0, commercial sites 11 ± 4.2, unidentified 7.6 ± 3.9, and nonphysician health professional site 7.0 ± 1.8. The accuracy score (maximum, 12 points) was 6.6 ± 2.4 for academic sites, 6.3 ± 3.0 for physician-professional sites, 6.0 ± 2.7 for unidentified sites, 5.5 ± 3.8 for nonphysician professional sites, and 5.0 ± 1.5 for commercial Web sites. The academic Web sites had the highest mean scores in both quality and accuracy content scores. Conclusion. The information about scoliosis on the Internet is of limited quality and poor information value. Although the majority of the Web sites were academic, the content quality and accuracy scores were still poor. The lowest scoring Web sites were the nonphysician professionals and the unidentified sites, which were often message boards. Overall, the highest scoring Web site related to both quality and accuracy of information was www.srs.org. This Web site was designed by the Scoliosis Research Society. The public and the medical communities need to be aware of these existing limitations of the Internet. Based on our review, the physician must assume primary responsibility of educating and counseling their patients.

Occult spinous process fractures associated with interspinous process spacers.

Study Design. Prospective observational study. Objective. To provide a more accurate estimate of the rate of acute spinous process fractures associated with IPS surgery. Summary of Background Data. Biomechanical cadaveric studies have suggested adequate spinous process strength to support placement of interspinous process spacers (IPS). Postoperative spinous process fractures have been reported in one%—to 5.8% of patients in previous series based on routine biplanar radiographic evaluation. However, most fractures occur between the base and midportion of the spinous process in an area that is typically difficult to visualize on plain radiographs due to device design. Methods. All patients underwent preoperative biplanar plain radiographs and computed tomography (CT) of the lumbar spine to confirm anatomy favorable for IPS placement and rule out fracture or spondylolysis. Postoperatively, all patients underwent repeat CT imaging within six months of surgery, biplanar radiographs at two weeks, six weeks, three months, six months, and one year. All studies were reviewed independently by a neuroradiologist and two orthopedic spine surgeons. Results. Fifty implants (38 L4–5, 12 L3–4) were placed in 38 patients who completed follow-up and were included in final analysis. Three IPS designs were included (34 Medtronic X-STOP titanium, 8 X-STOP PEEK, 8 Lanx Aspen). Postoperative CT revealed 11 nondisplaced spinous process fractures in 11 patients (28.9% of patients, 22% of levels). Five fractures were associated with mild to moderate lumbar back pain and six fractures were asymptomatic. No patient reported a traumatic incident. No fracture was identifiable on plain radiographs. One fracture displaced during follow-up evaluation. Three patients underwent IPS removal and laminectomy. Three fractures healed by CT in one year. Overall, patients with fractures tended toward poorer outcomes by Zurich Claudication Questionnaire (ZCQ) (28.5% vs. 34.8% improvement in symptom severity, P = 0.496; 21.4% vs. 30.7% improvement in physical function, P = 0.199) and tended toward lower satisfaction rates (50% vs. 73.7%, P = 0.24) at one year compared to patients without fracture. Conclusion. Interspinous process spacer surgery appears associated with a higher rate of early postoperative spinous process fracture than previously reported. In all cases, in this series, plain radiographs were inadequate to identify fractures because all fractures were initially minimal or nondisplaced, many patients were osteopenic, and the metallic wings of the devices often obscured fractures. Moreover, in most patients, fractures were associated with mild or no acute localized pain. This study suggests that unrecognized spinous process fracture may be responsible for a significant number of patients who experience unsatisfactory outcome after IPS surgery. CT imaging is required to identify the vast majority of such fractures.

Association between degenerative spondylolisthesis and spinous process fracture after interspinous process spacer surgery

BACKGROUND CONTEXT Spinous process fracture is a recognized complication associated with interspinous process spacer (IPS) surgery. Although occasionally identified by plain radiographs, computed tomography (CT) appears to identify a higher rate of such fractures. Although osteoporotic insufficiency fracture is considered a contraindication for IPS surgery, a formal risk factor analysis for this complication has not previously been reported. PURPOSE To identify risk factor(s) associated with early spinous process fracture after IPS surgery. STUDY DESIGN/SETTING Prospective cohort study of 39 consecutive patients with lumbar stenosis and neurogenic claudication undergoing IPS surgery at a single institution. METHODS Patients underwent preoperative dual-energy X-ray absorptiometry (DXA) scans, lumbar spine CT, and plain radiographs. Postoperatively, patients underwent repeat CT imaging within 6 months of surgery and serial radiographs at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. Preoperative CT scans were analyzed by calculating average Hounsfield units for a 1 cm(2) area of the midsagittal reconstructed image for four separate locations: midvertebral body, subcortical bone subjacent to the superior margin of the midspinous process, subcortical bone above the inferior margin of the midspinous process, and the midspinous process. RESULTS Thirty-eight patients underwent IPS surgery at a total of 50 levels (38 L4-L5, 12 L3-L4; 26 one-level, 12 two-level). One patient underwent laminectomy at index surgery and was excluded from the analysis. Implants included 34 titanium X-STOP (Medtronic, Memphis, TN, USA), 8 polyaryletheretherketone X-STOP (Medtronic, Memphis, TN, USA), and 8 Aspen (Lanx, Broomfield, CO, USA) devices. Eleven spinous process fractures were identified by CT in 11 patients (22.0% of levels). No fractures were apparent on plain radiographs. The rate of spondylolisthesis observed on preoperative radiographs was 100% (11 of 11) among patients with fractures compared with 33.3% (9 of 27) of patients without fracture (p=.0001). Overall, 21 of 39 patients in this series had spondylolisthesis, and the rate of fracture in this group was 52%. Among patients without spondylolisthesis, the fracture rate was 0%. A trend was observed toward decreased DXA lumbar spine and hip T-scores among fracture patients versus nonfracture patients (0.2 ± 1.7 vs. 0.8 ± 1.7; p=.389; -1.1 ± 1.4 vs. -0.3 ± 1.4; p=.201), but these differences were not significant. Similarly, bone density based on CT measurements at four different locations revealed a trend toward decreased density among fracture patients, but these differences were not significant. CONCLUSIONS Degenerative spondylolisthesis appears strongly associated with the occurrence of spinous process fracture after IPS surgery. There is a trend toward increased fracture risk in patients with decreased bone mineral density as measured by both DXA scan and CT-based volume averaging of Hounsfield units, but osteoporosis appears to be a relatively weaker risk factor. The association between spondylolisthesis and fracture observed in this study may account for the relatively poorer outcome of IPS surgery in patients with spondylolisthesis that has been reported in previous series.

End organ effects of high-dose human equivalent methylprednisolone in a spinal cord injury rat model

Study Design. Interventional study. Objective. To analyze the histologic effects of high-dose human equivalent methylprednisolone on the pulmonary, cardiac, intestinal, renal, hepatic, and splenic tissues in a spinal cord injury rat model. Summary of Background Data. There are numerous investigations of various medical interventions for the treatment of acute spinal cord trauma. Currently, the only generally accepted medical intervention in an acute spinal cord trauma is the intravenous administration of high doses of methylprednisolone. Although it has been nearly 2 decades since the first National Acute Spinal Cord Injury Study investigated the role high-dose steroids might play in the treatment of acute spinal cord trauma, controversy still exists regarding the efficacy of this treatment. To our knowledge, no study has examined the role of high-dose methylprednisolone in organ systems other than the spinal cord in an acute spinal cord injury model at the histologic level. This study attempts to characterize end organ histologic response to human dose equivalent (HDE) intravenous methylprednisolone administration in a rodent model of acute spinal cord injury. Methods. A total of 48 Sprague-Dawley rats were divided equally into control and experimental groups. Each group was subdivided into 6 sets of 4 animals each, according to intervals after injury. Groups 1–6 consisted of animals euthanized at 0, 4, 8, 16, 24, and 48 hours after spinal cord injury. Paraplegia after lower thoracic laminectomy was achieved using a standardized Allen weight drop technique. Within 1 hour of injury, experimental animals were treated with HDE methylprednisolone, infused for 23 hours continuously. Liver, kidney, lung, intestine, spleen, and heart were harvested at variable intervals after injury and prepared for histologic examination. These slides were analyzed with microscopic staining techniques and compared in a blinded manner by a qualified pathologist. Results. Of all the end organs analyzed, the spleens were most affected. Lymphocytic depletion was seen in as little as 4 hours after methylprednisolone infusion and continued until 48 hours. Pulmonary tissues variably showed interstitial congestion and eosinophilic alveolar collections. Intestinal mucosal tissues showed edema and autolyzed mucosa from 16 hours onwards. Cardiac, kidney, and hepatic tissue did not differ significantly from controls. Conclusions. Histologically, HDE methylprednisolone caused significant splenic lymphocytic depletion changes in as little as 4 hours. This trend of end organ lymphocytopenia continued to progress until 48 hours. Pulmonary eosinophilic infiltrates were seen from 8 until 24 hours. Intestinal mucosal edema and necrosis were seen in samples at 16 hours throughout 48 hours. This study was designed to evaluate end organ changes seen in an animal model of an acute spinal cord injury treated with HDE methylprednisolone. Study animals were infused with HDE methylprednisolone given according to the National Acute Spinal Cord Injury Study II protocol. The kidney, lung, cardiac, intestinal, splenic, and hepatic tissues from the aforementioned animals were then sectioned and analyzed using histologic staining techniques by a qualified pathologist.