Oliver M. Stokes

Do we have the right PROMs for measuring outcomes in lumbar spinal surgery

PurposePatient-reported outcome measures (PROMs) have become an important part of routine auditing of outcomes in spinal surgery in the UK. PROMs can be used to help assess the quality of care provided by surgical units by determining the comparative health status of patients, before and after surgery. This study was designed to review the PROMs used to assess outcomes in spinal surgery and to determine if they are fit for the purpose.MethodsA systematic literature search was undertaken to identify studies that reported PROMs data following lumbar spinal surgery. The PROMs that were used in each study were recorded and a separate search was undertaken to determine the evidence regarding the validity of each measure.ResultsThe initial search identified 1142 abstracts, which were reduced through de-duplication, filtering and review to 58 articles, which were retrieved and reviewed in full. The search identified that the majority of studies used either the Oswestry Disability Index (ODI), SF-36, Roland–Morris Disability Questionnaire (RMDQ) and EQ-5D along with visual analogue scales or numeric rating scales for back and leg pain.ConclusionsThe consistent use of PROMs supports the comparison of outcomes from different studies, although there was minimal evidence regarding the specificity and sensitivity of these measures for use with lumbar spinal patients. Our review highlights the need to determine a consensus regarding the use and reporting of outcome measures within the lumbar spine literature.

The current state of the evidence for the use of drains in spinal surgery: systematic review

PurposeSearch for evidence pertaining to the effectiveness of drains used in spinal surgeries.MethodPubMed and EMBASE databases were searched for articles pertaining to the use of drains in all types of spinal surgery. The bibliographies of relevant studies were searched for additional papers that met the initial inclusion criteria. Level I and II studies were scored according to guidelines in the Cochrane Collaboration Back Review Group. We utilised the Population, Intervention, Comparison, Outcomes and Study design (PICOS) method to define our study eligibility criteria.ResultsNineteen papers were identified: four level I studies, eight level III studies and seven level IV studies. The four level I, involving the randomization of patients into ‘drain’ and ‘non-drain’ groups, identified a total of 363 patients. Seven of the eight level III retrospective studies concluded that the use of drains did not reduce complications. Two of the seven level IV studies agreed with this conclusion. The remaining five level IV studies reported the benefits of lumbar drainage following dural tears.ConclusionsThere is a paucity of published literature on the use of drains following spinal surgery. This is the first study to assess the evidence for the benefits of drains post-operatively in spinal surgery. The identified studies have shown that drains do not reduce the incidence of complications in anterior cervical discectomy and fusion, one and two level posterior cervical fusions, lumbar laminectomies, lumbar decompressions or discectomies and posterior spinal fusion for adolescent scoliosis. Further level I and II studies are needed.

Surgical correction of kyphotic deformity in a patient with Proteus syndrome

BACKGROUND CONTEXT Proteus syndrome (PS) is an extremely rare congenital disorder causing asymmetric overgrowth of different tissues. The etiology remains unclear. Limb deformities are common and often necessitate amputations. Only a few cases associated with spinal deformities have been described. PURPOSE The aim was to report a rare case of PS associated with spinal deformity and its surgical management. STUDY DESIGN A case of young boy with PS causing vertebral hypertrophy and kyphoscoliotic deformity, which was surgically corrected, is presented. METHODS The patient was assessed clinically and with whole spine plain radiographs, computed tomography, and magnetic resonance imaging. Surgical correction was performed. RESULTS Satisfactory correction of the deformity was achieved by posterior spinal fusion with instrumentation from T4-L5, five Ponte osteotomies T8-L1, and an L2 pedicle subtraction osteotomy. The kyphosis was corrected from 87° to 55°; there was improvement in all spinopelvic parameters. One year after surgery, there was maintenance of the deformity correction with no deterioration of the sagittal balance, and the patient was free of pain and had no loss of neurologic function. CONCLUSIONS Proteus syndrome can be associated with spinal stenosis and deformity. Although the syndrome can be progressive in nature, the symptomatic spinal pathology should be treated appropriately.

Presentation of cauda equina syndrome during labour

Lumbar disc herniations are rare in pregnancy, with an incidence of 1:10 000. Less than 2% of these herniations result in cauda equina syndrome (CES). Diagnosing CES in pregnant patients can be difficult because changes in bladder and bowel habits are common in normal pregnancies. We present the case of a 29-year-old woman, with a history of lumbar radiculopathy, who presented at 39 weeks gestation with severe lower back and bilateral lower limb radiculopathy. Symptoms of CES began to develop only after the onset of labour. Diagnostic MRI was obtained following delivery and the patient was treated by microdiscectomy. Following surgery, bladder and bowel function began to normalise and at 3 months follow-up, she had made a full recovery. To the best of our knowledge, CES has never been reported to present during labour. This case highlights the diagnostic dilemma and need for a high index of suspicion.

Do Growing Rods for Idiopathic Early Onset Scoliosis Improve Activity and Participation for Children

Objective To investigate whether growing rod surgery for children with progressive idiopathic early onset scoliosis (EOS) effects activity and participation, and investigate factors that may affect this. Study design Multicenter retrospective cohort study using prospectively collected data on 60 children with idiopathic EOS and significant scoliosis (defined as a Cobb angle >40°). Thirty underwent brace treatment, and 30, growth rod surgery. Questionnaire and radiographic data were recorded at 1 year. The validated Activities Scale for Kids performance version (ASKp) questionnaire was used to measure activity and participation. Results In the brace group, Cobb angle increased from 60° to 68°. There was no change in ASKp score. In the operative group, Cobb angle decreased from 67° to 45°. ASKp decreased from 91 to 88 (P < .01). Presence of spinal pain correlated with greater reduction in activity and participation scores in both groups, as did occurrence of complications in the operative group (P < .05). Both treatments permitted growth of the immature spine. Conclusions In children with significant idiopathic EOS (Cobb angle>40°), growth rod surgery was associated with a reduction in activity and participation and Cobb angle, whereas brace treatment was associated with an increase in Cobb angle and no change in activity and participation. Pain was the most important factor affecting activity and participation in both groups.

Recommendations for Lengthening of Magnetically Controlled Growing Rods in Children With Pacemakers.

Purpose of the Study: Pacemakers are currently identified as a contraindication for the use of magnetic growth rods (MGRs). This arises from concern that magnetic fields generated by the MGR external remote controller (ERC) during lengthening procedures may induce pacemaker dysfunction. We investigated (1) whether MGR lengthening affects pacemaker function, and (2) if the magnetic field of a pacemaker affects MGR lengthening. Methods: MGRs were tested in conjunction with an magnetic resonance imaging-compatible pacemaker, which was connected to a virtual patient under continuous cardiac monitoring. To determine whether pacemaker function was affected during MGR lengthening, the electrocardiogram trace was monitored for arrhythmias, whereas an ERC was applied to lengthen the MGRs at varying distances from the pacemaker. To investigate if MGR lengthening was affected by the presence of a pacemaker, at the start and end of the experiment, the ability of the rods to fully elongate and shorten was tested to check for conservation of function. Results: When the pacemaker was in normal mode, <16 cm away from the activated ERC during MGR lengthening, pacemaker function was affected by the ERC’s magnetic forces. At this distance, prophylactically switching the pacemaker to tonic mode before lengthening prevented occurrence of inappropriate pacing discharges. No deleterious effect of the pacemaker’s magnetic field on the MGR lengthening mechanism was identified. Conclusions: Magnetic resonance imaging-compatible pacemakers appear safe for concomitant use with MGRs, provided a pacemaker technician prophylactically switches the pacemaker to tonic function before outpatient lengthening procedures. Clinical Relevance: This experiment was designed to provide the first safety information on MGR lengthening in children with pacemakers. Although currently a rare clinical scenario, with increasing use of MGRs, this clinical scenario may arise more frequently in the future.

Anterior lumbar discectomy and fusion for acute cauda equina syndrome caused by recurrent disc prolapse: report of 3 cases

There is a lack of information and consensus regarding the optimal treatment for recurrent disc herniation previously treated by posterior discectomy, and no reports have described an anterior approach for recurrent disc herniation causing cauda equina syndrome (CES). Revision posterior decompression, irrespective of the presence of CES, has been reported to be associated with significantly higher rates of dural tears, hematomas, and iatrogenic nerve root damage. The authors describe treatment and outcomes in 3 consecutive cases of patients who underwent anterior lumbar discectomy and fusion (ALDF) for CES caused by recurrent disc herniations that had been previously treated with posterior discectomy. All 3 patients were operated on within 12 hours of presentation and were treated with an anterior retroperitoneal lumbar approach. Follow-up ranged from 12 to 24 months. Complete retrieval of herniated disc material was achieved without encountering significant epidural scar tissue in all 3 cases. No perioperative infection or neurological injury occurred, and all 3 patients had neurological recovery with restoration of bladder and bowel function and improvement in back and leg pain. ALDF is one option to treat CES caused by recurrent lumbar disc prolapse previously treated with posterior discectomy. The main advantage is that it avoids dissection around epidural scar tissue, but the procedure is associated with other risks and further evaluation of its safety in larger series is required.

Answer to the Letter to the Editor of L. Denteneer et al. concerning "Do we have the right PROMs for measuring outcomes in lumbar spinal surgery?" by O.M. Stokes et al., Eur Spine J (2017) 26:816-824.

I agree that the modified version of ODI is often more applicable to our patients and that missing data, when some patients do not complete entire PROMs, can influence the results. The readers are correct that our search of the literature did not differentiate between the different versions of the ODI. I would like to thank the readers for highlighting the important distinction between these outcome measures and for their efforts to evaluate the MDQ.

Incomplete cauda equina syndrome secondary to haemorrhage within a Tarlov cyst

Sacral perineural (Tarlov) cysts are benign, cerebrospinal fluid containing lesions of the spinal nerve root sheath. They are usually asymptomatic; however, a small proportion have the potential to cause compression of nerve roots and/or the cauda equina. We report a case of a 61-year-old man who presented with acute onset back pain associated with bilateral radiculopathy. Between referral and consultation, the patient developed urinary dysfunction which resolved spontaneously. MRI revealed haemorrhage within a Tarlov cyst, resulting in compression of the cauda equina. Due to the considerable clinical improvement at the time of consultation, surgical decompression of the cyst was not considered to be indicated. An interval MRI scan 8 weeks later demonstrated that the haemorrhage within the perineural cyst had spontaneously resolved and the patient remained asymptomatic at 5-year follow-up.

Letter to the Editor concerning “Virtually bloodless posterior midline exposure of the lumbar spine using the ‘paramidline’ fatty plane” by Moghimi MH, Leonard DA, Cho CH, et al. (Eur Spine J (2016) 25;956–962)

To the Editor, Recently, the European Spine Journal published an interesting article describing a ‘virtually bloodless posterior midline exposure of the lumbar spine using the paramidline fatty plane’ [1]. The authors described a ‘paramidline’ approach to the posterior lumbar spine using ‘a virtually avascular surgical plane not previously described in the literature.’ In this approach, the deep lumbar fascia is longitudinally incised on either side of the spinous processes instead of directly in the midline, which reveals the paramidline fatty plane. This fatty plane is universally present on preoperative MRI. The authors prospectively analyzed 50 consecutive patients undergoing primary lumbar surgery on 1–3 levels and reported no blood loss during the approach for all procedures. Furthermore, the average blood loss for the entire procedure was 60 ml (20–200 ml). The case in which 200 ml of blood was lost was an L2–5, multi-level laminectomy, and fusion. We thank the authors for reporting their results with this approach, particularly their abilities to minimize blood loss (and therefore transfusion requirements); however, we note that the exposure lateral to the facets is not well described in their report. We have been using this same approach at our institution for many years. Weatherley et al. [2] describe the thoracolumbar fascia being incised lateral to the supraspinous ligament, and the paraspinal muscles raised laterally off the spinous processes, laminae, and facet joints subperiosteally with a Cobb elevator and a gauze swab. To expose the transverse processes for a posterolateral fusion, the dissection continues down the lateral side of the superior facet and onto the transverse process, in a fatty plane between the tendons of longissimus and multifidus, which attach to the accessory and mamillary processes of the facet joint, respectively [2]. While we have found that the dissection out to the facet joints is fairly avascular, the dissection lateral to the facet joint is less precise and associated with more bleeding. Wiltse and Spencer have noted similar difficulty with haemostasis in this area with a paraspinal approach [3]. Macnab and Dall [4] have described the arterial pattern lateral to the superior articular processes and at the base of the transverse process. These vessels are a continuation of the lumbar segmental arteries, passing posteriorly on each side around the waist of each vertebra. The location of the vessels is constant, although their identification at operation is difficult because of their placement in the depth of the exposure with the overhang of the facet joints and, lateral to the muscular attachments of multifidus to the mammillary, and longissimus to the accessory processes. Division of these tendons close to their attachments, and identification of the intervening fatty plane may enable easier visualization of these lateral facet vessels for cauterization. Weatherley et al. [2] did not formally measure blood loss; however, we consider this approach to be ‘a minimally avascular approach,’ with some blood loss being inevitable, particularly on dissection lateral to the facets. & Mathew David Sewell matbuzz1@hotmail.com