S. Samuel Bederman

Fixation techniques for complex traumatic transverse sacral fractures: a systematic review.

Study Design. Systematic review. Objective. To identify and describe reconstruction methods for the treatment of transverse sacral fracture (TSF) and to evaluate outcomes based on treatment interventions. Summary of Background Data. A variety of surgical interventions for stabilization of TSFs exist, yet the optimal management remains unclear. Although there are many individual case reports and series describing techniques to stabilize TSF, prior reviews fail to provide a comprehensive summary of current and past surgical techniques and their individual outcomes. Methods. Our systematic review searched the PubMed database using keywords identifying sacral fractures with a transverse component, requiring internal fixation for stabilization as well as a review of bibliographies and archives from meeting proceedings. Results. Our search located 417 publications for abstract review, of which 27 (109 patients) with TSF were included. Average follow-up was 22 months (range, 0–82 mo). Thirty-eight patients (34%) underwent spinopelvic fixation (SPF), 53 (49%) underwent posterior pelvic ring fixation (PPRF), and 18 (17%) underwent both. PPRF included iliosacral screws (37 patients), transiliac screws (11 patients), transiliac screws with plating (3 patients), posterior plating (1 patient), and transiliac bar (1 patient). Additional injuries causing lumbosacral instability were seen in 8 patients (42%) who underwent SPF, 2 patients (18%) treated with PPRF, and 5 patients (45%) who were treated with both SPF and PPRF. Of those who presented with a neurological deficit, 5 patients (45%) with SPF, 9 (39%) with PPRF, and 3 (30%) with SPF and PPRF experienced full neurological recovery. Five patients (45%) with SPF, 7 (30%) with PPRF, and 5 (50%) with both regained partial neurological function. One patient (9%) with SPF, 7 (30%) with PPRF, and 2 (20%) with both experienced no neurological recovery. Conclusion. PPRF seems to be effective for stabilization of TSF. However, in the setting of further injuries causing additional lumbosacral instability, SPF should be used to ensure effective stabilization. Level of Evidence: 4

Patterns of care after magnetic resonance imaging of the spine in primary care.

Study Design. Retrospective cohort study. Objective. To examine health care services use after a magnetic resonance imaging (MRI) scan of the lumbosacral or cervical spine ordered by a primary care physician. Summary of Background Data. The use of MRI of the spine in the primary care setting is increasing, yet little is known about the relationship between MRI scan findings and subsequent patterns of health care utilization. Methods. Linkage of records from an audit of outpatient MRI scans of the spine performed in Ontario, Canada, to administrative databases. Results. Of the 647 patients who had a lumbosacral spine MRI scan ordered by a primary care physician, 288 (44.5%) were seen in consultation by an orthopedic surgeon or neurosurgeon, and 42 (6.5%) received spine surgery during 3 years of follow-up. Of the 373 patients who had a cervical spine MRI scan ordered by a primary care physician, 164 (44.0%) were seen in consultation by an orthopedic surgeon or neurosurgeon, and none had spine surgery during 3 years of follow-up. Patients with severe disc herniation (likelihood ratio, 5.62, 95% confidence interval, 2.64–12.00) or severe spinal stenosis (likelihood ratio, 2.34; 95% confidence interval, 1.13–4.85) on lumbosacral spine MRI were more likely to undergo subsequent surgery. However, many patients with these MRI abnormalities did not receive surgery, and the absence of these MRI findings did not significantly lower the likelihood of subsequent surgery. Conclusion. Patients receiving MRI scans of the spine in the primary care setting are frequently referred for surgical assessment and most do not receive subsequent surgery. MRI scan results do not discriminate very well between those who will and will not undergo surgery, suggesting that alternative models for the assessment of patients with spinal complaints in primary care should be explored, particularly in jurisdictions with long wait times for elective spinal surgery consultation.

Drivers of surgery for the degenerative hip, knee, and spine: a systematic review.

BackgroundSurgical treatment for degenerative conditions of the hip, knee, and spine has an impact on overall healthcare spending. Surgical rates have increased dramatically and considerable regional variation has been observed. The reasons behind these increasing rates and variation across regions have not been well elucidated.Questions/purposesWe therefore identified demographic (D), social structure (SS), health belief (HB), personal (PR) and community resources (CR), and medical need (MN) factors that drive rates of hip, knee, and spine surgery.MethodsWe conducted a systematic review to include all observational, population-based studies that compared surgical rates with potential drivers (D, SS, HB, PR, CR, MN). We searched PubMed combining key words focusing on (1) disease and procedure; (2) study methodology; and (3) explanatory models. Independent investigators selected potentially eligible studies from abstract review and abstracted methodological and outcome data. From an initial search of 256 articles, we found 37 to be potentially eligible (kappa 0.86) but only 28 met all our inclusion criteria.ResultsAge, nonminority, insurance coverage, and surgeon enthusiasm all increased surgical rates. Rates of arthroplasty were higher for females with higher education, income, obesity, rurality, willingness to consider surgery, and prevalence of disease, whereas spinal rates increased with male gender, lower income, and the availability of advanced imaging.ConclusionsRegional variation in these procedures exists because they are examples of preference-sensitive care. With strategies that may affect change in factors that are potentially modifiable by behavior or resources, extreme variation in rates may be reduced.

Randomized clinical trials in orthopaedic surgery: strategies to improve quantity and quality.

Abstract Randomized clinical trials (RCTs) generally provide the highest quality and least biased evidence for treatment effectiveness. Relatively few high‐quality RCTs have been published in the orthopaedic literature. Barriers to increasing the quantity of trials include the orthopaedic culture, patient preferences, and the availability of treatment outside trials. Challenges to conducting better quality trials include sample size, random allocation, and blinding. Undertaking more high‐quality trials can improve the evidence available for determining treatment effectiveness, resulting in better patient care.

Randomized Trials in Surgery: How Far Have We Come?

Randomized controlled trials continue to be at the pinnacle of the evidence hierarchy. With this unique vantage point, they inform medical practice, clinical guidelines, health policy, and reimbursement. Prior to an emphasis on randomized controlled trials, traditional clinical research consisted primarily of uncontrolled case series and expert opinions. Randomized controlled trials are a true experiment in clinical practice and provide the most valid answers to clinical questions by reducing bias originating from patients, providers, and investigators. Riding on the coattails of other medical subspecialties, orthopaedic surgeons have recognized the importance of evidence-based medicine. From 1975 to 2005, the number of Level-I studies increased over fivefold and comprised >20% of studies published in The Journal of Bone and Joint Surgery (American Volume) (JBJS). With the emergence of comparative effectiveness research, the definition and methods of best evidence may continue to evolve. In conclusion, substantial improvements in both the quantity and the quality of randomized controlled trials in orthopaedic surgery have occurred, although unique considerations still limit their widespread use.

Referral practices for spinal surgery are poorly predicted by clinical guidelines and opinions of primary care physicians.

Background:Degenerative disease of the lumbar spine is common. Although surgery can benefit selected patients, variation in surgical referrals reduces overall access to care. Objectives:To compare the actual referral practices for patients with degenerative disease of the lumbar spine with recommendations for surgical referral based on clinical practice guidelines (CPGs) and family physician (FP) opinions. Research Design:An expert panel of primary and specialist physicians, using a Delphi process, came to a consensus on referral recommendations from CPGs based on a series of clinical vignettes. The vignettes were also presented to practicing FPs in Ontario, Canada, to determine their preferences for (or likelihood of) referral. Subjects:We assembled a 10-member multispecialty expert panel. Practicing FPs were randomly sampled, stratified by county, and their patients were sampled purposefully by the FP. Measures:Respondents, both panelists and FPs, were asked to rate the appropriateness of surgical referral for a series of clinical vignettes. Patients reported their clinical symptoms and whether they had been referred to a surgeon. Using random-effects probit regression, predictions were compared with actual referral. Receiver operating characteristic curves were constructed and area under the curve (AUC) was measured. Results:Consensus of the panel on recommendations for referral was achieved after 2 iterations (Cronbach &agr; = 0.96). Based on responses from 107 patients and 61 FPs, we found poor concordance of both predicted FP preferences (AUC 0.57) and CPG recommendations (AUC 0.64) with actual referral. Conclusions:Referral practices are poorly predicted by CPG recommendations and individual FP opinions, based on clinical factors. Understanding other nonclinical factors may be more important in reducing variation in referrals and improving access.

Robotic Guidance for S2-Alar-Iliac Screws In Spinal Deformity Correction.

Study Design: A retrospective cohort study of patients who underwent S2-alar-iliac (S2AI) screw insertion using robotic guidance in long constructs for spinal deformity correction extending to the sacrum performed at a single institution. Objective: To assess and evaluate the feasibility and accuracy of robotic guidance for S2AI screw insertion. Summary of Background Data: Pelvic fixation has become a common adjunct to long fusions extending to the sacrum. The S2AI method possesses advantages over the traditional Galveston technique. S2AI involves finding a pathway from S2 across the sacral ala and the sacroiliac joint into the ilium. Robotic guidance is a new modality for implant insertion that has shown high accuracy. Methods: We identified all patients who underwent robotic-guided S2AI screw insertion in long constructs extending to the sacrum. Cortical breaches and protrusions, assessed on postoperative imaging, and complications were recorded. Results: Fourteen patients (31 screws) underwent S2AI screw insertion using robotic guidance and free-hand probing. Average screw length was 80 mm (range, 65–90 mm). All trajectories were confirmed as accurate (no proximal breaches). Screw insertion, performed manually, resulted in 10 protrusions <2 mm, 1 by 2–4 mm, and 6 by ≥4 mm. No screw was intrapelvic or risked any visceral or neurovascular structures and none required removal or revision. Longer screws (>80 mm) were associated with distal protrusion. Conclusions: Robotic-guided S2AI screws are accurate and a feasible option. Although no complications from protrusion were identified, larger studies and instrumentation modifications are required to assess the clinical acceptance of robotic guidance in sacropelvic fixation.

Cost Variation Within Spinal Fusion Payment Groups

Study Design. Retrospective, large administrative database. Objective. To investigate cost variation within current spinal fusion diagnosis-related groups (DRGs). Summary of Background Data. Medicare reimbursement to hospitals for spinal fusion surgery is provided as a fixed payment for each admission based on DRG. This assumes that patients can be grouped into homogenous units of resource use such that a single payment will cover the costs of hospitalization for most patients within a given DRG. However, major differences in costs exist for different methods of spinal fusion surgery. A previous study in total joint arthroplasty (TJA) showed that variation within DRGs can lead to differences between hospital costs and Medicare reimbursement, resulting in predictable financial losses to hospitals and hindering access to care for some patients. No study to our knowledge has investigated cost variation within current spinal fusion DRGs. Methods. Direct hospital costs were obtained from the 2011 Nationwide Inpatient Sample (NIS) for patients in spinal fusion DRGs 453–460 and TJA DRGs 466–470. Our primary outcome was the coefficient of variation (CV), defined as the ratio of the standard deviation (SD) to the mean (CV = SD/mean × 100), for all costs within a given DRG. CVs were compared to an established TJA benchmark for within-DRG cost variation. Results. CVs for costs within spinal fusion DRGs ranged from 44.16 to 52.6 and were significantly higher than the CV of 38.2 found in the TJA benchmark group (P < 0.0001). Conclusion. As in TJA, the cost variation observed within spinal fusion DRGs in this study may be leading to differences between costs and reimbursement that places undue financial burden on some hospitals and potentially compromises access to care for some patients. Future studies should seek to identify drivers of cost variation to determine whether changes can be made to further homogenize current payment groups and ensure equal access for all patients. Level of Evidence: 3

The Influence of Insurance Status on the Surgical Treatment of Acute Spinal Fractures.

Study Design. A retrospective, propensity score, multivariate analysis of the National Trauma Data Bank (NTDB) between 2008 and2011. Objective. The aim of this study was to determine the relationship between insurance status and rates of surgery for acute spinal fractures with and without spinal cord injury (SCI). Summary of Background Data. The decision for surgery in patients with spinal fractures is often based on fracture pattern and stability, associated SCI, and the presence of ligamentous and other associated injuries. It is poorly understood how nonclinical factors, such as insurance status, influence the decision for surgical intervention in patients sustaining spinal trauma. Methods. Using NTDB admission years 2008 to 2011, we included patients 18 to 64 years old who sustained a fracture of the cervical or thoracolumbar spine. Patients were excluded if they sustained polytrauma (Injury Severity Score ≥27) or a major injury (Abbreviated Injury Scale severity ≥3) to the head, thorax, or abdomen. Our main outcome measure was surgical versus nonsurgical treatment for spinal injury; our main predictor was insurance status. Hierarchical multivariate regression analysis and propensity scores were used to determine the relationship between insurance status and surgical treatment, controlling for other factors. We calculated adjusted odds ratios (ORs) for rates of surgery. Results. Our propensity score multivariate analysis demonstrated significantly higher rates of surgery in patients with SCI (OR = 11.76, P < 0.001), insurance (OR = 1.27, P < 0.001), white (OR = 1.21, P = 0.018) versus black race, blunt trauma (OR = 5.63, P < 0.001), shock (OR = 1.62, P < 0.001), higher Glasgow Coma Scale (GCS) score (OR = 1.02, P = 0.002), transfer from lower acuity hospital (OR = 1.51, P < 0.001), and treatment at teaching hospitals (OR = 1.49, P < 0.001). Multivariable subgroup analysis of SCI patients similarly revealed higher surgical rates for insured patients (OR = 1.46, P < 0.001) than those without insurance. Conclusion. Patients with traumatic spine fractures were more likely to receive surgery if they were insured, regardless of the presence of SCI. Level of Evidence: 3

An Approach to Lumbar Revision Spine Surgery in Adults.

Along with the increase in lifestyle expectations in the aging population, a dramatic rise in surgical rates has been observed over the past 2 decades. Consequently, the rate of revision spine surgery is expected to increase. A systematic approach to treatment is required for the adult patient presenting with late or chronic complications after spinal surgery. Patient assessment includes elucidating current symptoms and knowledge of the previous surgery, performing a detailed assessment, and obtaining appropriate studies. Subsequently, differential diagnoses are formulated based on whether the pathology arises from the same levels or adjacent levels of the spine and whether it relates to the previous decompression or fusion. Finally, familiarity with different surgical approaches is imperative in treating the common pathologies encountered in this patient population.