Scott D. Daffner

Impact of neck and arm pain on overall health status.

Study Design. A prospective, multicenter, cross-sectional analysis of data from the National Spine Network database. Objectives. To compare the relative impact of radicular and axial symptoms associated with disease of the cervical spine on general health as measured by the SF-36 Health Survey, and to compare the impact of these symptoms among patients of varying age and symptom duration. Background. Degenerative disorders of the cervical spine can cause debilitating symptoms of neck and arm pain. Physicians generally treat radiculopathy more aggressively than axial neck pain alone, although it has never been shown that the presence of radiculopathy leads to a greater impairment of physical and mental function. Materials and Methods. SF-36 Health Survey data were collected from all consenting patients seen within the National Spine Network. Patients with symptoms referable to the cervical spine (as per their physician) were included (n = 1,809). SF-36 scores for all eight scales (bodily pain (BP), vitality (VT), general health (GH), mental health (MH), physical function (PF), role physical (RP), role emotional (RE), and social function (SF), and two summary scales (Physical Component Summary [PCS] and Mental Component Summary [MCS]) were calculated. Age/gender normative scores were subtracted from the scale scores to produce a negative “impact” score, which reflected how far below normal health status these patients were. Patients were grouped according to location of symptoms (axial only, radicular only, or axial and radicular), age (younger than 40, 40 to 60, and older than 60 years), and symptom duration (acute: <6 wk; subacute: 6 wk–6 mo; and chronic: >6 mo). SF-36 scores were compared between all groups using analysis of variance and multiple comparisons with Bonferroni adjustment. Results. Patients who presented with both axial and radicular symptoms had the lowest SF-36 scores relative to age and gender norms. These scores were significantly lower than those for patients with only axial or only radicular symptoms across all eight subscales (P < 0.05–P < 0.0001). Scores for patients with only axial pain were significantly lower than for patients with only radicular pain for VT (P < 0.04) and GH (P < 0.004). Patients younger than 40 and those between ages 40 to 60 years were significantly more impacted by their symptoms than patients older than 60 years for all eight scales (P < 0.01). PCS scores were similar for acute, subacute, and chronic groups, whereas MCS scores were significantly worse for patients with chronic pain. Conclusions. Combined neck and arm pain were much more disabling than either symptom alone. Younger patients (younger than 40 or 40–60) were more affected by these symptoms than patients older than 60 years. In addition, as symptom duration increased, a negative impact on mental health was observed, although chronic symptoms did not affect physical health. This study suggests that patients with a significant component of axial pain in conjunction with cervical radiculopathy should be considered the most affected of all patients with cervical spondylosis. Given the evidence that the treatment methods at the disposal of physicians are effective, this study suggests that prompt treatment of these patients may help avoid the harmful effects of chronic symptoms on mental functioning, especially among younger patients who were found to be more impacted by the symptoms.

Radiographic analysis of transforaminal lumbar interbody fusion for the treatment of adult isthmic spondylolisthesis.

The radiographs of 35 consecutive adult patients with isthmic spondylolisthesis who underwent a transforaminal lumbar interbody fusion (TLIF) with one or two Brantigan carbon fiber cages and pedicle screw instrumentation were evaluated. Anterolisthesis, disk space height, and slip angle were measured in preoperative and postoperative standing neutral radiographs. Anterolisthesis was reduced and disk space height was increased with the TLIF procedure. Average slip angle, however, was not significantly altered. The restoration of lordosis across the listhetic disk space correlated with a more anterior placement of the interbody cage within the disk space. The TLIF technique, performed with the Brantigan cage and pedicle screw instrumentation, appears to be able to restore disk height and reduce forward translation in patients with isthmic spondylolisthesis, but improvement in sagittal alignment is dependent upon anterior placement of the interbody device.

The role of classification of chronic low back pain.

Study Design. Systematic review. Objective. To describe the various ways chronic low back pain (CLBP) is classified, to determine if the classification systems are reliable and to assess whether classification-specific interventions have been shown to be effective in treating CLBP. Summary of Background Data. A classification system by which individual patients with CLBP could be identified and directed to an effective treatment protocol would be beneficial. Those systems that direct treatment have the greatest potential influence on patient outcomes. Methods. A systematic search was conducted in MEDLINE and the Cochrane Collaboration Library for English language literature published through January 2011. We included articles that specifically described a clinical classification system for CLBP, reported on the reliability of a classification system, or evaluated the effectiveness of classification-specific interventions. Results. A total of 60 articles were initially reviewed. We identified 28 classification systems that met inclusion criteria: 16 diagnostic systems, 7 prognostic systems, and 5 treatment-based systems. In addition, we found 10 randomized controlled trials of CLBP treatment from which we compared inclusion and exclusion criteria. Treatment-based systems were all directed at nonoperative management. Four of the 5 treatment-based systems underwent reliability testing and were found to have interobserver agreement of 70% to 100%. Reliability increased with training and familiarity with a given classification. As the number of subgroups within a classification increased, interobserver agreement decreased. Function and pain were similar between patients treated with the McKenzie classification system and those treated with dynamic strengthening training after 8 months of follow-up in one randomized controlled trial. One prospective cohort study reported better pain and function using the Canadian Back Institute Classification system than with standard rehabilitation. An analysis of the admission criteria to recent randomized studies with either nonoperative care or another surgical intervention provided a methodology for refining criteria to be met by patients considering surgery. Conclusion. There currently are many classification systems for CLBP; some that are descriptive, some prognostic, and some that attempt to direct treatment. We recommend that no one classification system be adopted for all purposes. We further recommend that future efforts in developing a classification system focus on one that helps to direct both surgical and nonsurgical treatments. Clinical Recommendations. There currently are many classification systems for CLBP; some that are descriptive, some prognostic, and some that attempt to direct treatment. We recommend that no one classification system be adopted for all purposes. We further recommend that future efforts in developing a classification system focus on one that helps to direct both surgical and nonsurgical treatments.

Geographic and demographic variability of cost and surgical treatment of idiopathic scoliosis.

Study Design. Retrospective database review. Objective. To determine the variability in cost and surgical technique by geographic region and patient demographic. Summary of Background Data. Some patients with idiopathic scoliosis (IS) ultimately require surgical treatment. The costs associated with hospitalization can be substantial, yet it is unknown how these vary depending on geographic region. Methods. Patients aged 10 to 24 who underwent surgical fusion for idiopathic scoliosis from 2004 to 2006 were identified in a publicly available, searchable national database of insurance billing records for patients with orthopaedic diagnoses (PearlDiver Patient Record Database) by searching ICD-9 diagnosis and procedure codes. Inpatient hospital charges for the procedure, length of stay (LOS), and surgical procedure (anterior, posterior, anterior-posterior, posterior interbody) were recorded. Patients were stratified by geographic region (Northeast, South, Midwest, West) and age group (10–14, 15–19, and 20–24). Results. Seventy-six thousand seven hundred forty-one patients had IS and 955 patients had spinal fusion procedure codes. Per patient average charge (PPAC) was

Modulation of In Vitro Microenvironment Facilitates Synovium-Derived Stem Cell-Based Nucleus Pulposus Tissue Regeneration

113,303 with average LOS 5.6 days. There was no significant difference in procedure type based on geographic region or age. The Northeast had the lowest rate of posterior surgery and highest rate of anterior only procedures. The Midwest had the highest rate of anterior-posterior surgery and Northeast had the lowest. Patients age 10 to 14 had the highest rate of posterior only procedures, those age 20 to 24 had the lowest. Patients age 15 to 19 were more likely to have anterior only procedures. Taken together, anterior-posterior and posterior interbody techniques were most common in patients age 20 to 24. Inpatient hospital charges varied significantly from region to region. Charges were highest in the West (

Cost and use of conservative management of lumbar disc herniation before surgical discectomy

152,637) and lowest in the South (

The effect of anterior cervical fusion on neck motion.

103,256). There was no significant difference in PPAC based on age. LOS was significantly highest in the Midwest (6.5 days) and lowest in the South (5.2 days). LOS was significantly higher in the oldest age group compared with the younger groups. Conclusion. PPAC and LOS varied by region. Although there was no significant difference in treatment type based on age or region, older patients tended to have more complex procedures and a higher LOS. This did not translate into a significant change in PPAC based on age. These data point to the need for further studies examining reasons for geographic variability in idiopathic scoliosis surgeries.

Cervical segmental motion at levels adjacent to disc herniation as determined with kinetic magnetic resonance imaging.

Study Design. Two experiments were conducted. Experiment 1 evaluated the effect of 3 kinds of decellularized extracellular matrices (DECMs) deposited by synovium-derived stem cells (SDSCs) and/or nucleus pulposus cells (NPCs) on SDSC expansion and NP lineage differentiation. Experiment 2 evaluated the effect of DECM deposited by SDSCs on NPC expansion and redifferentiation capacity. In both experiments, hypoxia was evaluated in DECM preparation and pellet culture. Objective. Modulating the in vitro microenvironment facilitates SDSC-based NP tissue regeneration. Summary of Background Data. Autologous cell therapy is a promising approach for NP regeneration. Current in vitro expansion in monolayer results in cell dedifferentiation. Methods. In Experiment 1, passage 3 SDSCs were expanded for 1 passage on DECM deposited by NPCs, SDSCs, or NPCs combined with SDSCs (50:50); DECM was prepared under either normoxia (21% O2) or hypoxia (5% O2). Expanded SDSCs were then cultured in a serum-free chondrogenic medium in hypoxia for 14 days. In Experiment 2, passage 2 NPCs were expanded for 1 passage on DECM deposited by SDSCs; DECM was prepared under either normoxia or hypoxia. Expanded NPCs were cultured in a serum-free chondrogenic medium under either hypoxia or normoxia for 14 days. Cell expansion on plastic flasks served as a control in both experiments. Fourteen-day pellets were evaluated for chondrogenesis using histology, immunostaining, biochemistry, and real-time polymerase chain reaction. Results. DECM deposited by NPCs combined with SDSCs effectively enhanced expanded SDSC viability and guided SDSC differentiation toward an NP lineage; this effect is comparable with DECM deposited by SDSCs but higher than that deposited by NPCs. DECM prepared under normoxia favored SDSC viability and NP lineage differentiation whereas DECM prepared under hypoxia benefited NPC viability and redifferentiation. Low oxygen in a pellet culture system enhanced NPC viability and redifferentiation. Conclusion. The in vitro microenvironment can be modulated by low oxygen and tissue-specific cell-based DECM to facilitate NP tissue regeneration.

Multiple roles of tumor necrosis factor-alpha in fracture healing.

BACKGROUND CONTEXT Lumbar discectomy is one of the most common spine surgical procedures. With the exception of true emergencies (eg, cauda equina syndrome), lumbar discectomy is usually performed as an elective procedure after a prudent trial of nonoperative treatment. Although several studies have compared costs of definitive operative or nonoperative management of lumbar disc herniation, no information has been published regarding the cost of conservative care in patients who ultimately underwent surgical discectomy. PURPOSE The purpose of this study was to determine the financial costs (and relative distribution of those costs) associated with the nonoperative management of lumbar disc herniation in patients who ultimately failed conservative care and elected to undergo surgical discectomy. STUDY DESIGN This is a retrospective database review. PATIENT SAMPLE The sample comprises patients within the database who underwent lumbar discectomy. OUTCOME MEASURES The outcome measures were frequency of associated procedures and the costs of those procedures. MATERIALS AND METHODS A search was conducted using a commercially available online database of insurance records of orthopedic patients to identify all patients within the database undergoing lumbar discectomy between 2004 and 2006. Patients were identified by American Medical Association Current Procedural Terminology code. The associated charge codes for the 90-day period before the surgery were reviewed and categorized as outpatient physician visits, imaging studies, physical therapy, injection, chiropractic manipulation, medication charges, preoperative studies, or miscellaneous charges. The frequency of each code and the percentage of patients for whom that code was submitted to the insurance companies were noted, as were the associated charges. RESULTS In total, 30,709 patients in the database met eligibility criteria. A total of

Migrated XLIF Cage: Case Report and Discussion of Surgical Technique

105,799,925 was charged during the 90 days preoperatively, an average of