Simpson Jm

Comparison between allograft plus demineralized bone matrix versus autograft in anterior cervical fusion. A prospective multicenter study.

Study Design. This study analyzed the fusion results of an allograft-demineralized bone matrix composite versus autograft in a prospective series of patients undergoing surgery for cervical disc disease. Objectives. To determine the fusion rates of allograft-demineralized bone matrix composite in anterior cervical fusion as compared with the gold standard autograft. Summary of Background Data. For the anterior cervical fusion, the use of freeze-dried allograft is well documented in the literature, citing its effectiveness and inferior fusion rates. The use of demineralized bone matrix in conjunction with freeze-dried allograft in anterior cervical fusion has not been reported. Methods. This study was done in a prospective fashion in two medical centers. One group received autograft from the anterior iliac crest, whereas others received freeze-dried allograft augmented with demineralized bone matrix (Grafton, Osteotech, inc, Shrewsbury, New Jersey). For the autograft group, the standard Smith-Robinson grafting technique was used. For the allograft composite group, demineralized bone matrix was pasted onto the freeze-dried allograft and into the disc space before graft insertion. The autograft group consisted of 38 patients with age ranging 26–71 years (mean, 46.1 years) and follow-up periods of 12–33 months (mean, 18.4 months). There were 19 onelevel, 17 two-level, and two three-level fusions, Similarly, the allograft group consisted of 39 patients with age ranging 28–80 years (mean, 48.0 years) with follow-up period of 12–31 months (mean, 17.5 months). There were 19 one-level, 16 two-level, and four three level fusions. Clinical and radiographic follow-up evaluations were completed at 3-month intervals. Radio graphs taken 12 months after surgery were analyzed blindly. Results. Pseudarthrosis developed in 46.2% of patients (33.3% of levels) in the allograft-demineralized bone matrix group compared with 26.3% (22% of levels) in the autograft group (p = 0.11 for patients, p = 0.23 for levels). For patients undergoing two-level fusions, 37.5% of allograft-demineralized bone matrix failed compared with 23.5% of of autografts, for singlelevel fusions, 47.4% of allograft patients developed a pseudarthrosis compared with 26.3% in the autograft group. Graft collapse of ≥ 3mm was noted in 11% of the autograft group versus 19% in the allograft-demineralized bone matrix group (p = 0.32). Graft collapse of ≥ 2mm occurred in 24.4% of autograft patients compared with 39.7% of the allograft-demineralized bone matrix group (p = 0.09). Smokers had an increased rate of pseudarthrosis (47.1%) compared with nonsmokers (27.9%, p = 0.13). Conclusions. The study revealed that the allograft-demineralized bone matrix construct gives a higher rate of graft collapse and pseudarthrosis when compared with autograft in a prospective series, although the differences were not statistically significant, The pseudar-throsis rate in the series may be high because of the large percentage of smokers and radiographic evaluation techniques. For the purpose of solid radiographic fusion, the use of autograft is recommended in anterior cervical surgery until other acceptable osteoinductive materials are developed.

The results of operations on the lumbar spine in patients who have diabetes mellitus.

The results for sixty-two patients who had had a diagnosis of diabetes mellitus and lumbar disc disease or spinal stenosis and had been managed with a posterior decompressive procedure were compared, in a retrospective study, with those for sixty-two age and sex-matched non-diabetic (control) patients who had had similar operative procedures. Forty-four of the sixty-two diabetic patients and fifty-five of the non-diabetic patients were available for long-term follow-up (mean, five and seven years, respectively). Among the diabetic patients, there were high rates of postoperative infection and prolonged hospitalization compared with the rates for the control group. The long-term result was excellent or good for seventeen (39 per cent) of the forty-four patients who had diabetes mellitus and for fifty-two (95 per cent) of the fifty-five non-diabetic patients. The poor results in the diabetic patients may have been related to coexisting diabetic neuropathy, to the associated microvascular disease that affects the spinal nerve roots in diabetic patients, or to the failure of the nerve roots of these patients to recover after decompressive procedures.

Comparison of smoking habits between patients with surgically confirmed herniated lumbar and cervical disc disease and controls.

There have been numerous studies that implicate cigarette smoking as a risk factor for the development of back pain or disc disease. The purpose of this article is to review patients who underwent surgery for cervical or lumbar radiculopathy and to investigate the relationship between cigarette smoking and development of surgical disc disease. A cigarette smoking study of 205 surgical patients with lumbar and cervical disc diseases was done, with the surgical patients compared to 205 age-sex-matched inpatient controls during 1987-1988. This study was conducted at the Pennsylvania Hospital in Philadelphia, Pennsylvania. There were 163 patients with lumbar disc disease and 42 patients with cervical disc disease. The ratio of men to women was 1.5:1 for lumbar disc and 2.5:1 for cervical disc disease. Smoking history (current and ex-smokers) was strikingly increased in both prolapsed lumbar intervertebral disc (56% vs. 37% of controls, p = 0.00029) and cervical disc disease (64.3% vs. 37% of controls, p = 0.0025). Calculated relative risks for smokers were 2.2 for lumbar disc and 2.9 for cervical disc diseases. This association between cigarette smoking and disc disease was more significant when comparing between current smokers versus nonsmokers (p = 0.000011 for lumbar disc disease, and p = 0.00064 for cervical disc disease). Relative risks for current smokers were 3.0 for lumbar disc and 3.9 for cervical disc diseases. This correlation was significant for both males (p = 0.000068 for lumbar disc disease, p = 0.043 for cervical disc disease) and females (p = 0.018 for lumbar disc disease, p = 0.006 for cervical disc disease).(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracic disc herniation. Re-evaluation of the posterior approach using a modified costotransversectomy

A consecutive series of 23 thoracic disc herniations in 21 patients treated between 1980 and 1988 were reviewed. All patients were decompressed through a posterolateral approach (costotransversectomy or transpedicular). Pain and weakness were the most common presenting symptoms. Twenty-one thoracic disc herniations in 19 patients were available for long-term follow-up, averaging 58.1 months. Sixteen patients had an excellent or good result. Three patients had a fair result. There were no poor results. All six patients with significant preoperative lower extremity weakness improved. Pain was relieved in 16 patients and reduced in three. There were no significant neurologic complications associated with the procedure. Posterolateral decompression for thoracic disc herniation remains a viable alternative without the inherent risk and morbidity of the transthoracic approach.

Low lumbar burst fractures : comparison between conservative and surgical treatments

Twenty-two low lumbar burst fractures (L3-L5) were treated, with an average follow up of 56.2 and 39.0 months in the conservative and surgically treated groups, respectively. Twenty patients were available for review; seven were treated conservatively and 13 were stabilized surgically. All patients were evaluated clinically for work status, activity level, residual pain, and subsequent development of neurologic symptoms. Roentgenograms were reviewed for severity of initial fracture, canal compromise, and maintenance of initial correction. In general, neurologically intact patients in both groups returned to similar postinjury employment levels. Persistent back pain was found to be more disabling in the surgically treated group, in which a fusion incorporating four or five lumbar segments was performed. There was no evidence of significant loss of initial reduction, and no patients experienced late neurological compromise in the surgical group. An average follow-up kyphosis of 9.2 degrees and 31% loss of vertebral height were observed in the conservative group, while a follow-up lordosis of 1 degree and 19% loss of vertebral height were observed in the surgical group. Conservative treatment of low lumbar burst fracture is a viable option in neurologically intact patients, but loss of lordosis and vertebral height may persist. Biomechanical and anatomic characteristics of the low lumbar spine differ from the thoracolumbar region and may account for the inherent stability of these injuries. If surgery is chosen, a long fusion with distraction instrumentation should be avoided in the low lumbar spine. A short rigid fixation with pedicular instrumentation may be of greater benefit.

Acute Anterior Compartment Syndrome in the Thigh: A Case Report and Review of the Literature

An unusual case of acute anterior thigh compartment syndrome promptly recognized and successfully treated in a young athletic patient is presented and the literature reviewed. With the increased interest in physical fitness in todays society, this condition may occur more frequently than it is recognized. Prompt diagnosis and treatment can reduce morbidity.

Outpatient laminotomy and discectomy.

This is a prospective study of 61 consecutive patients undergoing lumbar laminotomy and discectomy on an outpatient basis. The purpose of this study was to report on the feasibility of performing lumbar laminotomy and discectomy as an outpatient procedure and to assess perioperative complications, patient satisfaction, cost, and clinical results. Conventional lumbar laminotomy and discectomy traditionally requires a 1-3-day hospital stay. Recent advances in anesthesia and surgical techniques, as well as observation of patient progress after this procedure, has led the authors to believe that that this procedure may be performed on an outpatient basis without compromising patient satisfaction, outcome, or complications. Sixty-one consecutive patients underwent surgery for herniated nucleus pulposus in the lumbar spine. The procedure was performed under loupe magnification without the use of a microscope. Clinical outcome and patient satisfaction were assessed at an average follow-up of 12.5 months. The results showed 62% excellent, 31% good, 7% fair, and there were no reports of a poor outcome. During the time of the study, four patients (7%) were admitted to the hospital after the procedure for reasons of pain control, inability to void, or lack of caregiver at home. Overall cost savings were reflected in the cost of inpatient stay when compared to a representative group of inpatients. Laminotomy and discectomy for a hemiated nucleus pulposus has 93% good or excellent results as shown by this study and previous studies. Laminotomy and discectomy, which remains the gold-standard procedure for herniated disc surgery, can be performed safely and effectively as an outpatient procedure in the majority of patients.

INTERNAL FIXATION OF THE THORACIC AND LUMBAR SPINE USING ROY-CAMILLE PLATES

Thirty patients underwent fixation of the thoracic and lumbar spine from 1986 to 1990 using the Roy-Camille pedicular screw fixation system. The spine was stabilized for a variety of pathologic entities including fracture, tumor, spondylolisthesis, postlaminectomy instability, and pseudarthrosis. All but one patient obtained solid fusion based on radiographic and clinical criteria with an average follow up of 19.5 months. All patients reported subjective improvement in preoperative pain levels. There were no neurologic complications associated with the surgical procedure. Roy-Camille plate fixation appears to offer a stable surgical construct in the treatment of thoracic and lumbar spine instability.