Tom Faciszewski

The Dynamic Mobility of Vertebral Compression Fractures

We have observed that some osteoporotic vertebral compression fractures (VCFs) are mobile. The purpose of this report was to document the existence of dynamic fracture mobility, estimate the frequency of dynamic mobility in patients referred for vertebroplasty, define the magnitude and nature of dynamic mobility, and consider the implications of the dynamic mobility of osteoporotic VCFs. This was a prospective radiographic analysis of 41 consecutive patients with 65 VCFs who underwent vertebroplasty. Preoperative standing lateral radiographs of the fractured vertebrae were compared with supine cross‐table lateral radiographs to determine the presence or absence of dynamic mobility. Postoperative standing lateral radiographs were evaluated to document fracture mobility and assess final vertebral height restoration. Radiographs were manually digitized to calculate vertebral body morphometrics. Dynamic fracture mobility was demonstrated in 44% of patients (35% of treated vertebrae) who underwent vertebroplasty. Postoperatively, in mobile fractures, average anterior vertebral height increased 106% compared with initial fracture height (absolute increase, 8.41 ± 0.4 mm). Mean lateral vertebral area increased from 48% to 80% of normal, and kyphotic angle decreased 40%. Mobile fractures dominated at the thoracolumbar junction. Intravertebral clefts were defined and identified in every mobile fracture and were absent from every nonmobile (fixed) fracture. This radiographic series documents the previously unrecognized occurrence of dynamic fracture mobility in many osteoporotic VCFs. Fracture mobility can be substantial and clinically significant. Any intervention that claims vertebral height restoration must control for the occurrence of dynamic fracture mobility.

Quality of Life Following Vertebroplasty

BACKGROUND Percutaneous vertebroplasty may be indicated when a patient with a painful osteoporotic vertebral compression fracture remains intolerably symptomatic in spite of comprehensive, nonoperative management. Relief of pain and quality of life following percutaneous vertebroplasty, however, remain incompletely defined. We investigated these outcomes with use of a visual analog scale and a validated, osteoporosis-specific health-related quality-of-life instrument. METHODS We performed a prospective study of consecutive patients who underwent percutaneous vertebroplasty. At the time of enrollment, all patients completed the Osteoporosis Quality of Life Questionnaire, a validated thirty-item, five-domain, 7-point response-option instrument that measures health-related quality of life in osteoporotic women with back pain due to vertebral compression fracture. At two weeks, two months, and six months postoperatively, all patients completed a validated extraction of the Osteoporosis Quality of Life Questionnaire. The minimal, clinically important difference in this 7-point scale is 0.5 unit per question. To assess pain, a visual analog scale (ranging from 1 to 10) was completed preoperatively, one day postoperatively, and at each evaluation thereafter. RESULTS Forty-six consecutive patients (thirty-two women and fourteen men) underwent forty-nine percutaneous vertebroplasty procedures for the treatment of sixty-six vertebral compression fractures. The mean age of the patients was 74.3 years. The mean fracture age was 2.5 months. The mean pain rating decreased from 7.7 preoperatively to 2.8 one day after the vertebroplasty (p < 0.001), and it remained substantially improved at two weeks, two months, and six months postoperatively (p < 0.001). All five domains of the Osteoporosis Quality of Life Questionnaire were improved at two weeks postoperatively and remained improved at each evaluation point through six months (p </= 0.007). Multivariate analysis demonstrated no consistent correlation between postoperative pain relief or any postoperative Osteoporosis Quality of Life Questionnaire domain score and gender, smoking history, previous or current steroid use, bone mineral density, dynamic mobility, or the presence of an intravertebral cleft. Immediate postoperative pain relief was weakly and positively associated with age (p < 0.03). Four incident vertebral compression fractures occurred in three (6.5%) of the forty-six patients, and five patients died within six months after the vertebroplasty. No deaths or serious adverse events appeared to be related to vertebroplasty. CONCLUSIONS Rapid and substantial relief of pain and improvement in the quality of life are observed following percutaneous vertebroplasty, and these improvements are maintained for at least six months. Percutaneous vertebroplasty can be performed safely in frail, elderly patients, with no apparent increase in the incidence of fractures postoperatively. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Reporting height restoration in vertebral compression fractures

Study Design. Prospective radiographic analysis of vertebral compression fractures (VCFs) that underwent vertebroplasty. Objective. Illustrate the variability in apparent magnitude of vertebral height restoration when this outcome is reported by four different methods commonly used in the vertebroplasty literature. Propose a consensus method for reporting vertebral height restoration. Summary of Background Data. Measuring and reporting height restoration of fractured vertebrae presupposes a consensus of method that does not exist. Lack of consensus makes the interpretation of reports and comparison of outcomes of interventions that claim vertebral height restoration difficult. Materials and Methods. Preoperative and postoperative standing lateral radiographs of 65 VCFs in 41 patients were compared to assess operative vertebral height restoration. Restorations of vertebral height occurred in 23 instances and were reported by each of the following commonly used methods: (1) absolute restoration in millimeters; (2) percent restoration relative to initial fracture height; (3) percent restoration relative to lost vertebral height; and (4) percent restoration relative to referent vertebral height. Results. Apparent magnitude of height restoration varied nearly four-fold depending on initial fracture severity and reporting method. Conclusions. Substantial apparent variability in the reported magnitude of identical height restorations demonstrates the need for a consensus method for measuring, reporting, and interpreting this outcome. Rationale is presented to support the recommendation that reports of vertebral height restoration should: include all index vertebral height dimensions (posterior (Hp), middle (Hm) and anterior (Ha) vertebral height); include absolute measurements of all referent vertebral heights; be reported relative to a referent normative height; include a correction for inter-radiographic measurement error; take into consideration the dynamic mobility of some osteoporotic VCFs; and include the calculated precision error for all measurements.

Quality of Data Regarding Diagnoses of Spinal Disorders in Administrative Databases. A Multicenter Study

The purpose of the present study was to evaluate the accuracy of data regarding diagnoses of spinal disorders in administrative databases at eight different institutions. The records of 189 patients who had been managed for a disorder of the lumbar spine were independently reviewed by a physician who assigned the appropriate diagnostic codes according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The age range of the 189 patients was seventeen to eighty-four years. The six major diagnostic categories studied were herniation of a lumbar disc, a previous operation on the lumbar spine, spinal stenosis, cauda equina syndrome, acquired spondylolisthesis, and congenital spondylolisthesis. The diagnostic codes assigned by the physician were compared with the codes that had been assigned during the ordinary course of events by personnel in the medical records department of each of the eight hospitals. The accuracy of coding was also compared among the eight hospitals, and it was found to vary depending on the diagnosis. Although there were both false-negative and false-positive codes at each institution, most errors were related to the low sensitivity of coding for previous spinal operations: only seventeen (28 per cent) of sixty-one such diagnoses were coded correctly. Other errors in coding were less frequent, but their implications for conclusions drawn from the information in administrative databases depend on the frequency of a diagnosis and its importance in an analysis. This study demonstrated that the accuracy of a diagnosis of a spinal disorder recorded in an administrative database varies according to the specific condition being evaluated. It is necessary to document the relative accuracy of specific ICD-9-CM diagnostic codes in order to improve the ability to validate the conclusions derived from investigations based on administrative databases.

Does Vertebral Height Restoration Achieved at Vertebroplasty Matter

PURPOSE Altered vertebral and spinal configuration after osteoporotic vertebral compression fracture (VCF) is believed to contribute to postfracture morbidity. The objective of this study was to determine whether patients in whom partial vertebral height restoration (VHR) was achieved at percutaneous vertebroplasty had greater pain relief or improved quality of life compared with patients in whom no anatomic restoration was achieved. MATERIALS AND METHODS Consecutive subjects undergoing percutaneous vertebroplasty for painful osteoporotic VCFs completed the Osteoporosis Quality of Life Questionnaire (OQLQ) a validated, disease specific instrument that measures health related quality of life in women with osteoporosis with back pain caused by VCF. At postoperative week 2, month 2, and month 6, all subjects completed the mini-OQLQ, a validated extraction of OQLQ. Pain was rated with a standard visual analogue scale (VAS). Radiographs were manually digitized and evaluated for the presence of dynamic mobility and VHR. The relationship between VHR achieved at percutaneous vertebroplasty and postoperative pain relief and quality of life outcome was examined by multivariate analysis. RESULTS Forty-six subjects (32 women) underwent 49 percutaneous vertebroplasty procedures to treat 66 painful VCFs. Mean patient age was 74.3 years+/-10.9. Mean fracture age was 2.5 months+/-2.1. Pain rating fell from 7.7+/-1.8 to 2.8+/-1.8 within 1 day of percutaneous vertebroplasty and remained improved through month 6 (P<.001). All OQLQ domains improved substantially at week 2 (P<.02) and remained improved through month 6 (P<or=.007). Preoperative dynamic mobility ranged -2.9 to 19.9 mm (average, 5.5 mm). Postoperative VHR in mobile VCFs ranged -2.1 to 9.6 mm (average, 2.9 mm). At all postoperative time points up to 6 months, pain and OQLQ domain scores were similar in patients who achieved partial VHR at percutaneous vertebroplasty compared with those in whom no VHR was achieved. CONCLUSION Partial vertebral height restoration achieved at percutaneous vertebroplasty did not result in additional pain relief or improved quality of life beyond cement fixation alone.

Procedural coding of spinal surgeries (CPT-4 versus ICD-9-CM) and decisions regarding standards: a multicenter study.

Study Design. A comparison of procedural coding systems (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]vs. Current Procedural Terminology [CPT-4]) applied to lumbar spine surgery patients from six teaching institutions. Objective. To compare the detail reflected by coding systems used to describe spinal procedures. Summary of Background Data. Administrative databases contain ICD-9-CM procedural codes, which are derived from hospital discharge abstracts. These databases are used, in part, to establish health care utilization patterns and set health care policy. Previous studies have demonstrated inaccuracies in ICD diagnosis coding. However, the literature is void of information regarding the accuracy of ICD procedural coding of spine procedures. Methods. Data were complete in 143 of 150 lumbar spine surgery patients (aged 17–84 years). Surgeons assigned CPT-4 procedural codes. These codes were compared with ICD procedure codes assigned by hospital medical records staff. Results. On average, in four of six hospitals, there were more CPT codes assigned to patient records by the surgeon than ICD codes assigned by hospital medical records staff. Overall, CPT codes reflected a greater level of detail than ICD codes. Conclusions. These findings illustrate the increased detail of CPT coding over ICD coding in the spinal surgery cases reviewed. The ICD procedural codes contained in administrative databases tend to underrepresent the complexity of the surgical procedures actually performed.

Latent Mobility of Osteoporotic Vertebral Compression Fractures

PURPOSE To describe the property of latent mobility in osteoporotic vertebral compression fractures (VCFs) and discuss its clinical significance. MATERIALS AND METHODS This was a retrospective case series of 14 patients with 14 painful osteoporotic VCFs who were comfortably confined to the supine position overnight for the purpose of vertebral height restoration. There was sufficient additional vertebral height restoration the following morning to allow percutaneous vertebroplasty (PV) in some patients when this had initially been deemed unsafe or technically impossible. Anterior vertebral height of the index VCF was measured from the preoperative standing lateral, immediate cross-table supine lateral, and postconfinement cross-table supine lateral radiographs as well as the first postoperative standing lateral radiograph. Dynamic mobility was defined as the difference in anterior vertebral height between preoperative standing lateral and immediate cross-table supine lateral radiographs. Latent mobility was defined as difference in anterior vertebral height between immediate cross-table supine lateral and postconfinement cross-table supine lateral radiographs. Postoperative vertebral height restoration was defined as the difference in anterior vertebral height between preoperative and first postoperative standing lateral radiographs. Mean patient age was 81.0 years, and mean fracture age was 83.6 days. RESULTS Dynamic mobility averaged +4.7 mm (range, -2.1 to +12.6 mm; P = .001). Latent mobility averaged +2.7 mm (range, -1.9 to +15.5; P < .02). The average sum of preoperative dynamic and latent mobility (+7.4 mm; range -1.0 to +17.0; P < .001) was not different from final postoperative vertebral height restoration (P > .4). PV was successfully accomplished in all cases. CONCLUSIONS Latent mobility occurs in some VCFs and contributes to vertebral height restoration. Recognition of latent mobility may permit vertebroplasty in some patients in whom the procedure had otherwise been deemed unsafe. Reports of vertebral height restoration following vertebral augmentation should account for that proportion resulting from dynamic and latent mobility.

Cardiac risk stratification of patients with symptomatic spinal stenosis.

The leading cause of death in the perioperative period after noncardiac surgery is a cardiac event. As the number of lumbar surgeries performed in patients older than 65 years of age continues to increase, this patient population with neurogenic claudications is an at risk group for a cardiac event because of their age and associated cardiac risk factors. The authors attempted to document by means of cardiac chemical stress testing, the prevalence of silent ischemic cardiac disease in patients with neurogenic claudication who were candidates for elective lumbar surgery. Eleven of 140 patients (8%) had induced cardiac wall abnormalities on stress testing, indicating myocardial ischemia. The only risk factors associated with cardiac ischemia were smoking and history of heart disease. It is recommended that dobutamine stress echocardiography be performed in patients undergoing elective spinal surgery for symptomatic spinal stenosis if they have a history of previous heart disease, smoking, or both.

Peridiscal Metastatic Carcinoma Associated with Lumbar Disc Herniation. A Case Report

The pathological examination of tissue specimens obtained during lumbar discectomy and laminectomy is considered to be a routine practice at many institutions. The reasons for the submission of such specimens generally include hospital policy, the possible need for medicolegal proof of the procedure, and the need to evaluate the possibility of an occult malignant lesion2,3. The Joint Commission on Accreditation of Health Care Organizations has recommended a written policy regarding the submission of operative specimens2. At our institution (St. Josephs Hospital, Marshfield, Wisconsin), all tissues removed from the patient at the time of the operation, with the exception of tissues that have been exempted by the operating committee and the Department of Pathology, are submitted for pathological examination4. The exemptions must not adversely affect the quality of patient care, and the surgeon may request a pathological examination of the exempted tissue. Herniated nucleus pulposus is not considered to be an exempted tissue. Recently, the routine submission of disc specimens has been questioned by a number of investigators who have found that pathological findings are not likely to influence the treatment or the outcome1,2. In our review of the literature, we found only one report in which a patient who had had a discectomy for the treatment of lumbar disc herniation was diagnosed as having a tumor on the basis of the pathological examination of the operative specimen6. We present a case in which the results of the pathological examination of the operative specimen influenced the subsequent treatment as well as the outcome. A seventy-year-old man was seen with a history of two previous operations on the lumbar spine. A laminectomy had been performed in 1964 because of pain in the lower extremities. The patient had had …

60. Radiation dose reduction to medical staff during vertebroplasty: a review of techniques and methods to mitigate occupational dose

STUDY DESIGN Case crossover design was conducted. OBJECTIVES The purpose of the current study was to determine the radiation exposure level of operators performing fluoroscopically assisted vertebroplasty and to determine optimal techniques to reduce this exposure. SUMMARY OF BACKGROUND DATA The use of ionizing radiation to provide quality imaging during minimally invasive orthopedic procedures has dramatically increased. One such procedure, vertebroplasty, which is the percutaneous fixation of fractured vertebrae with polymethylmethacrylate, requires the use of ionizing radiation of biplanar fluoroscopy. The adverse effects of excessive radiation exposure to occupational personnel may not be realized for several years. METHODS Twelve months of occupational dose data for a single operator were evaluated and correlated to the modifications of practice habits implemented and shielding techniques used to reduce the operators exposure while maintaining adequate image quality. RESULTS Before the implementation of radiation-reduction procedures, the average whole-body dose per vertebroplasty procedure was 1.44 mSv/vertebrae, and the measured hand dose was 2.04 mSv/vertebrae. After implementation of radiation-reducing procedures and shielding techniques, the average whole-body dose per vertebroplasty procedure was 0.004 mSv/vertebrae, and the average hand dose was 0.074 mSv/vertebrae. Testing of the shielding device indicated a significant reduction in whole-body and hand doses. For the fluoroscopic modes investigated, the shielding used resulted in reductions ranging from 42.9% to 86.1%. CONCLUSION It is critical that operators performing vertebroplasty procedures have a fundamental understanding of radiation physics and radiation protection to minimize radiation exposure.