Vinod K. Podichetty

Complications associated with minimally invasive decompression for lumbar spinal stenosis.

Objective Surgical strategies for the decompression of lumbar spinal stenosis have evolved to include minimally invasive techniques providing for adequate and safe decompression while reducing perioperative morbidity. Retrospective case series analysis of 220 consecutive patients with lumbar spinal stenosis who underwent microscopic or microendoscopic minimally invasive decompression was performed. The objective was to evaluate the risks associated with performing a minimally invasive decompression for spinal stenosis in a large group of patients. Methods Two hundred twenty patients with symptomatic neurogenic claudication from lumbar spinal stenosis failing nonoperative treatment received a minimally invasive decompression surgery. Intraoperative data, postoperative data through hospital discharge, and clinical follow-up were analyzed. Results The average age was 74.2 years (range 49–98 years). There were 379 spinal levels decompressed in 220 patients. Sixty-nine patients (31.4%) had a grade 1 degenerative spondylolisthesis. One hundred sixty-eight patients (76%) received spinal anesthesia, and 52 received general anesthesia. Eighty-seven patients (40%) had a preoperative American Society of Anesthesiologists score of 3 or 4. Average operative blood loss was 92 mL. There were 17 intraoperative durotomies (4.5% rate). The average length of stay before discharge was 1.2 days. Ten patients went to inpatient rehabilitation at discharge. One hundred ninety-four patients (88.2%) were discharged within 24 hours. There were five readmissions within the first month after discharge, four of those for medical complications. There were 24 minor complications and 14 major complications. Forty-two patients (19%) took no oral or parenteral narcotic pain medications in the postanesthesia to discharge period. Conclusion Minimally invasive decompression strategies for spinal stenosis seem consistently to result in short hospital lengths of stay, minimal requirements for narcotic pain medications, and a low rate of readmission and complications.

A prospective analysis of prognostic factors in patients with spinal metastases: use of the revised Tokuhashi score.

Study Design. Prospective observational cohort study. Objective. To define the utility of the revised Tokuhashi score in relation to predicting survival in patients with spinal metastases regardless of the treatment pathway. Summary of Background Data. The revised Tokuhashi score has been used for the prediction of survival. In this scoring system, however, all the patients were sourced by orthopedic surgeons, and asymptomatic patients were excluded. That might present a significant source of patient selection bias. The treatment plan was also affected by the predicted survival in their system. Methods. All patients within 2 years of diagnosis of spinal metastases, whether symptomatic were recruited. Minimum 1-year follow-up was required. During the study period, a total of 85 patients were analyzed including 44 patients who died within 1 year. The relation between the revised Tokuhashi score and survival were analyzed using the Cox proportional hazard model and Spearmans rank correlation coefficient. Results. The mean age was 60.3 years (range: 35–84) and the median survival was 11.6 months. On multivariate analysis, lower performance status (Karnofsky performance status, 50%-70%) and unresectable organ metastases were significantly associated with poor survival, with hazard ratios of 2.92 and 4.44, respectively. In primary cancer type, lung and kidney cancer were also significantly associated with poor survival, with hazard ratios of 4.25 and 2.60, respectively. The revised Tokuhashi score groups were significantly correlated with the survival groups (&rgr; = 0.530, P < 0.001). In 67 (79%) of 85 patients, actual survival matched the predicted survival. Conclusion. Lower score on performance status, the existence of organ metastases, and primary cancer of the lung and the kidney were significantly associated with poor survival. The revised Tokuhashi score was found to be very useful to predict survival regardless of the treatment pathway. In most patients, actual survival matched their predicted survival.

The Progressive Roles of Electronic Medicine: Benefits, Concerns, and Costs

Electronic healthcare will significantly alter the way physicians practice medicine. Electronic medical records with specialized software programs can increase the quality of patient care, reduce unnecessary medical tests, and directly connect with pharmacies to transmit prescriptions. Electronic communication can allow physicians to respond to patients’ clinical concerns and questions, and Internet access can provide physicians better access to literature. Nevertheless, there is significant physician hesitance toward adopting medical computerization: patient e-mail can potentially overload physicians with extra work, web sites can direct patients to poor medical information, the computerized interface can degrade the patient-physician relationship, and health regulations can create concern over electronic privacy issues. The finances of e-health appear promising, yet conflicting studies create uncertainty. However, if managed appropriately, the potential disadvantages of e-health can be minimized, and the benefits of e-health in clinical practices can be obtained.

Effectiveness of salmon calcitonin nasal spray in the treatment of lumbar canal stenosis: a double-blind, randomized, placebo-controlled, parallel group trial.

Study Design. Double-blind, randomized, placebo-controlled study to assess the effectiveness of calcitonin nasal spray on symptoms and function in patients with lumbar canal stenosis. Objective. To compare effectiveness of calcitonin administered by nasal spray with placebo in patients with clinically symptomatic lumbar canal stenosis. Summary of Background Data. Lumbar canal stenosis is the most common reason for spine surgery in individuals over 65 years of age. Nonoperative approaches have been not well studied and limited primarily to physical therapy exercises. Several small trials in the past have suggested that subcutaneous and intramuscular calcitonin is an effective nonsurgical option in treating the symptoms of spinal stenosis patients. Only three trials were randomized and placebo-controlled. Methods. Fifty-five patients with clinical lumbar canal stenosis (pseudoclaudication), confirmatory MR imaging, and pain intensity index (VAS) of ≥6 were randomized to either placebo or intranasal calcitonin daily for 6 weeks, followed by an open label 6-week extension, during which all patients received active drug. Outcome parameters performed at baseline, 6 weeks, and 12 weeks, included pain intensity index, walking time and distance to pain, SF-36, and Oswestry disability index. Results. Thirty-six patients received calcitonin, and 19 placebo. Eight (14.54%) calcitonin and 4 (7.27%) placebo patients withdrew from the study. The mean baseline pain score for calcitonin group was 7.8 and 7.5 for placebo. Comparisons at week 6 showed no statistically significant difference in the change in pain intensity (VAS) between calcitonin group (−2.9) and placebo (−2.4) (P = 0.4382) from baseline. There was no significant difference in walking time to pain (calcitonin −10.0 seconds; placebo +32.2 seconds; P = 0.5136). Walking distance to pain showed a mean improvement of +91.4 ft in the calcitonin group and +254.7 ft in the placebo group (P = 0.4948). Nosignificant difference was observed in the SF-36 score between the treatment groups. Using a threshold of at least 50% reduction in pain from baseline to 6 weeks, 12 of 29 (41.37%) of calcitonin patients were considered responders versus 7 of 18 (38.88%) of placebo patients (P = 0.4238) Conclusions. In this first ever largest randomized placebo-controlled parallel group trial of nasal calcitonin in spinal stenosis, nasal calcitonin was not superior to placebo in treating the symptoms of spinal stenosis at 6 weeks. Based on this study, nasal calcitonin does not appear to have a role in nonoperative treatment of lumbar canal stenosis.

Thoracic microendoscopic discectomy: a human cadaver study.

Study Design. Feasibility analysis of percutaneous posterolateral thoracic microendoscopic discectomy in a human cadaver model. Objective. To describe a new, minimally invasive, posterolateral approach to the thoracic spine for the treatment of disc herniations. Summary of Background. Thoracoscopic discectomy offers surgeons direct ventral access to thoracic disc herniations but requires entry into the chest. Many surgeons favor a posterolateral approach to the thoracic spine, thereby avoiding morbidity associated with entry into the thoracic cavity. By adapting minimal access surgical techniques to the thoracic spine, effective treatment of thoracic disc herniations should be possible and may help expedite recovery. Methods. Two cadaveric human torsos were used. Using simple adaptations of our standard lumbar microendoscopic discectomy technique, endoscopic discectomies were performed throughout the mid and lower thoracic spine. Operative time was recorded. The extent of the discectomy as well as the extent of bony removal was evaluated using computed tomography myelography. Results. Nine discectomies were performed in two cadaveric specimens, from T5–T6–T9–T10. Operative times ranged from 46 to 77 minutes (mean 60 minutes). The procedure required removing 3.4 mm (±1.9 mm) of the ipsilateral facet, which amounted to 35.4% (±17.5%) of the facet complex. Canal decompression averaged 73.5% (±7.9%). Conclusions. Thoracic microendoscopic discectomy allows for a posterolateral approach to thoracic disc herniation without entry into the chest cavity that consistently gives access to the majority of the canal while requiring only a minimal amount of bone removal. This technique provides an approach angle similar to that obtained with other posterolateral discectomy techniques while limiting the morbidity associated with exposure.

Prediction rules in cervical spine injury

Can reduce unnecessary imaging, without missing fractures or increasing adverse events

Calcitonin treatment in lumbar spinal stenosis: a meta-analysis.

INTRODUCTION: The management of lumbar spinal stenosis (LSS) represents a significant cost to the healthcare system resulting from the functional limitations and diminished quality of life in patients. Calcitonin is presently indicated for the treatment of postmenopausal osteoporosis, Pagets disease, spine pain related to vertebral compression fractures, and spinal metastases. In spinal stenosis patients, it has been suggested to have both analgesic and anti-inflammatory properties. The aim of this metaanalysis was to review the published randomized control trials to determine the effect of calcitonin on walking distance and Visual Analog Pain Scale (VAS) for pain in patients with lumbar spinal stenosis compared to placebo.

Aortic disruption associated with L2-L3 fracture-dislocation in a case of child abuse: a case report.

The literature pertaining to child abuse indicates that very few victims (<3%) present with a spine injury1,2. A comprehensive review of the literature revealed a limited number of references to pediatric aortic rupture and only two instances of aortic rupture associated with spinal fracture3,4. All of the reports of pediatric aortic disruption described the injuries as being secondary to severe trauma due to a fall or a motor-vehicle accident. The purpose of this report is to describe a case of fatal aortic disruption and define the mechanism of injury in a child who presented with an L2-L3 fracture-dislocation. A girl who was three and a half years old was transported to the hospital emergency department by paramedics after she had presumably drowned in a children’s wading pool. Resuscitative efforts were administered en route and in the hospital emergency room but were unsuccessful, and the child was pronounced dead on the same day. The police investigated the death as a suspected accidental drowning, and an autopsy was performed the following day under a coroner’s warrant. At autopsy, external examination revealed minor abrasions and contusions scattered on the face and head, but there was no external evidence of blunt force injury to the torso. On internal examination, there was acute traumatic transection of the abdominal aorta just distal to the level of the origin of the inferior mesenteric artery with massive retroperitoneal hemorrhage. This was associated with a complete fracture-dislocation of the lumbar spine through the L2-L3 intervertebral disc with a completely disrupted anterior longitudinal ligament, hematomas within the paraspinal muscles, and an epidural hematoma around the caudal aspect of the spinal cord (Fig. 1). Histological examination of soft tissue from around the vertebral fracture site showed reparative changes with fibrosis consistent with prior …

Common origin of the artery of adamkiewicz and a posterior spinal artery with a spinal dural arteriovenous fistula: a case report.

Progressive nature of the myelopathy seen in patients with dural arteriovenous fistulas call for timely diagnosis and surgical intervention to alleviate symptoms of neurologic dysfunction. We present a case report of a 51-year-old male presented with progressive sensory and motor deficits, along with gait instability associated with urinary incontinence for a period of one year. MRI of the spine demonstrated a thoracic spinal dural arteriovenous fistula. Spinal angiography showed at T7 on the left a common origin of the artery of adamkiewicz, a posterior spinal artery and the spinal dural arteriovenous fistula. The fistula was surgically treated and the patient made an almost complete recovery. To the authors knowledge, this is the first time that this common origin, of the three vessels, is described in the literature.

e-Talking to patients: connecting with the health care consumer.

in theirarticle, “Who uses the patient Internet portal? The Patient-Site experience,” offer an interesting perspective on the imple-mentation of a patient portal called PatientSite. They describethe results of patient access to the features of the system andthe demographic and clinical profile of its enrollees. Further-more, this is one of the first steps in exploring and assessing theutility of patient portals and the value of its services in healthcare management, which the authors have pertinently de-scribed in the current paper. Similar to the tool developed byinformaticists at Beth Israel Deaconess Medical Center(BIDMC), which the authors have used enabling patients toenroll in a portal, the Cleveland Clinic Health System imple-mented the physician portal with features exclusive to physi-cian access termed as My Chart