Wajeeh Bakhsh

High-dose rhBMP-2 for adults: major and minor complications: a study of 502 spine cases.

BACKGROUND Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) has increased considerably since its introduction in 2002. The complications associated with high-dose rhBMP-2 (≥ 40 mg) are unknown. The purpose of our study was to determine outcomes and medical and surgical complications associated with high-dose rhBMP-2 at short-term and long-term follow-up evaluations. METHODS Five hundred and two consecutive adult patients who had received high-dose rhBMP-2 as a part of spinal surgery from 2002 to 2009 at one institution were enrolled. Data were entered prospectively and studied and analyzed retrospectively. Surgical procedures in the thoracic and lumbar spine were included. Major and minor complications were documented intraoperatively, perioperatively, and at the latest follow-up examination. Complications potentially associated with rhBMP-2 use were evaluated for correlation with rhBMP-2 dose. Scoliosis Research Society (SRS) and Oswestry Disability Index (ODI) outcome measures were obtained before and after surgery. RESULTS On average, 115 mg (range, 40 to 351 mg) of rhBMP-2 was used. The average age of the patients (410 women and ninety-two men) at the time of the index procedure was 52.4 years (range, eighteen to eighty years). There were 265 primary and 237 revision procedures, and 261 patients had interbody fusion. An average of 11.5 vertebrae were instrumented. The average duration of follow-up was forty-two months (range, fourteen to ninety-two months). The diagnoses included idiopathic scoliosis (41%), degenerative scoliosis (31%), fixed sagittal imbalance (18%), and other diagnoses (10%). The rate of intraoperative complications was 8.2%. The rate of perioperative major surgical complications was 11.6%. The rate of perioperative major medical complications was 11.6%. Minor medical complications occurred in 18.9% of the cases, and minor surgical complications occurred in 2.6%. Logistic regression analysis and Pearson correlation did not identify a significant correlation between rhBMP-2 dosage and radiculopathy (r = -0.006), seroma (r = -0.003), or cancer (r = -0.05). Significant improvements in the ODI score (from a mean of 41 points to a mean of 26 points; p < 0.001) and the SRS total score (from a mean of 3.0 points to a mean of 3.7 points; p < 0.001) were noted at the latest follow-up evaluation. CONCLUSIONS This is the largest study of which we are aware that examines complications associated with high-dose rhBMP-2. Major surgical complications occurred in 11.6% of patients, and 11.6% experienced major medical complications. There was a cancer prevalence of 3.4%, but no correlation between increasing rhBMP-2 dosage and cancer, radiculopathy (seen in 1% of the patients), or seroma (seen in 0.6%) was found.

Mycobacterium kansasii infection of the spine in a patient with sarcoidosis: a case report and literature review.

Mycobacterium kansasii is an acid-fast bacillus most commonly associated with pulmonary pathology. Infection of the spine is exceedingly rare, with just three reported cases, two of which were in human immunodeficiency virus and acquired immunodeficiency syndrome patients. This case report presents a case of vertebral osteomyelitis secondary to M. kansasii infection and reviews existing literature on this pathogen. The patient, a 37-year-old male with sarcoidosis, sustained a M. kansasii infection of the spine, resulting in vertebral osteomyelitis of L1 and L2 and discitis of the L1-L2 disc. This finding was confirmed by bone and intervertebral disc biopsy. Initially, the patient was thought to have a compression fracture of L2. However, the decision to perform a biopsy was made because of the patients persistent febrile episodes and magnetic resonance imaging findings. The patient did not have any neurological deficits. He was successfully treated with antimicrobials, with no recurrent symptoms at 2-year follow-up. This case is the first reported case of a M. kansasii infection of the spine in a patient with sarcoidosis.

Arachnoiditis ossificans after revision adolescent idiopathic scoliosis surgery: a 22-year follow-up and review.

Study Design. Case report. Objective. To report the clinical and imaging findings of a patient with arachnoiditis ossificans (AO) 22 years after revision surgery for adolescent idiopathic scoliosis (AIS). Summary of Background Data. To our knowledge, there are no reports in the literature that describe AO developing after primary or revision surgery for AIS. Ararchnoiditis ossificans is a rare finding and we provide a review of its presentation and management. Methods. We report the patients history, physical examination, radiographical findings, and management in addition to providing a literature review. Results. A 43 year-old-male who underwent revision surgery for AIS due to intradural migration of a laminar hook presented 22 years after surgery with subjective leg weakness. On physical examination, no weakness was elicited and radiographs demonstrated the instrumentation to be intact. Computed tomographic imaging was performed to assess for adjacent segment disease and diffuse ossification or AO of the thecal sac from L3 to S1 was noted. We recommended observation and nonoperative management because the patients symptoms were relatively mild. Conclusion. To our knowledge, this is the first report of AO after surgical management of primary or revision AIS. A discussion on the management of AO and a literature review is presented.

Cervical Scoliosis: Clinical and Radiographic Outcomes

Study Design Retrospective study. Objective Cervical scoliosis is a rare condition that can arise from various etiologies. Few reports on the surgical management of cervical scoliosis exist. Our objective was to evaluate clinical and radiographic outcomes following surgical management of cervical scoliosis. Methods We evaluated our cervical spine surgical database for patients with cervical scoliosis (Cobb angle > 10 degrees) from 2005 to 2010. Demographic data including age, gender, diagnoses, and primary versus revision surgery was collected. Surgical data including procedure (anterior versus posterior), estimated blood loss (EBL), length of surgery, length of hospitalization, and complications was recorded. Preoperative and postoperative Cobb angle measurements and Neck Disability Index (NDI) scores were recorded. Results Cervical scoliosis was identified in 18 patients. We excluded 5, leaving 5 men and 8 women with an average age of 50.7 (median 52, range 25 to 65). The average follow-up was 40 months (median 36.5, range 5 to 87). An anterior-only approach was used in 6 cases (average 4 levels fused), 5 cases were posterior-only approach (average 8.7 levels fused), and 2 cases were combined anterior-posterior approach. The EBL was an average of 286 mL (median 150, range 50 to 900), the average surgical time was 266 minutes (median 239, range 136 to 508), and the average hospital stay was 2.7 days (median 2, range 1 to 7). Complications occurred in 7 patients, and 2 developed adjacent segment pathology. The average coronal Cobb angle preoperatively was 35.1 degrees (median 31, range 13 to 63) and corrected was 15.7 degrees (median 10.5, range 2 to 59) postoperatively (p < 0.005). The average NDI preoperatively was 24.9 (median 26, range 6 to 37) and was reduced to 17.8 (median 18, range 7 to 30) postoperatively (p < 0.02). Conclusion Surgical management of cervical scoliosis can result in deformity correction and improvement in patient outcomes. Higher rates of complications may be encountered.

The Prevalence of Klippel-Feil Syndrome: A Computed Tomography–Based Analysis of 2,917 Patients

STUDY DESIGN Cross-sectional study. OBJECTIVE To determine the prevalence of KFS in asymptomatic patients in New York State. SUMMARY OF BACKGROUND DATA Klippel-Feil syndrome (KFS) is characterized by congenitally fused cervical vertebrae and may not be diagnosed clinically because most patients do not have the classic triad of short neck, low posterior hairline, and decreased neck range of motion. KFS may be associated with abnormalities such as congenital scoliosis and deafness, and patients are at higher risk for neurologic injury following cervical spine trauma. The prevalence of KFS has not been evaluated in a large series but is estimated to occur every 40,000 births. METHODS A total of 3,534 cervical computed tomography (CT) scans at the emergency department of a level I trauma center were obtained during a one-year period. Duplicate scans and outside hospital imaging were excluded, resulting in 2,917 cervical CT scans for review. Demographic information was collected, and if KFS was present, level(s) fused, Samartzis classification type, and presence of cervical scoliosis and cervical spine fractures were recorded. RESULTS The prevalence of KFS was 0.0058% (1 in 172). Of the 17 subjects with KFS, 8 were female and 9 were male. The most commonly fused levels were C5-C6 and C2-C3. All 17 subjects were classified as Samartzis type I, with a single congenitally fused cervical segment. None of the subjects had cervical scoliosis or cervical spine fractures. CONCLUSIONS The prevalence of KFS in our series is much higher than previously described. Because clinical diagnosis may not be reliable, it is likely that this condition is underreported and may only be found incidentally on imaging. LEVEL OF EVIDENCE Level III.STUDY DESIGN Cross-sectional study. OBJECTIVE To determine the prevalence of KFS in asymptomatic patients in New York State. Klippel-Feil syndrome (KFS) is characterized by congenitally fused cervical vertebrae and may not be diagnosed clinically because most patients do not have the classic triad of short neck, low posterior hairline, and decreased neck range of motion. KFS may be associated with abnormalities such as congenital scoliosis and deafness, and patients are at higher risk for neurologic injury following cervical spine trauma. The prevalence of KFS has not been evaluated in a large series but is estimated to occur every 40,000 births. METHODS A total of 3,534 cervical computed tomography (CT) scans at the emergency department of a level I trauma center were obtained during a one-year period. Duplicate scans and outside hospital imaging were excluded, resulting in 2,917 cervical CT scans for review. Demographic information was collected, and if KFS was present, level(s) fused, Samartzis classification type, and presence of cervical scoliosis and cervical spine fractures were recorded. RESULTS The prevalence of KFS was 0.0058% (1 in 172). Of the 17 subjects with KFS, 8 were female and 9 were male. The most commonly fused levels were C5-C6 and C2-C3. All 17 subjects were classified as Samartzis type I, with a single congenitally fused cervical segment. None of the subjects had cervical scoliosis or cervical spine fractures. CONCLUSIONS The prevalence of KFS in our series is much higher than previously described. Because clinical diagnosis may not be reliable, it is likely that this condition is underreported and may only be found incidentally on imaging. LEVEL OF EVIDENCE Level III.

Lumbar Spine Infection by Granulicatella and Abiotrophia Species

BACKGROUND The Granulicatella and Abiotrophia species are streptococci and natural inhabitants of the oral and urogenital flora. They are uncommonly associated with human pathology, although they can cause septicemia, endocarditis, or bacteremia. These microorganisms are difficult to culture and identify due to particular microenvironment requirements. Rarely, presentation is osteomyelitis or infections of the spine. CASE DESCRIPTION The case report referenced patient notes, laboratory values, and imaging from the electronic health record. In this 48-year-old male with a history of hepatitis C and intravenous drug use, back pain was a relatively common presentation of an uncommon infection. His hospital course was significant for low back pain that did not resolve with conservative measures. Imaging was concerning for infection of the lumbar spine. Biopsies, negative early on, were ultimately positive for Granulicatella and Abiotrophia species, a rare infectious etiology. This infection uncommonly affects the lumbar spine and has not been previously documented in IV drug users. Intravenous antibiotics were prescribed for 6 weeks, after which the patient demonstrated significant clinical improvement. CONCLUSION With such an uncommon pathogen, there are no universal protocol changes indicated. However, awareness of such unusual microbes and their potential role as the etiology of more common infections, such as lumbar osteomyelitis, is crucial in developing a thorough infectious workup in cases resistant to treatment targeting typical microorganisms.

Intra-articular “Cocktail” Offers Clinical Advantages over Femoral Nerve Block for Postoperative Analgesia in Patients Undergoing Arthroscopic Hip Surgery

Objectives: Arthroscopic hip surgery has gained considerable popularity over the past several years. Attempts to optimize peri and postoperative pain control continues to represent a challenge and opportunity for clinical improvement. Multiple regional anesthesia strategies have been utilized by arthroscopic hip surgeons, including lumbar plexus and femoral nerve blockade, however these options can be associated with setbacks including technical difficulty, intravascular injection, increased post-operative fall risk and the development of peripheral neuritis. Therefore, exploration of alternative regional anesthesia strategies holds promise for improved clinical outcomes. This study aims to explore the efficacy and complication rate of intra-articular anesthetic administration in patients undergoing arthroscopic hip surgery. Methods: A retrospective analysis of prospectively collected data was conducted to identify all patients undergoing elective arthroscopic hip surgery between November 2013 and April 2015. Subjects were stratified into either a group that had received a preoperative femoral nerve block for perioperative pain control or a group that had an intra-articular injection of local anesthetic administered by the surgical team intraoperatively. Objective data, including pre and post-op pain scores in the PACU, total dose of narcotics required perioperatively, occurrence of falls and development of peripheral neuropathy were collected for analysis. Data was compared between the two groups using linear and logistic regression modeling. Statistical significance was determined as p<0.05. Results: After excluding patients who did not meet the criteria for study participation, a total of 193 patients were included in this study. At the time of surgery, one hundred eighty three patients (95%) demonstrated evidence of labralchondral pathology and bony morphology characteristic of femoroacetabular impingement (FAI). One hundred five patients (54%) received a pre-operative femoral nerve block and 88 patients (46%) received an intra-operative intra-articular injection of anesthetic agents. Linear models for post-operative pain, controlled for patient age and pre-operative pain levels, revealed that patients receiving pre-operative femoral nerve blocks had significantly less pain at discharge (p<0.05). There was no statistically significant difference in pain scores between patients receiving pre-operative femoral nerve blocks and those receiving intra-articular injections at post-operative weeks 1, 3 and 6. Patients receiving pre-operative femoral nerve blocks were found to be 3.6 times more likely to experience a post-operative fall (OR 3.58, p < 0.05) and were 14 times more likely to experience post-operative neuropathy (OR 13.99, p < 0.01) than patients receiving an intra-articular injection. Conclusion: Intra-articular anesthetic administration was found to be similar in efficacy to pre-operative femoral nerve blocks at reducing post-operative pain in patients undergoing hip arthroscopy. Additionally, patients receiving intra-articular injections had a significantly decreased risk of falling post-operatively or developing peripheral neuritis, known complications of femoral nerve blocks. With this information, intra-articular anesthetic administration appears to be a safe alternative to femoral nerve blocks in patients undergoing hip arthroscopy. Table 1 Demographic Data Group 1: FemBlock (n=105) Group 2: IABlock (n=88) P value Sex, n  Male 38 27 0.42  Female 67 61 Age, mean ± SD, y 33.4 ± 13.02 31.3 ± 14.05 0.29 Smoking history, n 0.66  Yes 28 26  No 77 62 Workers Compensation, n 0.24  Yes 4 1  No 101 67 History of Chronic Pain, n 0.35  Yes 4 6  No 101 82 Table 2 Outcomes Group 1: FemBlock (n=105) Group 2: IA Block(n=88) P Value Preoperative Preoperative pain, mean ± SD 3.54 ± 2.69 3.69 ± 2.43 0.69 Intraoperative Total Dose of Dilaudid, mean ± SD, mg 0.18 ± 0.33 0.22 ± 0.37 0.40 Postoperative Pain on PACU Arrival 4.59 ± 2.85 6.16 ± 2.56 <0.01* Pain at Discharge 3.55 ± 2.26 4.28 ± 3.13 0.03* Pain at 1 week 3.05 ± 2.18 2.75 ± 2.16 0.34 Pain at 3 weeks 1.96 ± 2.13 1.82 ± 2.07 0.64 Pain at 6 weeks 1.70 ± 2.09 1.59 ± 1.95 0.7 Reported a fall, n 19 5 <0.01* Developed Peripheral Neuritis, n 26 2 <0.01*