Frequently, patients indicated for total hip arthroplasty (THA) present with low back pain (LBP) and hip pain. The purpose of this study was to compare patients whose back pain resolved after THA ...with those where back pain did not resolve and identify how to predict this using spinopelvic parameters.
We reviewed a series of 500 patients who underwent THA for unilateral hip osteoarthritis by 2 surgeons. Patients underwent biplanar standing and sitting EOS radiographs pre-operatively. Patients with previous spine surgery or femoral neck fracture were excluded. Demographic data was analyzed at baseline. The Oswestry Disability Index (ODI) scores were calculated pre-operatively and at 1 year postoperatively. Spinopelvic parameters included, pelvic incidence and sacral slope (SS) change from standing to sitting.
Two hundred and four patients (41%) had documented LBP before THA. The Oswestry Disability Index (ODI) for patients improved from 38.9 ± 17.8 pre-operatively to 17.0 ± 10.6 at 1 year post-operatively (P < .001). At 1- and 2-year follow-up, resolution of back pain occurred in 168 (82.4%) and 187 (91.2%) patients, respectively. Pelvic incidence was not predictive of back pain resolution. All patients whose back pain resolved had a sacral slope change from standing to sitting of >10°, while those patients whose back pain did not resolve had a change of <10°.
This study demonstrates that symptomatic low back pain (LBP) resolves in 82% of patients after THA. The results of this study may be used to counsel patients on back pain and its resolution following total hip replacement.
Purpose
Single position surgery has demonstrated to reduce hospital length of stay, operative times, blood loss, postoperative pain, ileus, and complications. ALIF and LLIF surgeries offer advantages ...of placing large interbody devices under direct compression and can be performed by a minimally invasive approach in the lateral position. Furthermore, simultaneous access to the anterior and posterior column is possible in the lateral position without the need for patient repositioning. The purpose of this study is to outline the anatomical and technical considerations for performing anterior lumbar interbody fusion (ALIF) in the lateral decubitus position.
Methods
Surgical technique and technical considerations for reconstruction of the anterior column in the lateral position by ALIF at the L4-5 and L5-S1 levels.
Results
Topics outlined in this review include: Operating room layout and patient positioning; surgical anatomy and approach; vessel mobilization and retractor placement for L4-5 and L5-S1 lateral ALIF exposure, in addition to comparative technique of disc space preparation, trialing and implant placement compared to the supine ALIF procedure.
Conclusions
Anterior exposure performed in the lateral decubitus position allows safe-, minimally invasive access and implant placement in ALIF. The approach requires less peritoneal and vessel retraction than in a supine position, in addition to allowing simultaneous access to the anterior and posterior columns when performing 360° Anterior–Posterior fusion.
Aim
This study investigated the prevalence of scoliosis in a large, population‐based cohort of individuals with cerebral palsy (CP) at skeletal maturity to identify associated risk factors that may ...inform scoliosis surveillance.
Methods
Young people with CP born between 1990 and 1992 were reviewed through routine orthopaedic review or a transition clinic. Classification of CP was recorded by movement disorder, distribution, gross and fine motor function. Clinical examination was undertaken and those with clinical evidence of scoliosis or risk factors had radiographs of the spine. Scoliosis severity was measured and categorised by Cobb angle.
Results
Two hundred and ninety‐two individuals were evaluated (78% of the birth cohort) at a mean age of 21 years, 4 months (range 16–29 years). Scoliosis (Cobb angle >10°) was found in 41%, with strong associations to the Gross Motor Function Classification System (GMFCS), Manual Abilities Classification System (MACS) and dystonic/mixed movement disorders. Those at GMFCS V were 23.4 times (95%CI 9.9–55.6) more likely to develop scoliosis than those at GMFCS I. Severe curves (Cobb >40°, 13% of the cohort) were found almost exclusively in those functioning at GMFCS IV and V, and were 18.2 times (95%CI 6.9–48.5) more likely to occur in those with dystonia than those with spasticity.
Conclusions
Scoliosis was very common in young people with CP, with prevalence and severity strongly associated with GMFCS and MACS level and dystonic movement disorder. Severe curves were almost exclusively found in non‐ambulant children. Clinical screening for scoliosis should occur for all children with CP, with radiographic surveillance focusing on those functioning at GMFCS IV and V.
The advantages of lateral single position surgery (LSPS) in the perioperative period has previously been demonstrated, however 2-year postoperative outcomes of this novel technique have not yet been ...compared to circumferential anterior-posterior fusion (FLIP) at 2-years postoperatively.
Evaluate the safety and efficacy of LSPS versus gold-standard FLIP
Multicenter retrospective cohort review.
Four hundred forty-two patients undergoing lumbar fusion via LSPS or FLIP
Levels fused, operative time, estimated blood loss, perioperative complications, and reasons for reoperation at 30-days, 90-days, 1-year, and 2-years. Radiographic outcomes included lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), PI-LL mismatch, and segmental lumbar lordosis.
Patients were grouped as LSPS if anterior and posterior portions of the procedure were performed in the lateral decubitus position, and FLIP if patients were repositioned from supine or lateral to prone position for the posterior portion of the procedure under the same anesthetic. Groups were compared in terms of demographics, intraoperative, perioperative and radiological outcomes, complications and reoperations up to 2-years follow-up. Measures were compared using independent samples or paired t-tests and chi-squared analyses with significance set at p<.05.
Four hundred forty-two patients met inclusion, including 352 LSPS and 90 FLIP patients. Significant differences were noted in age (62.4 vs 56.9; p≤.001) and smoking status (7% vs 16%; p=.023) between the LSPS and FLIP groups. LSPS demonstrated significantly lower Op time (97.7min vs 297.0 min; p<.001), fluoro dose (36.5mGy vs 78.8mGy; p<.001), EBL (88.8mL vs 270.0mL; p<.001), and LOS (1.91 days vs 3.61 days; p<.001) compared to FLIP. LSPS also demonstrated significantly fewer post-op complications than FLIP (21.9% vs 34.4%; p=.013), specifically regarding rates of ileus (0.0% vs 5.6%; p<.001). No differences in reoperation were noted at 30-day (1.7%LSPS vs 4.4%FLIP, p=.125), 90-day (5.1%LSPS vs 5.6%FLIP, p=.795) or 2-year follow-up (9.7%LSPS vs 12.2% FLIP; p=.441). LSPS group had a significantly lower preoperative PI-LL (4.1° LSPS vs 8.6°FLIP, p=.018), and a significantly greater postoperative LL (56.6° vs 51.8°, p = .006). No significant differences were noted in rates of fusion (94.3% LSPS vs 97.8% FLIP; p=.266) or subsidence (6.9% LSPS vs 12.2% FLIP; p=.260).
LSPS and circumferential fusions have similar outcomes at 2-years post-operatively, while reducing perioperative complications, improving perioperative efficiency and safety.
Purpose
This study compares perioperative and 1-year outcomes of lateral decubitus single position circumferential fusion (L-SPS) versus minimally invasive transforaminal lumbar interbody fusion (MIS ...TLIF) for degenerative pathologies.
Methods
Multicenter retrospective chart review of patients undergoing AP fusion with L-SPS or MIS TLIF. Demographics and clinical and radiographic outcomes were compared using independent samples t tests and chi-squared analyses with significance set at
p
< 0.05.
Results
A total of 445 patients were included: 353 L-SPS, 92 MIS TLIF. The L-SPS cohort was significantly older with fewer diabetics and more levels fused. The L-SPS cohort had significantly shorter operative time, blood loss, radiation dosage, and length of stay compared to MIS TLIF. 1-year follow-up showed that the L-SPS cohort had higher rates of fusion (97.87% vs. 81.11%;
p
= 0.006) and lower rates of subsidence (6.38% vs. 38.46%;
p
< 0.001) compared with MIS TLIF. There were significantly fewer returns to the OR within 1 year for early mechanical failures with L-SPS (0.0% vs. 5.4%;
p
< 0.001). 1-year radiographic outcomes revealed that the L-SPS cohort had a greater LL (56.6 ± 12.5 vs. 51.1 ± 15.9;
p
= 0.004), smaller PI-LL mismatch (0.2 ± 13.0 vs. 5.5 ± 10.5;
p
= 0.004). There were no significant differences in amount of change in VAS scores between cohorts.
Similar results were seen after propensity-matched analysis and sub-analysis of cases including L5-S1.
Conclusions
L-SPS improves perioperative outcomes and does not compromise clinical or radiographic results at 1-year follow-up compared with MIS TLIF. There may be decreased rates of early mechanical failure with L-SPS.
STUDY DESIGN.Retrospective cohort study.
OBJECTIVE.Assess trends in sports-related cervical spine trauma using a pediatric inpatient database.
SUMMARY OF BACKGROUND DATA.Injuries sustained from ...sports participation may include cervical spine trauma such as fractures and spinal cord injury (SCI). Large database studies analyzing sports-related cervical trauma in the pediatric population are currently lacking.
METHODS.The Kid Inpatient Database was queried for patients with external causes of injury secondary to sports-related activities from 2003 to 2012. Patients were further grouped for cervical spine injury (CSI) type, including C1–4 and C5–7 fracture with/without spinal cord injury (SCI), dislocation, and SCI without radiographic abnormality (SCIWORA). Patients were grouped by age into children (4–9), pre-adolescents (Pre, 10–13), and adolescents (14–17). Kruskall-Wallis tests with post-hoc Mann-Whitney Uʼs identified differences in CSI type across age groups and sport type. Logistic regression found predictors of TBI and specific cervical injuries.
RESULTS.A total of 38,539 patients were identified (12.76 years, 24.5% F). Adolescents had the highest rate of sports injuries per year (P < 0.001). Adolescents had the highest rate of any type of CSI, including C1–4 and C5–7 fracture with and without SCI, dislocation, and SCIWORA (all P < 0.001). Adolescence increased odds for C1-4 fracture w/o SCI 3.18×, C1-4 fx w/ SCI by 7.57×, C5-7 fx w/o SCI 4.11×, C5-7 w/SCI 3.63×, cervical dislocation 1.7×, and cervical SCIWORA 2.75×, all P < 0.05. Football injuries rose from 5.83% in 2009 to 9.14% in 2012 (P < 0.001), and were associated with more SCIWORA (1.6% vs. 1.0%, P = 0.012), and football injuries increased odds of SCI by 1.56×. Concurrent TBI was highest in adolescents at 58.4% (pre26.6%, child4.9%, P < 0.001), and SCIWORA was a significant predictor for concurrent TBI across all sports (odds ratio2.35 1.77–3.11, P < 0.001).
CONCLUSION.Adolescent athletes had the highest rates of upper/lower cervical fracture, dislocation, and SCIWORA. Adolescence and SCIWORA were significant predictors of concurrent TBI across sports. The increased prevalence of CSI with age sheds light on the growing concern for youth sports played at a competitive level, and supports recently updated regulations aimed at decreasing youth athletic injuries.Level of Evidence3
STUDY DESIGN.Retrospective review of a prospective multicenter database.
OBJECTIVE.The aim of this study was to study the effects of thoracic kyphosis (TK) restoration in adolescent idiopathic ...scoliosis (AIS) Type 1 and 2 curves on postoperative thoracic volume (TV) and pulmonary function.
SUMMARY OF BACKGROUND DATA.Surgical correction of AIS is advocated to preserve or improve pulmonary function, prevent progressive deformity and pain, and improve self-appearance. Restoration of sagittal and 3D alignment, particularly TK, has become increasingly emphasized in efforts to improve pulmonary function, TVs, sagittal balance, and prevent adjacent-segment degeneration and deformity.
METHODS.AIS patients 10 to 21years undergoing surgical correction of Lenke Type 1 and 2 curves with baseline, 1-erect-postoperative, and 5-year (5Y) postoperative visits including stereoradiographic assessment and pulmonary function tests (PFTs) were included. 3D-radiographic analysis was performed to assess spinal-alignment, chest-wall, and rib-cage dimensions at each time point. Outcome variables were analyzed between time points with one-way analysis of variance and between variables with linear regression analysis.
RESULTS.Thirty-nine patients (37 females, 14.4 ± 2.2 years) were included. 3D-spinal-alignment analyses demonstrated significant reduction in preoperative to first-erect thoracic and lumbar Cobb-angles, an increase in TK:T2–12 (19.67°–39.69°) and TK:T5–12 (9.47°–28.05°), and reduction in apical vertebral rotation (AVR) (P < 0.001 for all). Spinal-alignment remained stable from 1-erect to 5Y. 3D rib-cage analysis demonstrated small reductions in baseline to first-erect depth (145–139 mm), width (235–232 mm), and increase in height (219–230 mm, P < 0.01), but no significant change in volume (5161–5222 cm,P = 0.184). From 1-erect to 5Y, significant increases in depth, width, height, and volume (all P < 0.001) occurred. PFTs showed preoperative to 5Y improvement in first second of Forced Expiratory Volume (FEV1) (2.74–2.98 L, P = 0.005) and forced vital capacity (FVC) (3.23–3.47 L, P = 0.008); however, total lung capacity (TLC) did not change (P = 0.517). Percent-predicted TLC decreased (Pre101.3% to 5Y89.3%, P < 0.001); however, percent-predicted forced expiratory volume and FVC did not (P = 0.112 and P = 0.068).
CONCLUSION.Although TK increases, coronal-Cobb and AVR decrease postoperatively; these do not directly influence TV, which increases from 1-erect to 5Y due to growth, corresponding with increases in FEV1 and FVC at 5Y; however, surgical restoration of kyphosis does not directly improve pulmonary function.Level of Evidence3
STUDY DESIGN.A retrospective cohort study from a single institution.
OBJECTIVE.The aim of this study was to assess the thresholds for postoperative opioid consumption, which are predictive of ...continued long-term opioid dependence.
SUMMARY OF BACKGROUND DATA.The specific sum total of inpatient opioid consumption as a risk factor for long-term use after transforaminal lumbar interbody fusion (TLIF) has not been previously studied.
METHODS.Charts of patients who underwent a one, two, or three-level primary TLIF between 2014 and 2017 were reviewed. Total morphine milligram equivalents (MME) consumed was tabulated and separated into three categories based on ROC curve analysis of opioid utilization at 6-month follow-up. Multivariate binary regression analysis assessed these MME dosage categories. A further subanalysis grouped patients on the basis of whether they had used opioids preoperatively.
RESULTS.One hundred seventy-two patients met the inclusion criteria and were separated into groups who received less than 250 total inpatient MME (44%), between 250 and 500 total inpatient MME (26%), and greater than 500 total inpatient MME (27%). Patients undergoing a TLIF who received <250 total MME in the immediate postoperative period had a 3.73 (odds ratio) times smaller probability of requiring opioids at 6-month follow-up P = 0.027, 95% confidence interval (95% CI) 0.084–0.86. Patients who received >500 total MME had a 4.84 times greater probability (P = 0.002, 95% CI 1.8–13) of requiring opioids at 6-month follow-up. A subanalysis demonstrated individuals with preoperative opioid use who received <250 total MME had a 7.09 times smaller probability (P = 0.033, 95% CI 0.023–0.85) of requiring opioids at 6-month follow-up while those who received >500 total MME had a 5.43 times greater probability (P = 0.033, 95% CI 1.6–18) of requiring opioids at 6-month follow-up.
CONCLUSION.Exceeding the threshold of 500 total MMEs in the immediate postoperative period after a TLIF is a significant risk factor that predicts continued opioid use at 6-month follow-up, particularly among patients with a history of preoperative opioid utilization.Level of Evidence3
Study Design.
Retrospective cohort analysis.
Objective.
To compare outcomes of plastic
versus
spine surgeon wound closure in revision 1 to 4 level thoracolumbar fusions.
Summary of Background Data.
...Plastic surgeons perform layered musculocutaneous flap closures in high-risk spine patients such as revision posterior spinal fusion and complex deformity correction surgeries. Few studies have assessed outcomes of revision fusion performed with plastic surgical closures, particularly in nondeformity thoracolumbar spinal surgery.
Methods.
A retrospective review of 1 to 4 level revision thoracolumbar fusion performed by Orthopedic or Neurosurgical spine surgeons. Patient charts were reviewed for demographics and perioperative outcomes. Patients were divided into two cohorts: wound closures performed by spine surgeons and those closed by plastic surgeons. Outcomes were analyzed before and after propensity score match for prior levels fused, iliac fixation, and levels fused at index surgery. Significance was set at
P
< 0.05.
Results.
Three hundred fifty-seven (87.3%) spine surgeon (SS) and 52 (12.7%) plastic surgeon (PS) closures were identified. PS group had significantly higher number of levels fused at index (PS 2.7 ± 1.0
vs.
SS 1.8 ± 0.9,
P
< 0.001) and at prior surgeries (PS 1.8 ± 1.2
vs.
SS 1.0 ± 0.9,
P
< 0.001), and rate of iliac instrumentation (PS 17.3%
vs.
SS 2.8%,
P
< 0.001). Plastics closure was an independent risk factor for length of stay > 5 days (odds ratio 2.3) and postoperative seroma formation (odds ratio 7.8). After propensity score match, PS had higher rates of seromas (PS 36.5%
vs.
SS 3.8%,
P
< 0.001). There were no differences between PS and SS groups in surgical outcomes, perioperative complication, surgical site infection, seroma requiring aspiration, or return to operating room at all time points until follow-up (
P
> 0.05 for all).
Conclusion.
Plastic spinal closure for 1 to 4 level revision posterior thoracolumbar fusions had no advantage in reducing wound complications over spine surgeon closure but increased postoperative seroma formation.
Level of Evidence:
4
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