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Vrbos, Lori A.; Lorenz, Mark A.; Peabody, E. H.; McGregor, Marion
doi: N/Apmid: N/A
An analysis of 300 randomly drawn orthopaedic spine articles, published between 1970 and 1990, was performed to assess the quality of biostatistical testing and research design reported in the literature. Of the 300 articles, 269 dealt with topics of an experimental nature, while 31 documented descriptive studies. Statistical deficiencies were identified in 54.0% of the total articles. Conclusions drawn as the result of misleading significance values occurred in 124 experimental studies (46%) while 96 failed to document the form of analysis chosen (35.7%). Statistical testing was not documented in 34 studies (12.6%), while 20 (7.4%) employed analyses considered inappropriate for the specific design structure.
Lehmann, Thomas R.; Spratt, Kevin F.; Lehmann, Kathryn K.
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Low back pain (LBP) is the most common, costly, and disabling muscoloskeletal condition. Although most LBP patients recover within two months, 2–3% eventually develop disabling chronic low back pain (DCLBP). Due to the prevalence of DCLBP problems, models have been developed to predict which acute low back pain patients are predisposed to the problems associated with this condition. Many see the development of these models as a first step that must be taken before useful approaches for containing and reducing the problem can be conceptualized, implemented, and tested. A recent publication by Cats-Baril and Frymoyer6considered this specific problem. While the results of their study indicate considerable success in predicting DCLBP patients, the high prediction rates they obtained may be spurious because of the characteristios of their sampled patient population in conjunction with some of the predictors they found useful in identifying DCLBP patients. The purpose of the present study was to focus on the crucial patient population (i.e., acute LBP patients who perceive their problem as work-related and who have been unable to work for more than two but less than six weeks), and evaluate the ability of various personal, medical, occupational, and psychological factors to predict predisposition to DCLBP. Fifty-five patients referred by occupational physicians were evaluated and followed successfully for at least 6 months. Patients in the study were given a physical examination that included Spratt et al's assessment of pain behavior24They were then asked to fill out an extensive battery of self-report questionnaires, addressing issues associated with personal demographics, health history, work requirements, job satisfaction, injury information, and pain/function factors. At the 6-month follow-up, a structured telephone interview was used to obtain outcome information regarding patient status, including ability to return to work and general outcomes of treatment. Average patient age was 37.2 years (range, 22–57) and 67% of the patients were male. On average, patients had been unable to work for approximately 4 weeks when initially surveyed. Overall, 12.7% of the patients returned to work within 1 month of injury, 40% returned within 2 months, 54.5% within 3 months, 69% within 4 months, 74.5% within 5 months, 76.3% within 6 months, 80% within 7 months, and 83.6% after 7 months. Approximately 16% never successfully returned to work within the follow-up period of this study. DCLBP was found to be correlated only with marital status, as married patients returned to work more quickly than single patients (P< 0.01). No significant correlation was found between DCLBP and personal demographics, health factors, work-related variables, or pain and function variables. Explanations for the overall inability to predict accurately the recovery times and/or rates of long-term disability in this patient population are suggested. When isolating realistic cases where predicting which patients presenting with acute low back troubles are likely to become chronic cases, the optimal prediction equation would appear to be: Perception that low back trouble is work-related + absence from work for more than 2 weeks = High Risk Case.
Ferree, Bret A.; Wright, Alexander M.
doi: N/Apmid: N/A
Postoperative duplex scans were performed on 185 patients undergoing posterior lumbar spinal surgery in order to identify deep venous thrombosis (DVT). Elastic compression stockings were used for prophylaxis in 74 patients (Group E,S,); Intermittent pneumatic compression was used in the remaining 111 patients (Group P.C.). High-risk patients were not eliminated from either group. Laminectomy was performed on 84 patients (40 from Group E.S. and 44 from Group P.C.). and spinal fusion, on 101 patients (34 from Group E.S. and 67 from Group P.C.). A total of four patients, all from Group E.S., developed acute postoperative DVT. Intermittent pneumatic compression significantly reduced the incidence of acute postoperative DVT (P< 0.05). No statistically significant differences were found in the incidence of DVT in relation to the type of spinal procedure, length of procedure, duration of bed rest, or age of the patient, In conclusion, considering the low rate of DVT (2%) following posterior lumbar surgery and the potential complications of prophylactic anticoagulation, we continue to use intermittent pneumatic compression rather than elastic stockings for prophylaxis.
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One hundred, twenty-four patients undergoing lumbar or lumbosacral for degenerative conditions were entered into a prospective study. The patients were randomly assigned to one of three treatment groups. Group I underwent posterolateral fusion using autogenous bone graft. Group II had autogenous posterolateral fusions supplemented by a semi-rigid pedicle screw/plate fixation system (Luque II; Danek Medical, Memphis, Tannessee). Group III patients underwant posterolateral autogenous fusion with a rigid pedicle screw/rod fixation system (Texas Scottish Rite Hospital [TSRH]-Danek Medical, Memphis, Tennessee). All the patients were operated on by the same surgeon, Identical bone grafting technique was used in all, and all were treated in an identical fashion postoparatively. Fusion status was determined from the anteroposterior, oblique, and flexion-extension radiographs obtained at 1 year. Clinical results were rated as excellent if the patients were pain-free and had returned to work; good if the patients had mild backache requiring non-narcotic analgesics and had returned to work; fair if continuing back pain prevented a return to work; or poor if the pain was worse than that which the patient experienced preoperatively or the patient required revision surgery.
Vanharanta, Heikki ; Floyd, Timothy ; Ohnmeiss, Donna D.; Hochschuler, Stephen H.; Guyer, Richard D.
doi: N/Apmid: N/A
The role of facet tropism (asymmetry) in the pathogenesis of degenerative disc disease is unknown, and several conflicting reports have been published. We studied this association using CT/discography performed at 324 lumbar levels (108 patients). The stage of disc degeneration as well as the patient's pain response upon discographic injection were scored using a standardized protocol. The facet angles were measured directly from the axial CT/discographic images and defined, in each case, as the angle formed by the facet orientation with respect to the midsagitial plane. The facet tropism angle was defined as the difference between the left and right facet angles at each disc level. The mean and standard deviation (SD) of the tropism angles were calculated. From this calculation, each pair of facet joints was classified as symmetric (within 1 SD of the mean), moderately asymmetric (between 1 and 2 SD), or severely asymmetric (beyond 2 SD of the mean). There were no differences in degree of disc degeneration or pain response with respect to the facet tropism. The total facet angle was also studied. The total facet angle was greater at the more caudal levels. The total angle size was not associated, however, with disc degeneration or pain pravooation. These findings do not support the hypothesis that there is an association between facet tropism and degenerative lumbar disc disease.
Beaman, Douglas N.; Graziano, Gregory P.; Glover, Roy A.; Wojtys, Edward M.; Chang, Virginia
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Sixteen adult human lumbar spine facet joints were harvested from patients undergoing various lumbar spine procedures. Diagnoses included degenerative disc disease, adult spinal deformity, facet joint degenerative arthritis, and degenerative spondyiolisthasis. Facet joints were processed for routine hematoxylin and eosin staining. Immunohistochemical analysis was performed using a monoclonal antibody to substance P. All facets grossly exhibited evidence of degenerative disease, including cartilage surface irregularity and fibrillation. Histological examination of facets obtained from patients with degenerative spinal conditions demonstrated erosion channels extending through the subchondral bone and calcified cartilage into the articular cartilage. Immunostaining showed the presence of substance P-positive nerve fibers within these erosion channels, and also within marrow spaces. The presence of substance P nerve fibers within subchondral bone of degenerative lumbar facet joints implicates this type of joint in the etiology of low back pain.
Albert, Todd J.; Desai, Darius ; McIntosh, Theresa ; Lamb, David ; Balderston, Richard A.
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The use of autologous blood is a well established and extremely popular technique to decrease the necessity for homologous transfusions and the attendant risks of hepatitis, HIV, and HTLV–I/II infections. The most beneficial timing for autologous reinfusion of predonated blood remains unknown. The present study was undertaken to determine the optimal timing of autologous blood reinfusion in elective spinal surgery. Fifty-seven patients were prospectively individually rendomly allocated into early versus delayed reinfusion groups prior to undergoing elective spinal surgery by a single surgeon. Three surgical aubgroups were entered into the study: anterior/posterior (A/P) spinal fusion patients, posterior thoracolumbar scoliosis fusion patients (PSF), and degenerative posterior lumbar fusion patients (LF). Randomization was successful in that there was no significant difference in male to female ratio, age, preoperative hemoglobin, or number of units predonated between the early and delayed reinfusion groups. Likewise, there was no significant difference in the details of the operative procedure when compared as a group for the early versus delayed reinfusion groups. A significant increase in the postoperative day #1, 2 and 3 hemoglobin was seen in the early reinfusion group, while there was no significant difference seen in the postoperative day #7 hemoglobin between the early versus delayed reinfusion group. There was no effect of surgical grouping on these significant comparisons. Earliar patient mobilization was also seen in the early reinfusion groups for the A/P and PSF groups. There was no difference in patients' subjective evaluation of satisfaction and discomfort between the early or delayed reinfusion groups as determined by blinded interview on days 1, 3, 5, and 7 postoperatively. Only the PSF patients in the early reinfusion group reported significantly higher pain scores on postoperative day #3 which may correlate with their earlier ambulation (mean = 2.3 days). There was no difference in the nutritional parameters measured preoperatively or on postoperative day #7 between the early and delayed reinfusion groups, though all nutritional parameters were decreased on postoperative day #7 as is common in postoperative surgical patients. A significant increase was noted in the reticulocyte count obtained on postoperative day 7 in the early reinfusion patients. This study demonstrates beneficial effects of early (on the day of operation) reinfusion of predonated autologous blood. The prevention of early postoperative anemia and the potential for earlier ambulation suggest that earlier reinfusion of autologous blood is prudent. Furthermore, no detrimental effects of early autologous reinfusion were demonstrated. Further studies are needed to better determine the optimal hemoglobin level to which patients should be titrated after elective spinal surgery.
Glassman, Steven D.; Shields, Christopher B.; Linden, R. Dean; Zhang, Y. Ping; Nixon, Alexander R.; Johnson, John R.
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The effects of the various anesthetic agents on the production of transcranial magnetic motor evoked potentials (tcMMEP) were studied in a canine model. Pre-anesthetic baseline tcMMEPs demonstrated consistency in onset latency measurements and variability in measurement of peak-to-peak amplitudes. Changes in tcMMEPs were evaluated following the individual administrations of sodium pentothal, etomidate, halothane, fentanyl, and ketamine. For induction of anesthesia, etomidate was compatible with tcMMEP production, whereas sodium pentothal resulted in loss of hindlimb potentials for a period of 45 minutes. For maintenance of anesthesia, halothane was incompatible with the measurement of tcMMEPs. Fentanyl administration was consistent with the recording of reliable tcMMEPs, with consistent onset latencies but widely variable peak-to-peak amplitudes. Ketamine was compatible with stable and reproducible tcMMEP production. The results of this study suggest that anesthetic agents have a predictable and consistent effect on tcMMEP responses.
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