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Study Design: Retrospective study.Objective: Compare outcomes of different treatment methods for intraspinal synovial cysts.Summary Of Background Data: Intraspinal synovial cysts are cited as an increasing cause of back pain and radiculopathy. To date, few studies have compared outcomes of differing treatment methods in patients with synovial cysts.Methods: We retrospectively reviewed 167 consecutive patients undergoing surgical management of 195 symptomatic synovial cysts at a single institution over 19 years. The incidence of postoperative mechanical back pain, radiculopathy, and cyst recurrence was compared between patients undergoing unilateral hemilaminectomy (n = 51), bilateral laminectomy (n = 39), facetectomy with in situ fusion (n = 18), and facetectomy with instrumented fusion (n = 56).Results: A total of 155 (97.5%) patients presented with radiculopathy, 132(82.5%) with mechanical back pain, 31 (20%) with neurogenic claudication, and 5 (3.2%) with bladder dysfunction. Most cysts occurred in the lumbar spine. After surgery, back and radicular pain improved in 91.6% and 91.9% patients, respectively. By a mean follow-up of 16 +/- 9 months, 36 (21.6%) patients developed recurrent back pain, 20 (11.8%) recurrent leg pain, and 5 (3%) recurrent synovial cysts. Patients undergoing laminectomy had a significantly increased cyst recurrence incidence compared to fusion groups via log-rank test (P = 0.042), and this risk was decreased to baseline with instrumented fusion on reoperation. Laminectomy was also associated with the highest increased risk of recurrent back pain in both log-rank test (P = 0.018) and proportional hazards regression (HR): 1.64 (1.00-3.45), P = 0.05. Instrumented fusion had the lowest risk for back pain recurrence.Conclusion: Hemilaminectomy or laminectomy remains one of the mainstay surgical treatments for symptomatic intraspinal synovial cysts. Our experience shows that the majority of patients undergoing decompression/excision of synovial cysts will have immediate improvement in back and leg pain. However, within 2 years, patients receiving hemilaminectomy or laminectomy alone have an increased incidence of back pain and cyst recurrence. Decompression with instrumented fusion appears to be associated with the lowest incidences of cyst recurrence or back pain. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective study. Objective: To assess the utility of postoperative radiographs in patients across a spectrum of cervical fusion procedures, surgical indication, and time since surgery. Summary Of Background Data: Postoperative radiographs are routinely obtained after cervical spine fusion despite lack of evidence supporting such practice. Studies assessing postoperative radiographical utility in the cervical spine have been limited. To date, no study has comprehensively evaluated the utility of obtaining such radiographs across multiple cervical fusion procedures. Methods: A total of 972 clinic notes from 301 patients during a 10-year period at a single institution were retrospectively reviewed. Patients in this study underwent an anterior cervical discectomy and fusion, anterior corpectomy and fusion, a combined anterior cervical discectomy and fusion and anterior corpectomy and fusion (hybrid), posterior spine fusion, or 360° fusion. All postoperative clinic notes and radiographs were reviewed for abnormalities and changes in treatment course. It was determined whether an abnormal radiograph alone led to a change in treatment course among the various operative techniques, surgical indication, or time since surgery. Results: No statistical significant difference in radiograph utility between anterior cervical discectomy and fusion (0 changes in treatment course due to radiograph alone out of 332 clinic notes), anterior corpectomy and fusion (0 of 140), hybrid procedure (1 of 72), posterior spine fusion (5 of 357), and 360° fusion (0 of 71) was found. Surgical indication (trauma vs. degeneration) and duration from surgery yielded no statistical significant difference in radiograph utility. The overall sensitivity, specificity, and positive and negative predictive values of radiographs were 33.8%, 87.6%, 19.0%, and 93.9%, respectively. Conclusion: Regardless of operative techniques performed, surgical indication, and time since surgery, routine postoperative radiographs provide low utility in guiding treatment course in asymptomatic patients. Although radiographs may provide important diagnostic utility in certain individual cases, the results of this study provide further evidence that radiographs should not be considered routine during postoperative visits, thus minimizing unnecessary radiation exposure and medical costs. [ABSTRACT FROM AUTHOR]

STUDY DESIGN.: Prospective study. OBJECTIVE.: Assess the contamination rates of sterile microscope drapes after spine surgery. SUMMARY OF BACKGROUND DATA.: The use of the operating microscope has become more prevalent in certain spine procedures, providing superior magnification, visualization, and illumination of the operative field. However, it may represent an additional source of bacterial contamination and increase the risk of developing a postoperative infection. METHODS.: This study included 25 surgical spine cases performed by a single spine surgeon that required the use of the operative microscope. Sterile culture swabs were used to obtain samples from 7 defined locations on the microscope drape after its use during the operation. The undraped technician's console was sampled in each case as a positive control, and an additional 25 microscope drapes were swabbed immediately after they were applied to the microscope to obtain negative controls. Swab samples were assessed for bacterial growth on 5% sheep blood Columbia agar plates using a semiquantitative technique. RESULTS.: No growth was observed on any of the 25 negative control drapes. In contrast, 100% of preoperative and 96% of postoperative positive controls demonstrated obvious contamination. In the postoperative group, all 7 sites of evaluation were found to be contaminated with rates of 12% to 44%. Four of the 7 evaluated locations were found to have significant contamination rates compared with negative controls, including the shafts of the optic eyepieces on the main surgeon side (24%, P = 0.022), 'forehead' portion on both the main surgeon (24%, P = 0.022) and assistant sides (28%, P = 0.010), and 'overhead' portion of the drape (44%, P = 0.0002). CONCLUSION.: Bacterial contamination of the operative microscope was found to be significant after spine surgery. Contamination was more common around the optic eyepieces, likely due to inadvertent touching of unsterile portions. Similarly, all regions above the eyepieces also have a propensity for contamination because of unknown contact with unsterile parts of the surgeon. Therefore, we believe that changing gloves after making adjustments to the optic eyepieces and avoid handling any portion of the drape above the eyepieces may decrease the risks of intraoperative contamination and possibly postoperative infection as well. [ABSTRACT FROM AUTHOR]

Study Design: This is a prospective cohort study with serial imaging. Objective: We set out to determine the incidence of symptomatic and asymptomatic same-level recurrent disc herniation and assess their effect on 2-year outcome. Summary Of Background Data: The reported incidence of symptomatic same-level recurrent disc herniation after lumbar discectomy varies widely in retrospective studies. To date, the incidence of radiographic same-level recurrent disc herniation has not been studied prospectively with sequential imaging. Furthermore, the clinical relevance of recurrent disc herniation on magnetic resonance imaging (MRI) after discectomy remains unknown, particularly in patients with poorly specific pain after surgery. Methods: One hundred eight patients undergoing lumbar discectomy for a single-level herniated disc at five institutions were prospectively observed for 2 years. Computed tomography (CT) and MRI of the lumbar spine were obtained every 3 months to assess reherniation and disc height loss. Leg and back pain visual analog scale (VAS), Oswestry Disability Index (ODI), and quality of life (SF-36 physical component) were assessed 3, 6, 12, and 24 months after surgery. Results: No patients demonstrated residual disc on postoperative MRI. By 2 years after discectomy, 25 (23.1%) patients had demonstrated radiographic evidence of recurrent disc herniation at the level of prior discectomy on serial imaging (mean ± SD, 11.8 ± 8.3 months after surgery). Radiographic disc herniation was asymptomatic in 14 (13%) patients and symptomatic in 11 (10.2%) patients. The occurrence of symptomatic recurrent disc herniation was associated with worse 2-year leg pain (VAS-LP, P=0.002) and disability (ODI, P=0.036) but not quality of life (SF-36) or disc height loss. The occurrence of asymptomatic reherniation was not associated with disc height loss or any outcome measure (VAS, ODI, and SF-36) by 2 years. Conclusion: Nearly one-fourth of patients undergoing lumbar discectomy demonstrated radiographic evidence of recurrent disc herniation at the level of prior surgery, the majority of which were asymptomatic. Asymptomatic disc herniation was not associated with clinical consequences by 2 years. Clinically silent recurrent disc herniation is common after lumbar discectomy. When obtaining MRI evaluation within the first 2 years of discectomy, providers should expect that radiographic evidence of reherniation may be encountered and that treatment should be considered only when correlating radicular symptoms exist. [ABSTRACT FROM AUTHOR]

STUDY DESIGN.: We conducted a retrospective, case control study on patients undergoing surgery for spinal tumors. OBJECTIVE.: Our aim was to determine the incidence and to identify risk factors for surgical site infections (SSIs) in patients undergoing surgery for spinal tumors. SUMMARY OF BACKGROUND DATA.: SSIs after spinal tumor surgery may be particularly devastating as they may add to substantial surgical morbidity and may further exacerbate already existing neurologic deficits. Incidence and risk factors predisposing to SSIs in patients undergoing surgery for spinal tumors are not well studied yet. METHODS.: Between January 1995 and February 2008, 971 procedures for spinal tumors were performed on 739 patients. Excluding sacral tumors from the current study, 895 procedures on 678 patients were reviewed to identify those cases with SSIs. Furthermore, 65 infected cases and a randomly selected subset of 162 controls were analyzed by logistic regression modeling to identify the risk factors associated with SSIs. RESULTS.: There were 678 patients that were included in this study with 364 men (54%) and 314 women (46%), with an average age of 47.2 year. Sixty-five patients who developed SSIs underwent a total of 162 procedures including 78 procedures for wound debridement and washout. The incidence of SSIs was 8.89% for primary nonbony spinal tumors, 9.5% for metastatic spinal tumors, and 13.7% for primary bony spinal tumors. Staphylococcus aureus was the most commonly isolated organism (n = 22 of 65, 33%). In the multivariate logistic regression model, previous spinal surgeries, complex plastic closures, increasing number of comorbidities, presence of a hospital acquired infection at the time of a previous surgery, and increasing duration of hospital stay during primary surgery were significantly associated with increased likelihood of developing postoperative SSIs. CONCLUSION.: Surgery for spine tumors appears to be associated with a higher incidence of SSI than nontumor spine surgery. Identification of perioperative risk factors will help delineate this subset of patients with high risk for developing SSIs thus potentially allowing perioperative modification for such factors, which may lead to an overall better clinical outcome and patient satisfaction. [ABSTRACT FROM AUTHOR]

Study Design: Review of historical archival records.Objective: Describe Harvey Cushing's patients with spinal pathology.Summary Of Background Data: Harvey Cushing was a pioneer of modern surgery but his work on spine remains largely unknown.Methods: Review of the Chesney Medical Archives of the Johns Hopkins Hospital from 1896 to 1912.Results: This is the first time that Cushing's spinal cases while he was at the Johns Hopkins Hospital, including those with Pott disease, have been described.Cushing treated three young men with psoas abscesses secondary to Pott disease during his residency: he drained the abscesses, debrided any accompanying necrotic vertebral bodies, irrigated the cavity with salt, and left the incision open to close by secondary intention. Although Cushing used Koch's "tuberculin therapy" (of intravenous administration of isolated tubercular bacilli) in one patient, he did not do so in the other two, likely because of the poor response of this first patient. Later in his tenure, Cushing performed a laminectomy on a patient with kyphosis and paraplegia secondary to Pott disease.Conclusion: These cases provide a view of Cushing early in his career, pointing to the extraordinary degree of independence that he had during his residency under William Steward Halsted; these cases may have been important in the surgical upbringing both of Cushing and his coresident, William Stevenson Baer, who became the first professor of Orthopedics at Johns Hopkins Hospital. At the turn of the last century, Pott disease was primarily treated by immobilization with bed rest, braces, and plaster-of-paris jackets; some surgeons also employed gradual correction of the deformity by hyperextension. Patients who failed a trial of conservative therapy (of months to years) were treated with a laminectomy. However, the limitations of these strategies led to the development of techniques that form the basis of contemporary spine surgery-instrumentation and fusion. [ABSTRACT FROM AUTHOR]

Background Context: With improvements in neurological imaging, there are increasing reports of symptomatic spinal synovial cysts. Surgical excision has been recognized as the definitive treatment for symptomatic juxtafacet cysts. However, the role for concomitant fusion and the incidence of recurrent back pain and recurrent cyst formation after surgery remain unclear.Purpose: To determine the cumulative incidence of postoperative symptomatic relief, recurrent back and leg pain after cyst resection and decompression, and synovial cyst recurrence.Study Design: Systematic review of the literature.Patient Sample: All published studies to date reporting outcomes of synovial cyst excision with and without spinal fusion.Outcome Measures: Cyst recurrence and Kawabata, Macnab, Prolo, or Stauffer pain scales.Methods: We performed a systematic literature review of all articles published between 1970 and 2009 reporting outcomes after surgical management of spinal synovial cysts.Results: Eighty-two published studies encompassing 966 patients were identified and reviewed. Six hundred seventy-two (69.6%) patients presented with radicular pain and 467 (48.3%) with back pain. The most commonly involved spinal level was L4-L5 (75.4%), with only 25 (2.6%) and 12 (1.2%) reported synovial cysts in the cervical or thoracic area, respectively. Eight hundred eleven (84.0%) patients were treated with decompressive surgical excision alone, whereas 155 (16.0%) received additional concomitant spinal fusion. Six hundred fifty-four (92.5%) and 880 (91.1%) patients experienced complete resolution of their back or leg pain after surgery, respectively. By a mean follow-up of 25.4 months, back and leg pain recurred in 155 (21.9%) and 123 (12.7%) patients, respectively. Sixty (6.2%) patients required reoperation, of which the majority (n=47) required fusion for correction of spinal instability and mechanical back pain. Same-level synovial cyst recurrence occurred in 17 (1.8%) patients after decompression alone but has been reported in no (0%) patients after decompression and fusion.Conclusions: Surgical decompression results in symptomatic resolution in the vast majority of patients; however, recurrent back pain occurs in a significant number of patients. Cyst recurrence occurs in less than 2% of patients but has never been reported after cyst excision with concomitant fusion. The lack of cyst recurrence after concomitant fusion supports the need to investigate the value of fusion of the involved motion segment in the treatment of symptomatic synovial cysts of the spine. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective study of 20 consecutive patients who underwent en bloc tumor excision of sacral chordomas and chondrosarcomas.Objective: To evaluate the functional and oncological outcomes following en bloc tumor excision for sacral chordomas and chondrosarcomas.Summary Of Background Data: Chordomas and chondrosarcomas are 2 of the most common malignant primary tumors of the sacrum in adults. To date, few large clinical series with en bloc resection of these tumors exist.Methods: An institutional primary spine tumor surgical database was retrospective reviewed. Twenty consecutive patients with sacral chordomas and chondrosarcomas who underwent primary en bloc tumor excisions from 2002 to 2007 were included in the study. Surgical margin, perioperative complications, and postoperative functional status in these patients were analyzed. Disease-free survival following en bloc tumor excision was determined using the Kaplan-Meier method.Results: The study cohort included 8 males and 12 females with an average age of 53.5 years and a man follow-up of 47.8 months. Wide or marginal en bloc resection was achieved in 14 patients. In 6 other patients, tumor was identified at the surgical margins, and they were considered to have contaminated/intralesional resections. The 30-day perioperative morbidities in this series included 1 death from pulmonary embolism and 9 wound complications. Forty percent of the patients had normal bladder and bowel functions after surgery, while 60% of the patients had partial or complete loss of bladder and bowel functions. All but 2 patients in this group remained ambulatory after the surgery. The mean disease-free survival for patients with wide or marginal en bloc tumor excisions was 51 months, but the mean disease-free survival was only 17.5 months for patients who had contaminated/intralesional resections.Conclusion: Wide or marginal en bloc excision of sacral chordoma and chondrosarcoma is associated with significant improvement in disease-free survival with acceptable perioperative morbidity rate. [ABSTRACT FROM AUTHOR]

STUDY DESIGN.: A prospective cohort study. OBJECTIVE.: To evaluate the effects of epidural steroid injections (ESIs) on blood glucose levels in patients with diabetes mellitus. SUMMARY OF BACKGROUND DATA.: ESIs are commonly used in the treatment of multiple spinal disorders. Corticosteroid injections have been evaluated in the total joints and hand literature showing systemic effects to diabetics. METHODS.: Diabetic patients who were scheduled for an ESI were given an opportunity to enroll in our IRB-approved study. We collected the patient's most recent hemoglobin A1c (hA1c) and then asked them to track their blood glucose numbers at least twice per day for 2 weeks prior to and after their ESIs. RESULTS.: We noted a statistically significant increase in blood glucose levels in diabetic patients (n = 30) after ESI. The mean blood glucose level prior to ESI was 160.18 ± 47.46, and, after ESI, it was 286.13 ± 111.11. This represents an average 125.96 ± 100.97 increase in blood glucose levels after injection. Using a nonlinear mixed effect model, the estimated half-life of this increase was 1.06 days (95% CI 0.80, 1.58), meaning that the patients were back within their normal standard deviation mean glucose levels within 2 days of injection. There was no association between observed glucose level change and preinjection hA1c levels or age (Spearman = 0.0326 and -0.1091 separately), indicating that there is no correlation between preinjection hA1c levels and systemic response to ESI. CONCLUSION.: ESIs were noted to cause a significant increase in the blood glucose levels in diabetics. There was no correlation between preinjection diabetic control, represented by hA1c levels, and postinjection response. Diabetics who are candidates for ESI should be counseled that a blood glucose increase may be apparent post intervention, but effects should not last longer than approximately 2 days. [ABSTRACT FROM AUTHOR]

STUDY DESIGN.: Systematic review. OBJECTIVE.: To identify, describe, and evaluate common outcome measures in patients with chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA.: The treatment of CLBP has been associated with multiple clinical challenges. Further complicating this is the myriad of outcome scores used to assess treatment of CLBP. These scores have been used to examine different domains of patient satisfaction and quality of life in the literature. Critical assessment of the frequency, parity, and the quality of these outcomes are essential to improve our understanding of CLBP. METHODS.: A systematic review of the English-language literature was undertaken for articles published from January 2001 through December 31, 2010. Electronic databases and reference lists of key articles were searched to identify measures used to evaluate outcomes in six different domains in patients with CLBP. The titles and abstracts of the peer-reviewed literature of LBP were searched to determine which of these measures were most commonly reported in the literature and which have been validated in populations with CLBP. RESULTS.: We identified 75 outcome measures cited to evaluate CLBP. Twenty-nine of these outcome measures were excluded because of only a single citation leaving 46 measures for the evaluation. The most commonly used functional outcomes were the Oswestry Disability Index, Roland Morris Disability Index, and range of motion. For pain, the Numeric Pain Rating Scale, Brief Pain Inventory, Pain Disability Index, McGill Pain Questionnaire, and visual analog scale were most commonly cited. For psychosocial function, the Fear Avoidance Beliefs Questionnaire, Tampa Scale for Kinesiophobia, and Beck Depression Inventory were most commonly used. For generic quality of life, short form 36, Nottingham Health Profile, short form 12, and Sickness Impact Profile were the most common measures. For objective measures, the work status/return to work, complications or adverse events, and medications used were the most commonly cited. For preference-based measures, the Euro-Quol 5 dimensions and short form 6 dimensions were most commonly cited. The validity, reliability, responsiveness, universality, and potential proprietary requirements are summarized for each. CONCLUSION.: Outcome measures should be routinely assessed in patients with CLBP. The choice of appropriate outcome measure should be influenced by the study objectives and design, as well as properties of the particular measure within the context of CLBP. CLINICAL RECOMMENDATIONS.: Recommendation 1: When selecting the appropriate outcome measures for clinical or research purposes, consider domains that best measure what are most important to patients. Measures that are valid, reliable, and responsive to change should be considered first. Other considerations include the number of items required (especially in the context of multiple measures), whether the measure is validated in the relevant language, and the associated costs or fees. Strength: StrongRecommendation 2: Domains of greatest importance include pain, function, and quality of life. If cost utilization is a priority, then preference-based measures should be considered. For pain, we recommend the VAS and NRPS because of their ease of administration and responsiveness. For function, we recommend the ODI and RMDQ. The SF-36 and its shorter versions are most commonly used and should be considered if quality of life is important. If cost utility is important, consider the EQ-5D or SF-6D. Psychosocial tests are best used as screening tools prior to surgery because of their lack of responsiveness. Complications should always be assessed as a standard of clinical practice. Return to work and medication use are complicated outcome measures and not recommended unless the specific study question is focused on these domains. Consider staff and patient burden when prioritizing one's battery of measures. [ABSTRACT FROM AUTHOR]

STUDY DESIGN.: Systematic review of spine care pathways and case study of the Saskatchewan Spine Pathway (SSP). OBJECTIVE.: (1) What are the differences between clinical pathways and clinical guidelines? (2) Are there examples of clinical pathways in the management of lower back pain (LBP)? Is there evidence that they are successful? (3) What is the SSP, and what are its key features? SUMMARY OF BACKGROUND DATA.: Adherence to evidence-based guidelines for LBP produces superior outcomes and may improve efficiency by reducing unnecessary imaging, ineffective treatments, and inappropriate surgical referrals. A clinical pathway is an attempt to bridge the 'translation gap' between guidelines and clinical practice. METHODS.: A qualitative review was performed for question 1. For question 2, a systematic review of the English language literature was performed for articles published through March 31, 2011. A case study is provided for question 3. RESULTS.: (1) Evidence for clinical pathways is mainly derived from guidelines, but pathways are distinguished by several features including the coordination of multidisciplinary care, facilitation of communication among care providers, resources for ongoing quality improvements, and a central focus on the patient experience. (2) Five articles describing four clinical pathways met the a priori criteria, but none tested comparative effectiveness. (3) The SSP is unique in that it is (a) inclusive for all types of LBP, (b) based on a classification system, (c) patient-focused mostly at primary care rather than in specialized clinics, (d) implemented in the health care system of a geopolitically defined region, and (e) includes all of the defining features of modern care pathways. CONCLUSION.: Several clinical pathways for LBP have been described, but effectiveness has not been tested. CLINICAL RECOMMENDATIONS.: Clinical pathways for LBP need to be further developed and investigated as a means to facilitate guidelines-concordant practice and improve patient outcomes. Level of evidence: Insufficient. Recommendation: Weak. [ABSTRACT FROM AUTHOR]

Study Design: Case report.Objective: The diagnosis and surgical management of a patient with a traumatic bilateral dislocation of the lumbosacral junction (L5-S1) without facet or pars interarticularis fracture is presented with a thorough review of the existing literature.Summary Of Background Data: Lumbar fracture-dislocations have been widely reported. However, only five cases of lumbosacral junction dislocation without a fracture have been previously reported.Methods: A 23-year-old patient was involved in a high-energy occupational injury and presented with complaints of back pain and inability to ambulate. Neurological assessment confirmed adequate motor strength (4+/5 bilaterally), normal perianal and lower extremity sensation, and urinary retention (postvoid residual: 1000 mL). Imaging studies revealed bilateral L5-S1 facet dislocation (bilateral jumped facets) without articulating processes or pars interarticularis fractures. Three-column ligamentous injury was confirmed on magnetic resonance imaging with complete tear of the ligamentum flavum, anterior and posterior longitudinal ligaments, interspinous and supraspinous ligaments, and avulsion of the L5 spinous process. The patient underwent bilateral facetectomies, diskectomy, laminectomies, and reduction of slippage with interbody and posterolateral transpedicular instrumented fusion.Results: At 1-year follow-up, the patient reported mild back pain well controlled with naproxen. He continued to report good improvement in his daily function.Conclusion: A careful clinical examination and imaging assessment must be done for appropriate diagnosis and treatment of this rare type of injury. Reduction in the face of intact articulating processes and pars interarticularis is challenging because of acting heavy forces on the lumbosacral joint. Facetectomies, nerve root decompression, and circumferential instrumented fusion are ways to decompress the neural elements, restore alignment, and maintain segmental stability. [ABSTRACT FROM AUTHOR]