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Background: Depression is common in spine surgery candidates and may influence postoperative outcomes. Ecological momentary assessments (EMAs) can overcome limitations of existing depression screening methods (e.g., recall bias, inaccuracy of historical diagnoses) by longitudinally monitoring depression symptoms in daily life. In this study, we compared EMA-based depression assessment with retrospective self-report (a 9-item Patient Health Questionnaire [PHQ-9]) and chart-based depression diagnosis in lumbar spine surgery candidates. We further examined the associations of each depression assessment method with surgical outcomes. Methods: Adult patients undergoing lumbar spine surgery (n = 122) completed EMAs quantifying depressive symptoms up to 5 times daily for 3 weeks preoperatively. Correlations (rank-biserial or Spearman) among EMA means, a chart-based depression history, and 1-time preoperative depression surveys (PHQ-9 and Psychache Scale) were analyzed. Confirmatory factor analysis was used to categorize PHQ-9 questions as somatic or non-somatic; subscores were compared with a propensity score-matched general population cohort. The associations of each screening modality with 6-month surgical outcomes (pain, disability, physical function, pain interference) were analyzed with multivariable regression. Results: The association between EMA Depression scores and a depression history was weak (rrb = 0.34 [95% confidence interval (CI), 0.14 to 0.52]). Moderate correlations with EMA-measured depression symptoms were observed for the PHQ-9 (rs = 0.51 [95% CI, 0.37 to 0.63]) and the Psychache Scale (rs = 0.68 [95% CI, 0.57 to 0.76]). Compared with the matched general population cohort, spine surgery candidates endorsed similar non-somatic symptoms but significantly greater somatic symptoms on the PHQ-9. EMA Depression scores had a stronger association with 6-month surgical outcomes than the other depression screening modalities did. Conclusions: A history of depression in the medical record is not a reliable indication of preoperative depression symptom severity. Cross-sectional depression assessments such as PHQ-9 have stronger associations with daily depression symptoms but may conflate somatic depression symptoms with spine-related disability. As an alternative to these methods, mobile health technology and EMAs provide an opportunity to collect real-time, longitudinal data on depression symptom severity, potentially improving prognostic accuracy. [ABSTRACT FROM AUTHOR]

Background: The comparative effectiveness of decompression plus lumbar facet arthroplasty versus decompression plus instrumented lumbar spinal fusion in patients with lumbar spinal stenosis and grade-I degenerative spondylolisthesis is unknown. Methods: In this randomized, controlled, Food and Drug Administration Investigational Device Exemption trial, we assigned patients who had single-level lumbar spinal stenosis and grade-I degenerative spondylolisthesis to undergo decompression plus lumbar facet arthroplasty (arthroplasty group) or decompression plus fusion (fusion group). The primary outcome was a predetermined composite clinical success score. Secondary outcomes included the Oswestry Disability Index (ODI), visual analog scale (VAS) back and leg pain, Zurich Claudication Questionnaire (ZCQ), Short Form (SF)-12, radiographic parameters, surgical variables, and complications. Results: A total of 321 adult patients were randomized in a 2:1 fashion, with 219 patients assigned to undergo facet arthroplasty and 102 patients assigned to undergo fusion. Of these, 113 patients (51.6%) in the arthroplasty group and 47 (46.1%) in the fusion group who had either reached 24 months of postoperative follow-up or were deemed early clinical failures were included in the primary outcome analysis. The arthroplasty group had a higher proportion of patients who achieved composite clinical success than did the fusion group (73.5% versus 25.5%; p < 0.001), equating to a between-group difference of 47.9% (95% confidence interval, 33.0% to 62.8%). The arthroplasty group outperformed the fusion group in most patient-reported outcome measures (including the ODI, VAS back pain, and all ZCQ component scores) at 24 months postoperatively. There were no significant differences between groups in surgical variables or complications, except that the fusion group had a higher rate of developing symptomatic adjacent segment degeneration. Conclusions: Among patients with lumbar spinal stenosis and grade-I degenerative spondylolisthesis, lumbar facet arthroplasty was associated with a higher rate of composite clinical success than fusion was at 24 months postoperatively. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

BACKGROUND: Correction of tetralogy of Fallot (cTOF) often results in pulmonary valve pathology and right ventricular (RV) dysfunction. Reduced exercise capacity in cTOF patients cannot be explained by these findings alone. We aimed to explore why cTOF patients exhibit impaired exercise capacity with the aid of a comprehensive cardiopulmonary exercise testing (CPET) and real-time cardiovascular magnetic resonance exercise testing (CMR-ET) protocol. METHODS: Thirty three cTOF patients and 35 matched healthy controls underwent CPET and CMR-ET in a prospective casecontrol study. Real-time steady-state free precession cine and phase-contrast sequences were obtained during incremental supine in-scanner cycling at 50, 70, and 90 W. RV and left ventricle (LV) volumes and pulmonary blood flow (Qp) were calculated. Differences of CPET and CMR-ET between cTOF versus controls and correlations between CPET and CMR-ET parameters in cTOF were evaluated statistically for all CMR exercise levels using Mann-Whitney U and Spearman rank-order correlation tests. RESULTS: CPET capacity was significantly lower in cTOF than in controls. cTOF patients exhibited not only significantly reduced Qp and RV function but also lower LV function on CMR-ET. Higher CPET values in cTOF correlated with higher Qp (Qp 90 W versus carbon dioxide ventilatory equivalent %: R=-0.519, P<0.05), higher LV-end-diastolic volume indexed to body surface area (LV-end-diastolic volume indexed to body surface area at 50 W versus oxygen uptake in % at maximum exercise on CPET R=0.452, P<0.05), and change in LV ejection fraction (EF; LV-EF at 90 W versus Watt %: r=-0.463, P<0.05). No correlation was found with regard to RV-EF. Significant RV-LV interaction was observed during CMR-ET (RV-EF versus LV-EF at 50 W and 70 W: r=0.66, P<0.02 and r=0.52, P<0.05, respectively). CONCLUSIONS: Impaired exercise capacity in cTOF resulted from a reduction in not only RV, but also LV function. cTOF with good exercise capacity on CPET demonstrated higher LV reserve and pulmonary blood flow during incremental CMR-ET. Apart from RV parameters, CMR-ET-derived LV function could be a valuable tool to stratify cTOF patients for pulmonary valve replacement. [ABSTRACT FROM AUTHOR]

The classification of clinical severity of Ebstein anomaly still remains a challenge. The aim of this study was to focus on the interaction of the pathologically altered right heart with the anatomically—supposedly—normal left heart and to derive from cardiac magnetic resonance (CMR) a simple imaging measure for the clinical severity of Ebstein anomaly.Twenty-five patients at a mean age of 26±14 years with unrepaired Ebstein anomaly were examined in a prospective study. Disease severity was classified using CMR volumes and functional measurements in comparison with heart failure markers from clinical data, ECG, laboratory and cardiopulmonary exercise testing, and echocardiography. All examinations were completed within 24 hours. A total right/left-volume index was defined from end-diastolic volume measurements in CMR: total right/left-volume index=(RA+aRV+fRV)/(LA+LV). Mean total right/left-volume index was 2.6±1.7 (normal values: 1.1±0.1). This new total right/left-volume index correlated with almost all clinically used biomarkers of heart failure: brain natriuretic peptide (r=0.691; P=0.0003), QRS (r=0.432; P=0.039), peak oxygen consumption/kg (r=-0.479; P=0.024), ventilatory response to carbon dioxide production at anaerobic threshold (r=0.426; P=0.048), the severity of tricuspid regurgitation (r=0.692; P=0.009), tricuspid valve offset (r=0.583; P=0.004), and tricuspid annular plane systolic excursion (r=0.554; P=0.006). Previously described severity indices ([RA+aRV]/[fRV+LA+LV]) and fRV/LV end-diastolic volume corresponded only to some parameters.In patients with Ebstein anomaly, the easily acquired index of right-sided to left-sided heart volumes from CMR correlated well with established heart failure markers. Our data suggest that the total right/left-volume index should be used as a new and simplified CMR measure, allowing more accurate assessment of disease severity than previously described scoring systems. [ABSTRACT FROM AUTHOR]

The article presents a study which analyzes lateral masses of the lower cervical spine. In this study, morphometric and volumetric analyses of the lower cervical spine lateral masses of male and female patients who underwent a cervical computed tomography scanning were performed. Result shows that the sagittal height of C5 and C6 lateral masses differed in both men and women. It adds that the C7 lateral mass has greater height and comparable thickness as higher cervical spine.

The article focuses on the study which examines the safety profile of recombinant human bone morphogenetic protein (rhBMP)-2 in posterior cervical fusion. Researchers have performed retrospective chart review of patients who underwent posterior cervical fusion in a year. It found that the use of rhBMP-2 has produced less complications rate compared to the anterior cervical spine surgery.

There is substantial controversy regarding the current evidence basis of practice for neurophysiologic intraoperative monitoring (NIOM). The randomized controlled trial is clearly the highest level of evidence of efficacy for intervention in health care. The low rate of new neurologic deficits in many types of surgeries for which NIOM is considered means that statistical power would require tremendous trial size; however, there are some surgeries with higher rates of new neurologic deficit for which this effect is not the case. For some surgeries, NIOM has clearly become the standard of care, and there would be no equipoise in randomization to NIOM versus no NIOM at all. For this situation, careful study design to permit comparison of different NIOM approaches or anesthesiological regimens might permit the achievement of equipoise. In oncological contexts, NIOM is often used to delimit the extent of resection to avoid motor new neurologic deficits, but this approach may lower complete resection rates; in this setting, a randomization to restrictive versus permissive NIOM parameters limiting resection could test the long-term advantages of motor versus oncological outcomes. Clearly, randomized controlled trial demonstration of NIOM efficacy for the prevention of new neurologic deficits would be difficult to accomplish. However, with careful choice of surgical population and randomization design, prospective trials would in fact not be impossible.

Study Design: Retrospective review., Objective: The objective of the study was to determine the morbidity and mortality rate associated with same day versus staged cervical circumferential approach., Summary of Background Data: A combined approach to the cervical spine is often indicated for complex cervical pathologies. Previous studies suggested superior results associated with same day combined surgery for thoracolumbar patients. This study examines the usefulness of p-Physiological and Operative Severity Score for enumeration of Morbidity and Mortality (POSSUM), an estimated mortality risk assessment for cervical spine patients and will compare same day surgery to staged procedures., Methods: This is a retrospective chart review including patients who underwent ventral and dorsal approach within 2 weeks. Estimated mortality was calculated using p-POSSUM. The cohort was divided into same day surgery group and staged group. Risk factors were compared between groups. Mean p-POSSUM was calculated and compared with the actual mortality rate. Univariate analysis was used to compare the risk factors between groups and the groups' outcomes. Multivariable analysis was used to adjust for risk factor differences when comparing group outcomes., Results: One hundred thirty-five patients were included, 106 patients were in the same day surgery group whereas 29 patients were in the staged group. Mean p-POSSUM was 2.8% predicted mortality with a 95% confidence interval of 1.6% to 4.1%. The actual mortality rate was 3.7%. The groups did not vary in most risk factors assessed. Univariate analysis demonstrated a statistically significantly higher rate of major complications (0.62 vs. 0.34, P=0.0369), infection (41.4% vs. 9.4%, P<0.0001), and length of hospital stay (9.3 vs. 6.8 d, P=0.0120) in the staged group. Multivariable analysis demonstrated significantly higher infection rate in the staged group., Conclusions: P-POSSUM mortality estimate may serve as a useful and valid tool for spine surgery studies. Staged combined cervical surgery harbors a higher complication rate and may be associated with lengthier hospitalization.

Study Design: A prospective clinical research article., Objective: The primary goals were to determine (1) radiation exposure to the spine surgeon with the use of an intraoperative 3-dimensional imaging system and (2) to define the safe distance from the computed tomographic scanner., Summary of Background: Intraoperative radiation exposure to the spinal surgeon has been assessed during 2-dimensional fluoroscopy but has not been investigated during intraoperative 3-dimensional imaging., Methods: Ten patients undergoing lumbar or thoracolumbar fusion were enrolled in a prospective trial to determine the radiation exposure to a spine surgeon standing in the substerile room, with the use of the O-ARM Imaging System (Medtronic, Memphis, TN). A thermolucent digital dosimeter was worn at chest level without a lead apron. Dosimeter readings and distance from the spine surgeon were recorded. RESULTS.: Average surgeon exposure was 44.22 ± 17.4 μrem (range: 17.71-70.76 μrem). The mean distance from the O-ARM was 4.56 ± .32 m, and the surgeon was exposed for an average of 19.6 ± 5.7 seconds (range: 8.05-28.7 s). The annual number of necessary procedures required to surpass the exposure limit, according to the data presented here, would be 113,071 operations using O-ARM. Hence, the number of necessary procedures for O-ARM use is predicted to be 1,130,710 annual procedures to reach the occupational exposure limits for extremity, skin, and all other organs and 339,213 procedures to reach the limits for the lens of eye., Conclusion: Radiation exposure is minimal to the surgical team during routine use of the O-ARM imaging system. The number of procedures required to surpass occupational exposure limits is high if using appropriate distance from the O-ARM.

Study Design: Review of literature., Objective: To evaluate the available literature supporting the use of lumbar fusion extenders in clinical practice., Summary of Background Data: Because of the morbidity associated with the harvest of autologous iliac crest bone grafts, the search for lumber fusion extenders and replacements has accelerated. Many formulations of lumbar fusion extenders have been developed, and it is essential to evaluate clinical literature and available outcome metrics of these extenders., Methods: A review of English-language literature was performed between 1990 and January of 2010 for all literature presenting clinical outcomes of lumbar fusion extenders. After controlling for inclusion and exclusion criteria and assigning levels of evidence, 19 clinical studies were fully reviewed including those for demineralized bone matrix, recombinant human bone morphogenetic protein 2 (rhBMP-2), β-tricalcium phosphate, and calcium sulfate., Results: The most extensively studied of the lumbar fusion extenders is β-tricalcium phosphate, especially with regard to its use in adolescent scoliosis correction. The use of rhBMP-2 and demineralized bone matrix is supported only by two and three clinical studies, respectively. Calcium sulfate and other miscellaneous extenders are not conclusively or consistently supported by available clinical studies., Conclusion: Calcium phosphate is the most supported of the lumbar fusion extenders. rhBMP-2 and demineralized bone matrix are supported by smaller bodies of evidence. These formulations are supported by these initial studies but in some cases need to be better examined with regard to side effect profiles.