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STUDY DESIGN Retrospective review. OBJECTIVE To quantify and describe perioperative complication rates in a large series of well-matched elderly patients who underwent lumbar decompression and arthrodesis. SUMMARY OF BACKGROUND DATA Posterior lumbar decompression and fusion is frequently performed to treat lumbar stenosis with instability. An increasing number of elderly patients are undergoing operative treatment for degenerative lumbar disease. The reported morbidity of performing decompression and arthrodesis in this population varies widely in the literature, with recent reports showing a high rate of major complications. METHODS A total of 166 patients age 65 or older that underwent primary posterior lumbar decompression and fusion with (group 1; n = 75) or without (group 2; n = 91) instrumentation were included. Hospital records were reviewed for the occurrence of any complications (major and minor), the need for transfusion, estimated length of stay, and disposition at discharge. Logistic regression (with the presence/absence of major complications as the dependent variable) was used to identify risk factors for the occurrence of a complication. RESULTS Five major complications (3%) occurred (group 1, 1; group 2, 4). Minor complications developed in 30.7% of group 1 and 31.9% of group 2. There were no deaths, and only one perioperative complication was attributable to the use of instrumentation. Decompression/fusion of 4 or more segments was significantly associated with the occurrence of a major complication. Advanced age, the presence of medical comorbidities, or the use of instrumentation did not increase the rate of major or minor complications. The occurrence of either a major or minor complication prolonged hospital stay. CONCLUSIONS Posterior lumbar decompression and fusion can be safely performed in elderly patients, with a low rate of major complications. The addition of instrumentation does not increase the complication rate. These results differ from those previously reported in the literature, which describe a significantly higher rate of complications in this age group, with a prolonged rate of hospitalization.

Objective Previous case series have examined the relationship between anti–Jo-1 antibody levels and myositis disease activity, demonstrating equivocal results. Using enzyme-linked immunosorbent assays (ELISAs) and novel measures of myositis disease activity, the current study was undertaken to systematically reexamine the association between anti–Jo-1 antibody levels and various disease manifestations of myositis. Methods Serum anti–Jo-1 antibody levels were quantified using 2 independent ELISA methods, while disease activity was retrospectively graded using the Myositis Disease Activity Assessment Tool, which measures disease activity in 7 different organ systems via the Myositis Disease Activity Assessment Visual Analog Scale (VAS) and the Myositis Intention-to-Treat Index (MITAX) components. Spearman's rank correlation coefficients and mixed linear regression analysis were used to identify associations between anti–Jo-1 antibody levels and organ-specific disease activity in cross-sectional and longitudinal analyses, respectively. Results Cross-sectional assessment of 81 patients with anti–Jo-1 antibody revealed a modest correlation between the anti–Jo-1 antibody level and the serum creatine kinase (CK) level, as well as muscle and joint disease activity. Correlation coefficients were similar for CK levels (rs = 0.38, P = 0.002), myositis VAS (rs = 0.36, P = 0.002), and arthritis VAS (rs = 0.40, P = 0.001). In multiple regression analyses of 11 patients with serial samples, anti–Jo-1 antibody levels correlated significantly with CK levels (R2 = 0.65, P = 0.0002), myositis VAS (R2 = 0.53, P = 0.0008), arthritis VAS (R2 = 0.53, P = 0.006), pulmonary VAS (R2 = 0.69, P = 0.005), global VAS (R2 = 0.63, P = 0.002), and global MITAX (R2 = 0.64, P = 0.0003). Conclusion In this large series of patients with idiopathic inflammatory myopathy, anti–Jo-1 antibody levels correlated modestly with muscle and joint disease, an association confirmed by a custom ELISA using recombinant human Jo-1. More striking associations emerged in a smaller longitudinal subset of patients that link anti–Jo-1 antibody levels to muscle, joint, lung, and global disease activity.

STUDY DESIGN Cross-sectional. OBJECTIVES To determine the prevalence of symptoms typical of cervical and lumbar stenosis, evaluate the relationship between lumbar and cervical symptoms, and assess the impact of these symptoms on health status. SUMMARY OF BACKGROUND DATA Degenerative changes of the spine frequently associated with aging, may result in stenosis, a narrowing of the spinal canal. Little is known about the prevalence or health impact of symptoms associated with stenosis in older individuals. METHODS Between March 2000 and April 2002, 5995 men aged > or = 65 years participating in the Osteoporotic Fractures in Men Study completed a self-administered questionnaire and clinical examination. Information was collected on demographics, spinal/joint health, and general health status. RESULTS Overall, 14.4% of men had had clinically relevant neck pain during the previous year, and almost half this group (6.5%) had numbness/tingling/weakness (NTW) extending into the arm; 26.2% reported clinically relevant lower back pain, which in 12.2%, was accompanied by NTW extending into the leg. Men with spinal pain (neck or lower back) accompanied by NTW radiating into a limb had poorer health status than those with milder pain. CONCLUSIONS Symptoms suggestive of cervical and lumbar stenosis are relatively common among this cohort of older men, and generalized spinal stenosis may occur in as many as 4%.

The diagnosis of compartment syndrome is most commonly made by clinical examination. Direct compartmental measurements generally serve an adjunctive role in establishing the diagnosis, except when patients have an alteration in mental status. There is little known on what are the expected baseline elevations in compartments after the simple occurrence of a fracture when clinical compartment syndrome does not exist. Knowledge of such measurements might influence the utility of pressure measurements in diagnosing compartment syndrome.A prospective analysis of compartment measurements was performed in 19 isolated lower extremity fractures with the opposite leg as the control. The patients had no clinical evidence of compartment syndrome, had no alteration in mental status, and underwent planned surgical treatment within 48 hours of injury.Average compartment measurements were 35.5 +/- 13.6 mm Hg (range 10 to 62 mm Hg) in the injured leg versus 16.6 +/- 7.5 mm Hg (range 3 to 40 mm Hg) in the control leg (p = 0.0001). Eighteen patients (95%) had at least one compartment measurement that exceeded a single threshold of 30 mm Hg and 12 patients (63%) exceeded a threshold of 45 mm Hg. Eleven patients (58%) had at least one compartment reading within 20 mm Hg of their diastolic pressure and 16 patients (84%) had one within 30 mm Hg of their diastolic pressure. Ten patients (53%) had a reading within 40 mm Hg of their mean arterial pressure (delta P) and eight patients (42%) had a reading within 30 mm Hg of the mean arterial pressure. No patient developed sequelae or required surgery related to an unrecognized compartment syndrome during a minimum 1-year follow-up.Based on our data, use of direct compartment measurements with existing thresholds and formulations to determine the diagnosis of compartment syndrome may not accurately reflect a true existence of the syndrome. A search for other quantitative measures to more accurately reflect the presence of compartment syndrome is warranted.

Background Single-injection femoral nerve block analgesia and spinal anesthesia have been associated with fewer postoperative nursing interventions and successful same-day discharge after anterior cruciate ligament reconstruction. In the current study, the authors prospectively determined the effect of continuous femoral nerve block on a numeric rating scale (NRS) of pain intensity with movement for 7 postoperative days. Methods Patients undergoing this surgery with no history of previous invasive surgery on the same knee were recruited for this study. After standardized spinal anesthesia, intravenous sedation, and perioperative multimodal analgesia, patients received a femoral nerve catheter with (1) saline bolus (30 ml) plus saline infusion (270 ml at 5 ml/h, placebo group); (2) levobupivacaine (0.25%) bolus with saline infusion (group I), or (3) levobupivacaine (0.25%) bolus and infusion (group II). Patients were surveyed preoperatively and on postoperative days 1-4 and 7 to determine NRS scores (scale 0-10). Results Data from 233 participants were analyzed. On days 1-2, 50% of placebo patients had NRS scores of 5 or above, whereas among group II patients, only 25% had scores of 5 or above (P < 0.001). In regression models for NRS scores during days 1-4, group II was the only factor predicting lower pain scores (odds ratios, 0.3-0.5; P = 0.001-0.03). Overall, patients with preoperative NRS scores greater than 2 were likely to report higher NRS scores during days 1-7 (odds ratios, 3.3-5.2; P < 0.001). Conclusions Femoral nerve block catheters reliably keep NRS scores below the moderate-to-severe pain threshold for the first 4 days after anterior cruciate ligament reconstruction.

The objective of the Drug Information Center Arthritis Project was to create and assess the value of a patient-focused interactive arthritis education program. A multidisciplinary team developed three content areas: an interactive ask-a-pharmacist component with a satisfaction survey; health assessment tools (SF-8™, osteoarthritis [OA] Impact Survey™, and rheumatoid arthritis [RA] Impact Survey™); and disease and drug information. Results: There were 1,800 patients with OA, RA, or both from a collaborating rheumatology practice who were invited to use a personalized, interactive, secured Internet arthritis Web site. During a 6-week pilot, 56 patients accessed the site for a total of 128 visits. Patient satisfaction scores showed that 83% of patients rated the site as useful to very useful; 83 % would both use the site again and recommend the site to a friend. Overall health-related quality of life as measured by the SF-8 physical and mental component scores and the OA and RA Impact Surveys for patients accessing the Web site was slightly higher than the US population norms for patients with arthritis. Conclusions: To our knowledge, there are no other Web sites that provide confidential, patient-specific arthritis Internet information as an extension of a rheumatology practice. Our Web site provided novel access to personalized, evidence-based, and up-to-date information for patients.

Background Previous studies have shown that work-related injuries are often associated with inferior outcomes. The aim of the current study was to compare the long-term functional outcome after polytrauma between work-related and non-work-related injuries at a minimum follow-up of 10 years. Methods Six hundred thirty-seven polytrauma patients were evaluated using a patient questionnaire and a physical examination. The average follow-up was 17.5 years (range 10–28 years); the average Injury Severity Score (ISS) was 20.7 (range 4 to 54). Results A multivariate analysis, with adjustments for age, sex, injury severity, and injury pattern, demonstrated that work-related injuries resulted in significantly inferior outcomes measured by the Hannove Score for Polytrauma Outcome (HASPOC), 12-Item Short-Form Health Survey (SF-12), requirement for medical aids and devices, length of rehabilitation, and retirement status (P Conclusions Polytrauma patients receiving workers’ compensation achieve significantly inferior long-term outcomes than other patients. The obtained results demonstrate that psychosocial variables such as insurance status have a significant impact on the functional recovery following polytrauma.

This article describes the clinical application of gene therapy to a nonlethal disease, rheumatoid arthritis (RA). Intraarticular transfer of IL-1 receptor antagonist (IL-1Ra) cDNA reduces disease in animal models of RA. Whether this procedure is safe and feasible in humans was addressed in a phase I clinical study involving nine postmenopausal women with advanced RA who required unilateral sialastic implant arthroplasty of the 2nd-5th metacarpophalangeal (MCP) joints. Cultures of autologous synovial fibroblasts were established and divided into two. One was transduced with a retrovirus carrying IL-1Ra cDNA; the other provided untransduced, control cells. In a dose escalation, double-blinded fashion, two MCP joints were injected with transduced cells, and two MCP joints received control cells. One week later, injected joints were resected and examined for evidence of successful gene transfer and expression by using RT-PCR,ex vivoproduction of IL-1Ra,in situhybridization, and immunohistochemistry. All subjects tolerated the protocol well, without adverse events. Unlike control joints, those receiving transduced cells gave positive RT-PCR signals. Synovia that were recovered from the MCP joints of intermediate and high dose subjects produced elevated amounts of IL-1Ra (P= 0.01). Clusters of cells expressing high levels of IL-1Ra were present on synovia of transduced joints. No adverse events occurred. Thus, it is possible to transfer a potentially therapeutic gene safely to human rheumatoid joints and to obtain intraarticular, transgene expression. This conclusion justifies additional efficacy studies and encourages further development of genetic approaches to the treatment of arthritis and related disorders.

Purpose. The quality and reliability of Internet-based arthritis information were studied. Methods. The search terms “arthritis,” “osteoarthritis,” and “rheumatoid arthritis” were entered into the AOL, MSN, Yahoo, Google, and Lycos search engines. The Web sites for the first 40 matches generated by each search engine were grouped by URL suffix and evaluated on the basis of four categories of criteria: disease and medication information content, Web-site navigability, required literacy level, and currentness of information. Ratings were assigned by using an assessment tool derived from published literature (maximum score of 15 points). Results. Of the 600 arthritis Web sites identified, only 69 were unique and included in the analysis. Fifty-seven percent were .com sites, 20% .org sites, 7% .gov sites, 6% .edu sites, and 10% other sites. Total scores for individual sites reviewed ranged from 3 to 14. Eighty percent of .gov sites, 75% of .edu sites, 29% of other sites, 36% of .com sites, and 21% of .org sites were within the top tertile of scores. No Web site met the criterion for being understandable to people with no more than a sixth-grade reading ability. .Gov sites scored significantly higher overall than .com sites, .org sites, and other sites. .Edu sites also scored relatively well. Conclusion. The quality of arthritis information on the Internet varied widely. Sites with URLs having suffixes of .gov and .edu were ranked higher than other types of sites.

The proportion of fractures that occur in women without osteoporosis has not been fully described, and the characteristics of nonosteoporotic women who fracture are not well understood. We measured total hip bone mineral density (BMD) and baseline characteristics including physical activity, falls, and strength for 8065 women aged 65 yr or older participating in the Study of Osteoporotic Fractures and then followed these women for hip fracture for up to 5 yr after BMD measurement. Among all participants, 17% had osteoporosis (total hip BMD T-score < or = -2.5). Of the 243 women with incident hip fracture, 54% were not osteoporotic at start of follow-up. Nonosteoporotic women who fractured were less likely than osteoporotic women with fracture to have baseline characteristics associated with frailty. Nevertheless, among nonosteoporotic participants, several characteristics increased fracture risk, including advancing age, lack of exercise in the last year, reduced visual contrast sensitivity, falls in the last year, prevalent vertebral fracture, and lower total hip BMD. These findings call attention to the many older women who suffer hip fracture but do not have particularly low antecedent BMD measures and help begin to identify risk factors associated with higher bone density levels.

Purpose There have been few prospective studies evaluating the results of nonsurgical treatment of a well-defined patient cohort with symptomatic basal joint osteoarthritis of the thumb. This prospective study uses a validated outcome instrument to examine the effectiveness of a single steroid injection and 3 weeks of splinting in patients with osteoarthritis in Eaton stages 1 to 4 with a minimum of 18 months of follow-up evaluation. Methods Thirty consecutive patients (30 thumbs) were studied prospectively to evaluate the efficacy of a single injection of corticosteroid into the trapeziometacarpal joint, followed by immobilization in a thumb spica splint for 3 weeks. All patients answered an outcome-based questionnaire (Disabilities of the Arm, Shoulder, and Hand) and were examined before injection, 6 weeks after injection, and at final follow-up examination (minimum, 18 months). Eaton radiographic stage was recorded by 3 independent observers. Results At 6 weeks 13 patients had improvement in pain intensity and 17 patients reported no symptomatic improvement. Twelve of those with relief at 6 weeks continued to have relief at long term follow-up evaluation (mean, 25 months). Of patients with long-term relief average grip strength of the affected thumb was 95% of contralateral side, whereas those without relief had grip strength values that were 60% of contralateral side. For those patients without relief at 6 weeks there was no improvement seen at later follow-up evaluation. Five patients with Eaton stage 1 disease had an average of 23 months of relief with nonsurgical treatment. In stage 2 and stage 3 disease 7 thumbs improved at 6 weeks after injection and 6 thumbs had long-term relief. In stage 4 disease, 6 thumbs had neither short-term nor long-term relief with the injection. Disease side, handedness, and smoking did not affect outcomes. At final follow-up evaluation 12 thumbs had had surgical treatment. Conclusions Steroid injection with splinting for the treatment of basal joint arthritis of the thumb provided reliable long-term relief in thumbs with Eaton stage 1 disease but provided long-term relief in only 7 of 17 thumbs with Eaton stage 2 and stage 3 basal joint arthritis.

Background Anterior cruciate ligament reconstruction is a complex outpatient surgical procedure often associated with pain. Traditionally, the procedure is performed under general anesthesia and often requires the use of the PACU. Refractory pain and/or nausea/vomiting occasionally leads to an unplanned hospital admission. In this study, the authors examine the associations of nerve block analgesia for these patients and its associated reductions in PACU use, hospital admission, and hospital costs. Methods This was an observational, nonrandomized study in which existing data regarding patients' day-of-surgery outcomes were merged with hospital cost data. We reviewed a consecutive sample of 948 men and women who were in good health and underwent anterior cruciate ligament reconstruction in an outpatient surgery unit between July 1995 and June 1999. Results The use of nerve block analgesia was associated with reduced PACU admissions to 18% and decreased unplanned hospital admission rates from 17% to 4%. Multivariate linear regression analysis showed that patients bypassing the PACU had an associated hospital cost reduction of 12% (P = 0.0001), whereas patients who needed hospital admission had an associated hospital cost increase of 11% (P = 0.0003). Conclusions The use of nerve blocks for acute pain management in patients undergoing anterior cruciate ligament reconstruction is associated with PACU bypass and reliable same-day discharge. Although the cost savings for this one procedure are unlikely to generate sufficient cost savings via staffing reductions, extrapolating these results to a large volume of all types of invasive outpatient orthopedic procedures may have the potential to create significant hospital cost savings.

Background context Musculoskeletal pain in the cervicobrachial region is considered a major health problem among adults of working age, but little is known about the impact of this pain in the elderly. Purpose Determine the prevalence of neck and shoulder pain in a well-functioning cohort, identify factors associated with this pain, assess the pattern of coexisting joint pain and evaluate the impact of this pain on physical functioning. Study design Cross-sectional study. Patient sample Black and white men and women, aged 70 to 79 years, participating in the Health, Aging and Body Composition (Health ABC) study. Outcome measures Not applicable. Methods Between April 1997 and June 1998, 3,075 men and women participating in Health ABC study completed the initial home interview and clinical examination. Information was collected on musculoskeletal pain, medical history, depressive symptomatology and physical function. Physical performance measures were obtained. Results A total of 11.9% of participants reported neck pain of one month or more in duration and 18.9% reported shoulder pain. White women had the highest prevalence of neck pain (15.4%) and black women the highest prevalence of shoulder pain (24.3%). The correlates of both neck and shoulder pain were female gender, no education beyond high school, poorer self-rated health, depressive symptomatology and a medical history of arthritis, heart attack, angina. Increasing severity of both neck and shoulder pain was associated with an increased prevalence of joint pain at other body sites and with poor functional capacity. Measures of physical performance involving the upper extremity were also decreased. Conclusions Neck and shoulder pain, either alone or in conjunction with pain in other joints, has a substantial impact on the function and well-being of the older adults in this cohort.

A retrospective analysis of charts identified cases of superior mesenteric artery (SMA) syndrome occurring after scoliosis surgery over a 23-year period. Despite numerous reports on this potentially fatal complication of scoliosis surgery, no method exists to stratify patients for risk of developing disease after spine surgery. A study of charts was performed to identify all cases of SMA syndrome occurring after scoliosis surgery from 1972 to 1995. An upper gastrointestinal study with findings specific for the syndrome was requisite for inclusion. Patients' weight and height at the time of diagnosis of SMA syndrome were recorded. Based on standard national data tables, a percentile for weight, percentile for height, and a weight percentile for height were derived for each patient. The syndrome occurred after posterior spinal fusion in six patients (three boys, three girls). The average weight percentile for height, available in five of the six patients, was 3%, significantly different from both age-matched controls in the general population and from age-matched controls undergoing posterior spinal fusion for adolescent idiopathic scoliosis. This study, the largest reported from a single institution, suggests that a weight percentile for height of 5% is the degree of asthenia that allows compromise of the duodenum. The percentile identifies patients at risk for SMA syndrome for the purposes of increasing postoperative vigilance for gastrointestinal complaints, decreasing the threshold for diagnostic workup, and guiding perioperative dietary supplementation.

BACKGROUND CONTEXT: Degenerative changes in the lumbar spine may result in a loss of spinal stability and subluxation of one vertebra relative to another. Cadaveric studies and clinical case series have suggested that listhesis may be much more common in African Americans than in whites. PURPOSE: To determine the prevalence of lumbar spine listhesis (anterolisthesis and retrolisthesis) among African American women aged 65 years and older and the relationship of listhesis to low back pain, physical function and quality of life. STUDY DESIGN/SETTING: Cross-sectional study. PATIENT SAMPLE: A total of 481 African American women aged 65 years and older who were enrolled in the Study of Osteoporotic Fractures. These women were recruited from population-based listings in Baltimore, MD, Minneapolis, MN, Pittsburgh, PA, and Portland, OR. OUTCOME MEASURES: Not applicable. METHODS: Lateral radiographs of the lumbar spine were digitized, and listhesis (anterolisthesis and retrolisthesis) was assessed at spinal levels L3–L4, L4–L5 and L5–S1. Usable data were obtained for 470 women. Listhesis was defined as present when the subluxation (antero or retro) was 3 mm or more. RESULTS: The overall prevalence of anterolisthesis was 58.3% and varied by spinal level (13.2% at L3–L4, 36.5% at L4–L5 and 29.6% at L5–S1). The prevalence increased with age but was lower among oophorectomized women and those currently on estrogen replacement therapy. Anterolisthesis was not associated (p>.05) with disc height nor was it related to back function. Retrolisthesis occurred in 4% of women and was associated with decreased disc height and an increased prevalence of spinal problems and walking problems. CONCLUSIONS: The prevalence of anterolisthesis among older African American women living in the community was two to three times greater than that found in white women of a similar age. This condition was not related to an increased frequency of back problems nor did it adversely affect general physical function. Retrolisthesis was relatively rare but was associated with decreased back function.

Background Outpatient knee surgery has come to involve increasingly complex procedures. The authors present observational data from a nerve block algorithm designed for the care of outpatients undergoing knee surgery. The aim of this report is to demonstrate differences in pain and unplanned hospital admission associated with surgical complexity and nerve blocks used. Methods Day-of-surgery outcomes were studied for 1,200 consecutive outpatients undergoing routine arthroscopy or one of six complex outpatient knee procedures. Nerve blocks were administered on the basis of anticipated pain from open incisions in the femoral and sciatic nerve distributions. Regression analysis was used to determine factors associated with postoperative pain and unplanned hospital admissions, and patients were categorized as having received femoral and sciatic nerve blocks (FSB), femoral nerve block only (FNB), or no nerve blocks. Results Patients undergoing more complex (vs. less invasive) knee surgery were at greater risk for pain (P Conclusions For complex knee surgery, the use of FSB was associated with less pain; the use of FNB or FSB (vs. no block) was associated with fewer hospital admissions.

Several authors have hypothesized that there is a link between lumbar lordosis and low back pain. These relationships have not been previously described in a sample consisting exclusively of elderly, African-American women. The purpose of this study was to describe the relationship between lumbar lordosis and radiologic variables and lumbar lordosis and clinical variables in elderly, African-American women. A total of 475 African-American women enrolled in the multicenter Study of Osteoporotic Fractures participated in this ancillary, cross-sectional, study of lumbar lordosis. These women received lumbar spine radiographs and completed a questionnaire on low back pain and its impact on their daily lives. Lumbar lordosis tertiles were created based on radiographic measurements. Comparisons were made between the tertiles for differences in radiologic and clinical variables. Significant differences (p < 0.0025) were observed between the lordosis tertiles and the presence of spondylolisthesis, intervertebral disc space, and vertebral wedging. No significant differences were observed between the lordosis tertiles for the occurrence of low back pain, symptoms associated with low back pain, and disability experienced from low back pain. The degree of lumbar lordosis was associated with radiologic variables but was not associated with symptoms or decreased function from low back pain. These findings question the clinical utility of the lumbar lordosis measurement in elderly, African-American women.

Study design Multicenter, cross-sectional analysis of data from the National Spine Network. Objectives Investigate the association between the smoking status of spinal patients, duration and severity of symptoms, and their self-reported health status. Background Although cigarette smoking was identified as a potential risk factor for lower back pain many years ago, more recent research is challenging this finding. Methods The National Spine Network database contains information on the initial visit of spinal patients visiting physicians at 23 health care institutions in the United States. All patients for whom data were available regarding smoking status are included in this study (n = 25,455). Results Data from a total of 25,455 patients (11,494 men and 13,961 women) were included in the study; 16.7% (n = 4249) were smokers. Smokers were younger than nonsmokers (44.2 vs. 48.7 years) and were more likely to report severe back symptoms (37 vs. 50%) and to report symptoms of depression (54 vs. 37%). Smokers of each gender scored 10-15 points lower than nonsmokers on each of the SF-36 subscales. These differences persisted when the absolute scores were compared with age- and sex-specific population norms and after adjustment for comorbid conditions, educational level, and depression. Similar results were obtained when the cohort was stratified by primary diagnosis or by surgical status. When postsurgical patients were grouped by time since surgery, those who were nonsmokers reported improved health status by time period; those who smoked did not. Conclusions Smokers and nonsmokers had had spinal symptoms for similar duration, but the smokers reported more severe symptoms, which were present for a greater proportion of time each day. Also, the smokers had lower physical and mental health status scores (based on the SF-36) than did nonsmokers.

Study Design. A retrospective study of blood transfusion practices after posterior lumbar spine surgery was performed. Objectives. To determine the overall use rate of autologous blood donations for different spine surgeries, and to identify the risk of requiring additional allogeneic blood transfusions. Summary of Background Data. In an attempt to avoid allogeneic blood transfusions and its associated risks, patients frequently are asked to donate autologous blood before many efective spine surgeries. There is a lack of published data on the use rate for these autoiogous blood donations, and on their ability to prevent allogeneic blood exposure. Methods. A retrospective review of hospital charts and blood bank records was conducted on 191 consecutive patients who had undergone three categories of lumbar spine surgery: laminectomy alone, laminectomy with a noninstrumented posteroiateral fusion, and laminectomy with an instrumented posteroiateral fusion. Results. Nearly 80% of the autologous blood donated by patients who underwent simple laminectomies was wasted. However, the vast majority (70-90%) of patients who underwent fusion used their autologous blood. In the patients who underwent fusion, autologous blood donations decreased the risk of aliogenic blood transfusions by 75% in noninstrumented fusions and 50% in instrumented fusions, as compared with the patients who elected not to donate blood before the fusion (P < 0.05). A substantial number of patients who underwent instrumented fusions (nearly 40%) required additional alloge neic blood transfusions despite predonation of blood. Conclusions. Autologous blood donations are indeed advantageous n decreasing aliogeneic blood usage of patients undergoing fusion, but additional methods of blood conservation (intraoperative salvage and preoper ative erythropoietin) seem necessary to diminish the al logeneic blood requirements further, especially in those patients undergoing instrumented lumber fusion.

Sixty-four patients (66 elbows) treated for refractory cubital tunnel syndrome had minimal medial epicondylectomy and in situ decompression to minimize the potential disadvantages of classic medial epicondylectomy. After a mean followup of 27 months results were excellent in 27 patients (44%), good in 23 patients (35%), fair in 10 patients (15%), and poor in four patients (6%). No ulnar nerve palsy, ulnar nerve subluxation, or medial elbow instability were seen. The main complaint of patients regarding the procedure was tenderness at the osteotomy site. The results show that minimal medial epicondylectomy and in situ decompression of the ulnar nerve is a safe and effective method to treat patients with cubital tunnel syndrome. This procedure minimizes the disadvantage of medial instability and recurrent symptoms attributable to nerve trauma after a classic medial epicondylectomy.

Study design Cross-sectional and prospective. Objectives To investigate the association between estrogen replacement therapy use, back pain, and back function in a large cohort of elderly women. Background Several studies have suggested that women who use estrogen replacement therapy may be more likely to experience back pain than those who do not. However, the relationships between estrogen replacement therapy, back pain, and impaired back function have not been clearly delineated. Methods At baseline information on estrogen replacement therapy use, functional status, back pain and function, and general lifestyle variables was obtained from 7209 elderly white women (mean age 71 years)enrolled in the Study of Osteoporotic Fractures. Lateral radiographs of the lumbar and thoracic spine were taken at baseline and at the third clinic visit, an average of 3.7 years after the baseline visit. Bone mineral density at the hip and spine was measured approximately 2 years after baseline. Follow-up information on back pain and function was also obtained at the third clinic visit. Results A total of 1039 (14.4%) women were using estrogen replacement therapy at baseline, 2016(28.0%) reported former use, and 4154 (57.6%) had never used estrogen replacement therapy. Compared with never-users, a statistically significant higher percentage of current estrogen users reported clinical back pain (52.7% vs. 43.4%) and back impairment (12.3% vs. 9.2%) at baseline and at the follow-up visit (pain 50.8% vs. 41%; impairment 16.0% vs. 12.1%). This occurred despite a higher prevalence of vertebral fractures in never-users of estrogen at the baseline visit. Current and former estrogen users without vertebral fractures had statistically significant higher likelihoods of having back pain and back dysfunction at both the baseline and third follow-up visit. The increased likelihood of back pain and back impairment in current and former estrogen users remained despite statistical adjustment for age, vertebral fracture, body mass index,smoking history, parity, exercise, arthritis, and diabetes in multivariate models. The relative risk (95%confidence interval) for impaired back function in former and current users at follow-up was 1.1 (0.9, 1.3) and 1.6 (1.3, 2.0), respectively. Conclusions Our results indicate that postmenopausal estrogen use is associated with an increased likelihood of back pain and impaired back function in elderly white women.

Background —Postmenopausal estrogen use has been associated with reduced carotid atherosclerosis in observational studies, but this relationship has not been confirmed in a clinical trial. The impact of estrogen on atherosclerotic disease in other peripheral arteries is unknown. Methods and Results —Postmenopausal women with coronary heart disease (CHD) and an intact uterus (n=2763) were randomly assigned to conjugated equine estrogens (0.625 mg) combined with medroxyprogesterone acetate (2.5 mg) daily or to placebo in a secondary CHD prevention trial. This analysis focuses on incident peripheral arterial procedures and deaths in the 2 treatment groups; peripheral vascular disease was a predefined secondary outcome. During a mean of 4.1 years of follow-up, 311 peripheral arterial events were reported in 213 women, an annual incidence of 2.9%. The number of women who had peripheral arterial events was 99 among those assigned to active estrogen/progestin and 114 among those assigned to placebo, a nonsignificant difference (relative hazard 0.87, 95% CI 0.66 to 1.14). In the placebo group, hypertension and diabetes mellitus were independently associated with higher rates of peripheral arterial events, and plasma HDL cholesterol and body mass index were associated with lower rates of peripheral arterial events. In the estrogen/progestin group, current smoking and diabetes were independent predictors of peripheral arterial events. Incident peripheral arterial disease was not a significant predictor of coronary, cardiovascular, or total mortality. Conclusions —Treatment with oral conjugated estrogen plus medroxyprogesterone acetate was not associated with a significant reduction in incident peripheral arterial events in postmenopausal women with preexisting CHD.

This retrospective study investigated outcomes of wound healing in a series of 63 consecutive patients with 64 fractures of the calcaneus who underwent open reduction and internal fixation done by two surgeons experienced in this fracture during a 3-year period. Thirty-nine patients were managed preoperatively as outpatient referrals before surgery. Twenty-four patients were admitted directly to the trauma service and were managed as inpatients preoperatively. Minimum patient follow-up was 6 months, with an average follow-up of 18 months. A trend correlating the time between injury and operative intervention with the incidence of complications in wounds was noted; the incidence rose in patients who underwent surgery5 days after their injury. Two-layered closures had a lower incidence of dehiscence compared to single-layered tension-relieving sutures. Patients with a higher body-mass index (BMI) (kg/ m2) took longer to heal their wounds. Strong trends were noted to link BMI and severity of fractures. In the outpatient group, a history of active smoking preoperatively correlated with increased time to wound healing. In 43 patients, there were no wound-healing complications. In 21 feet, there were varying degrees of wound dehiscence. Average wound healing took 47 days. Risk factors for complications in the wound after calcaneal open reduction and internal fixation include single layered closure, high BMI, extended time between injury and surgery, and smoking. Age, type of immobilization, medical illness (including diabetes), type of bone graft, or use of a Hemovac did not influence wound healing.

Recent studies have suggested that bone mineral density (BMD) is related to risk of breast cancer in elderly women. This study investigated whether the level of breast cancer risk associated with BMD in women with a positive family history of breast cancer is different from that in women without a family history of breast cancer. Radial and calcaneus BMD were measured at baseline (1986-1988) in 7,250 elderly white women enrolled in the Study of Osteoporotic Fractures, and initial breast cancer status was ascertained at year 1 of follow-up. After a mean of 3.2 years of additional follow-up, 104 incident breast cancer cases, 20 of which appeared in women with a family history of breast cancer, were identified and confirmed by medical record review. Modification of the BMD effect by family history status was assessed by inclusion of interaction terms in proportional hazards regression models. Among women without a family history of breast cancer, those with a proximal radius BMD in the highest tertile were at a 1.48-fold increased risk compared with women in the lowest tertile; among women with a positive family history of breast cancer, those with highest tertile BMD were at a 3.41-fold increased risk compared with women in the lowest tertile. These results suggest that the association between BMD and breast cancer may be different in subgroups of women defined by family history.

This study tests the hypothesis that reduced blood flow to the lower extremities may affect bone remodeling, resulting in a decrease in bone mineral density (BMD). BMD was measured in the axial and appendicular skeleton of 1292 elderly women (mean age, 71 years) enrolled in the Study of Osteoporotic Fractures. The ratio of the posterior tibial and brachial systolic blood pressures, the ankle/arm index, was used as a measure of blood flow to the legs. In the cross-sectional analysis, this index was positively correlated with BMD at the radius, calcaneus, and hip, but not at the spine. A decrease in the index of 2 standard deviations (SD) (as might occur in patients with moderate arterial disease) was associated with a decrease of 3.7% (95% CI, 1.7%, 5.8%) in hip BMD. The effect size at the hip decreased from 3.7 to 1.8% (and was not statistically significant) when adjustment was made for smoking and/or body mass index (BMI). In the prospective analysis, the rate of bone loss at the hip and calcaneus was greater (p < 0.05) among women whose annual decrease in ankle/arm index was more than 1 SD greater than the mean decrease. This increase was independent of estrogen use, smoking, BMI, pattern of fat distribution, history of diabetes, exercise, and ability to walk. The results from this prospective community-based study provide the first evidence that among relatively healthy older women decreased vascular flow in the lower extremities may be associated with an increased rate of bone loss at the hip and calcaneus.

This study is an investigation of the relationship between apolipoprotein E (apoE) phenotype, arterial disease, and mortality in a group of women (n = 1,751) aged 65 years and older enrolled in the Study of Osteoporotic Fractures. Crude mortality rates were highest among women with the 4-3 and 4-4 phenotypes but age-adjusted mortality showed no statistically significant variations across the phenotype groups. Using multivariate analysis, the mortality experience of women with 4-3 or 4-4 apoE phenotypes was compared to that of women with the 3-3 phenotype: no significant excess total mortality was found [relative risk (RR) = 1.2, 95% confidence interval (CI) 0.8, 1.8] among women with the epsilon 4 allele. Similarly, neither cardiovascular (RR = 0.9. 95% CI 0.5, 1.8) nor cancer (RR = 1.5, 95% CI 0.8, 2.8) mortality rates were significantly different in this group of women. Inclusion of cholesterol levels in the regression models did not change the relative mortality risks. Among women 65-69 year of age epsilon 4 was associated with an approximate doubling of RR for death due to both cardiovascular disease and cancer. No association was found between apoE phenotype and the presence of lower extremity arterial disease (defined as an ankle/arm index of 0.9 or less). These results suggest that women with the epsilon 4 who survive to age 70 years or beyond have a life expectancy that is similar to that for women homozygous for the 3 allele who comprise the majority of the population.

OBJECTIVE To test the hypothesis that bone mineral density (BMD) is associated with the risk of developing breast cancer in older women. DESIGN Prospective cohort study with mean (SD) follow-up of 3.2 (1.6) years. SETTING Four clinical centers, one each located in the following areas: Baltimore, Md; Minneapolis, Minn; Portland, Ore; and the Monongahela Valley in Pennsylvania. PARTICIPANTS A total of 6854 nonblack women who were 65 years of age or older and enrolled in the Study of Osteoporotic Fractures. MEASUREMENTS Radius and calcaneus BMD by single photon absorptiometry at baseline; hip and spine BMD by dual-energy x-ray absorptiometry 2 years later. MAIN OUTCOME MEASURE Breast cancer confirmed by medical record review. RESULTS A total of 97 women developed breast cancer. In the multivariate model, adjusting for age, the degree of obesity, and other important covariates, the risk of breast cancer was about 30% to 50% higher per 1 SD increase in BMD (relative risk, distal radius BMD=1.50; 95% confidence interval, 1.16-1.95). The age-adjusted incidence rate of breast cancer per 1000 person-years among women in the lowest quartile of distal radius BMD was 2.46, compared with 5.99 among women with the highest BMD. Women with BMD above the 25th percentile were at 2.0 to 2.5 times increased risk of breast cancer compared with women below the 25th percentile. Results were consistent across all BMD sites. CONCLUSIONS Bone mineral density predicts the risk of breast cancer in older women. The magnitude of the association is similar to that observed between BMD and all fractures. Our findings suggest a link between 2 of the most common conditions affecting a woman's health. Identifying a common denominator for these conditions should substantially improve our understanding of their etiology and prevention.

Objective To determine whether the ankle-arm blood pressure index is a useful predictor of mortality in a large group of patients aged 50 or older. Design Cohort study over a 13-year period. Setting Peripheral vascular laboratory in a hospital affiliated with an academic health center. Participants 1,027 male and 903 female patients referred for arterial evaluation. Outcome Measures All-cause and cause-specific mortality. Results A decrease in ankle-arm index was a strong independent predictor of all-cause mortality [relative risk (RR) for men = 1.8(95% CI 1.5, 1.9); for women = 1.5, (1.2, 2.0)] and atherosclerotic heart disease mortality [RR for men = 2.0 (1.4, 2.9); for women = 2.1 (1.4, 3.1)]. The risk of mortality was inversely proportional to the ankle-arm index. No relationship was found between the index and mortality due to stroke or cancer. Conclusions These results suggest that a decreased ankle-arm index has important prognostic significance for mortality due to atherosclerotic heart disease in older men and women. Measurement of this index may be useful in identifying those at high risk who may benefit from aggressive therapeutic intervention.

Vertebral fractures are the most common osteoporotic fracture. Hip and clinical fractures are less common in black women, but there is little information on vertebral fractures. We studied 7860 white and 472 black women ≥65 yr of age enrolled in the Study of Osteoporotic Fractures. Prevalent vertebral fractures were identified from lateral spine radiographs using vertebral morphometry and defined if any vertebral height ratio was >3 SD below race-specific means for each vertebral level. Information on risk factors was obtained by questionnaire or examination. Lumbar spine, total hip, and femoral neck BMD and BMC were measured by DXA. The prevalence of vertebral fractures was 10.6% in black and 19.1% in white women. In age-adjusted logistic regression models, a 1 SD decrease in femoral neck BMD was associated with 47% increased odds of fracture in black women (OR = 1.47; 95% CI, 1.12–1.94) and 80% increased odds in white women (OR = 1.80; 95% CI, 1.68–1.94; interaction p = 0.14). The overall lower odds of fracture among black women compared with white women was independent of femoral neck BMD and other risk factors (OR = 0.51; 95% CI, 0.37–0.72). However, the prevalence of vertebral fractures increased with increasing number of risk factors in both groups. The prevalence of vertebral fractures is lower in black compared with white women but increases with age, low BMD, and number of risk factors.

STUDY DESIGN: Retrospective database review and analysis. OBJECTIVE: The purpose of this study is to determine the rate of cervical spine injuries with correct and incorrect use of front driver and passenger-side airbags.Summary of Background Data. Although there are abundant literature showing reduced injury severity and fatalities from seatbelts and airbags, no recent studies have delineated the affect of incorrect use of airbags in cervical spine injuries. METHODS: The database from the Pennsylvania Trauma Systems Foundation was searched for drivers and front-seat passenger injuries from 1990 to 2002. The resulting records were then grouped into those using both seatbelt and the airbag, airbag-only, seatbelt-only, and no restraints. The data were then analyzed for frequency of cervical spine fractures with or without spinal cord injury and injury severity indexes. RESULTS: The drivers using the airbag-only had significantly higher rate (54.1%) of cervical fractures than those using both airbag and a seatbelt (42.1%). Overall, drivers using the airbag-alone were 1.7 times more likely to suffer a cervical spine fracture than those using both protective devices. Likewise, passengers using the airbag-alone were 6.7 times more likely to suffer from a cervical spine fracture with spinal cord injury than those using both protective devices. In addition, the injury severity indexes (Glasgow coma scale, Injury Severity Score, Intensive Care Unit stays, and Total Hospital days) were significantly worse in patients who used an airbag-only. CONCLUSION: Airbag use without the concomitant use of a seatbelt is associated with a higher incidence of cervical spine fractures with or without spinal cord injuries. Airbag misuse is also associated with higher Injury Severity Score, lower Glasgow coma scale, and longer intensive care unit and total hospital stays, indicating that these patients suffer worse injury than those who use the airbag properly. Language: en

Objectives. To determine whether older women with abdominal aortic calcification had a greater cardiovascular and all-cause mortality, as such data are limited in older adults. Design. Prospective cohort study with a mean follow-up of 13 years Setting. Community-based sample with four US clinical centres. Subjects. A total of 2056 women aged ≥65 years with abdominal aortic calcification assessed on baseline radiographs. Main outcome measure. Mortality rate (all, cardiovascular, cancer or other cause) adjudicated from death certificates and hospital records. Results. The prevalence of abdominal aortic calcification increased with age, ranging from 60% at age 65–69 years to 96% at 85 years and older. Participants with aortic calcification were more likely to die during follow-up of any cause (47% vs. 27%) or a cardiovascular-specific cause (18% vs. 11%, both P

STUDY DESIGN Repeated measures design to examine reliability and longitudinal variation of lumbar lordosis measurement. OBJECTIVES To determine the interrater reliability, minimum detectable change (MDC) and longitudinal variation of the Cobb method for measuring lumbar lordosis using standardized rules. SUMMARY OF BACKGROUND DATA The reliability of the 4-line Cobb method for measuring lumbar lordosis was not examined when standardized rules were instituted for drawing the lines. METHODS A random sample of participants was selected from the Pittsburgh clinic of the multicenter Study of Osteoporotic Fractures for radiographic measurement of lumbar lordosis reliability (n=48) and stability (n=109). A standardized version of the 4-line Cobb method was used for all measurements of lordosis. The Intraclass Correlation Coefficient (ICC) was used to calculate interrater reliability for lordosis and to measure the stability of this measure over an approximate 2-year-time period. The standard error of measurement and MDC were calculated for lordosis measurement based on the ICC value. RESULTS The interrater reliability coefficient for lumbar lordosis was in the excellent range (ICC=0.98; 95% CI: 0.95, 0.99). The MDC based on measurements between raters was 3.90 degrees. The ICC value for the stability, or reliability from time 1 to time 2, of lordosis measurement over time was 0.81 (95% CI: 0.74, 0.87). CONCLUSION This study demonstrates that the 4-line Cobb method can be a highly reliable and precise method for measuring lumbar lordosis if standardized procedures are used. The Cobb method has an MDC that is appropriate for clinical use. Also, there is minimal longitudinal variation in lordosis measurements over a 2-year period.

Placing K-wires obliquely through the anterior ulnar cortex is a common modification of traditional olecranon tension-band wiring. Wire tip protrusion, however, risks injury to adjacent neurovascular structures and may impede forearm rotation. This study examines the proximity of neurovascular structures to the anterior proximal ulnar cortex. The anatomy of 47 adult elbows was examined through magnetic resonance imaging. A radiologist measured the spatial relationship of 6 neurovascular structures to a mid-sagittal reference point 1.5 cm distal to the coronoid on the anterior surface of the ulna. Distance and angular measurements were made in the transverse plane of the reference point. Within a reasonable arc of K-wire placement, the ulnar artery and median nerve were at greatest risk yet were still beyond 10 mm from the anterior ulnar cortex. To avoid iatrogenic neurovascular injury during tension-band wiring of the olecranon, protrusion of wire tips beyond the anterior ulnar cortex should be no more than 1 cm at a distance of 1.5 cm distal to the coronoid.

OBJECTIVES: This study was designed to evaluate the efficacy and safety of immediate spica casting in the emergency room (ER) and evaluate the effect of discharge from the emergency room on short- term complications. DESIGN: Retrospective review of patients treated with immediate spica casting in the ER between June 1, 1993 and July 30, 2001. SETTING: Major, pediatric, orthopaedic trauma and referral center. PATIENTS: A total of 145 pediatric femur fractures in children, younger than age 7 years, treated with immediate spica casting in the ER were reviewed to determine radiographic outcome and short-term complication rates. INTERVENTION: All patients underwent immediate spica cast placement in the ER under conscious sedation. Patients meeting specific criteria were discharged immediately from the ER. MAIN OUTCOME MEASUREMENTS: Radiographic acceptability of alignment at fracture union (angulation, shortening), loss of reduction, number of return visits to the emergency room, and clinical outcome at final follow-up. RESULTS: Average follow-up was 20 +/- 16 weeks (range, 1-9 months). Forty-eight patients (33%) were discharged from the ER. No clinical complications were noted at last follow-up. All children younger than age 2 years, and 86.5% of children ages 2 to 5 years, met acceptable malalignment parameters on final radiographs. There were 16 ER visits (11%) for cast problems. Re-reduction in the operating room was needed in 11 patients (8.9%); 6.9% of patients had a cast problem noted during follow-up visits. Only 9% of patients developed a major complication. Initial shortening was the only independent risk factor found to be associated with loss of reduction. Admission status had no significant effect on the number of ER visits or development of a complication. CONCLUSIONS: If there are no associated factors requiring admission (ie, child abuse or polytrauma), spica casting in the ER for pediatric femur fractures followed by immediate discharge can be safely performed with a low complication rate in children younger than age 6 years, nearly eliminating the need for general anesthesia.

Background context Posterior lumbar interbody fusion (PLIF) is a popular method of arthrodesis for surgical treatment of instabilities and degenerative conditions of the spine. With the introduction of threaded titanium cage devices, surgeons began performing PLIF procedures using these cages as stand-alone devices. Complications have been reported, however, including pseudarthrosis with persistent pain. Outcomes after revision surgical treatment for these patients with failed PLIF are not known. Purpose To prospectively evaluate clinical outcomes of revision fusion surgery in patients who previously underwent posterior lumbar interbody fusion with stand-alone metallic cages resulting in pseudarthrosis. Study design/setting Prospective case series. Methods Nineteen patients referred to the senior author were evaluated and diagnosed with pseudoarthrosis having previously undergone a PLIF procedure with stand-alone metallic cages. History, physical exam, and imaging studies were performed preoperatively and postoperatively. All underwent revision posterolateral fusion with iliac crest graft and pedicle screw instrumentation. Patient demographics, SF-36, and Oswestry Disability Index (ODI) data were collected prior to surgery and two years postoperatively. Results Patients undergoing revision fusion surgery were found to have had extensive facetectomies and pseudarthrosis intraoperatively. Outcomes data was collected on eighteen of nineteen patients (95%). Mean clinical follow up was 3.2 years (range 2.5–3.5 years). Seventeen patients (94%) achieved a solid fusion. Improvement was noted in seven of eight SF-36 sub-categories, but was significant only in two (Physical Function and Role Emotional). There was no significant difference in ODI scores. Conclusions Pseudarthrosis should be considered in the differential diagnosis if severe symptoms persist in patients who undergo PLIF with stand-alone metallic cages. Successful revision fusion did not always correlate with improved clinical outcomes in these challenging patients undergoing further surgery. Performing PLIF using stand-alone metallic cages, especially after total resection of the facet joints, is not advocated unless supplemental instrumentation is utilized.

Study design The progression of intervertebral disc degeneration following anterolateral "stab" of adult rabbit lumbar discs by 16-gauge hypodermic needle to a limited (5-mm) depth was studied for up to 24 weeks using magnetic resonance imaging, radiograph, and histologic outcome measures. Objectives To develop a slowly progressive, reproducible rabbit model of intervertebral disc degeneration suitable for studying pathogenesis and pathophysiology of intervertebral disc degeneration and testing safety and efficacy of novel approaches to the treatment of intervertebral disc degeneration (e.g., growth factors, gene therapy, cell therapy, and tissue engineering). Summary of background data Numerous animal models of intervertebral disc degeneration have been proposed in the literature, each with attendant advantages and disadvantages. The classic "stab model," involving full-thickness stab of anterior anulus fibrosus of adult rabbit lumbar discs by a number 11 scalpel blade, appears to produce changes in certain biochemical and histologic outcome measures that are similar to changes seen in human intervertebral disc degeneration. However, the immediate herniation of nucleus pulposus on full-thickness stab renders this model less suitable for 1) studying effects of less precipitous changes in nucleus pulposus and anulus fibrosus that may be important in the onset and progression of intervertebral disc degeneration and 2) testing novel therapeutic approaches that target the processes of early intervertebral disc degeneration. Methods The L2-L3, L3-L4, and L4-L5 lumbar intervertebral discs of 18 skeletally mature female New Zealand White rabbits were stabbed by 16-gauge hypodermic needle to a depth of 5 mm in the left anterolateral anulus fibrosus. Serial magnetic resonance imaging scans of the stabbed discs and intact L1-L2 and L5-L6 control discs were performed at 3, 6, 12, and 24 weeks post surgery and compared with preoperative magnetic resonance images. Supplemental radiograph and histologic analyses were performed. Results The stabbed discs exhibited a progressive decrease in "magnetic resonance imaging index" (the product of nucleus pulposus area and signal intensity from T2-weighted midsagittal plane images) starting at 3 weeks post stab and continuing through 24 weeks, with no evidence of spontaneous recovery or reversal of magnetic resonance imaging changes. Radiograph findings included early osteophyte formation by 6 weeks post stab and extensive, bridging osteophytes by 24 weeks. Histologic analysis revealed progressive loss of notochordal cells from the nucleus pulposus, filling of the nucleus pulposus space with fibrocartilage, and derangement of anulus fibrosus. Conclusions Stabbing the anterolateral anulus fibrosus of adult rabbit lumbar discs with a 16-gauge hypodermic needle to a limited (5-mm) depth results in a number of slowly progressive and reproducible magnetic resonance imaging, radiograph, and histologic changes over 24 weeks that show a similarity to changes seen in human intervertebral disc degeneration. This model would appear suitable for studying pathogenesis and pathophysiology of intervertebral disc degeneration and testing safety and efficacy of novel treatments of intervertebral disc degeneration.

Musculoskeletal pain in the cervicobrachial region is considered a major health problem among adults of working age, but little is known about the impact of this pain in the elderly.Determine the prevalence of neck and shoulder pain in a well-functioning cohort, identify factors associated with this pain, assess the pattern of coexisting joint pain and evaluate the impact of this pain on physical functioning.Cross-sectional study.Black and white men and women, aged 70 to 79 years, participating in the Health, Aging and Body Composition (Health ABC) study.Not applicable.Between April 1997 and June 1998, 3,075 men and women participating in Health ABC study completed the initial home interview and clinical examination. Information was collected on musculoskeletal pain, medical history, depressive symptomatology and physical function. Physical performance measures were obtained.A total of 11.9% of participants reported neck pain of one month or more in duration and 18.9% reported shoulder pain. White women had the highest prevalence of neck pain (15.4%) and black women the highest prevalence of shoulder pain (24.3%). The correlates of both neck and shoulder pain were female gender, no education beyond high school, poorer self-rated health, depressive symptomatology and a medical history of arthritis, heart attack, angina. Increasing severity of both neck and shoulder pain was associated with an increased prevalence of joint pain at other body sites and with poor functional capacity. Measures of physical performance involving the upper extremity were also decreased.Neck and shoulder pain, either alone or in conjunction with pain in other joints, has a substantial impact on the function and well-being of the older adults in this cohort.

Background: Although foot and ankle fractures are among the most common nonspinal fractures occurring in older women, little is known about their epidemiology. This study was designed to determine the incidence of and risk factors for foot and ankle fractures in a cohort of 9704 elderly, nonblack women enrolled in the multicenter Study of Osteoporotic Fractures. Methods: At their first clinic visit, between 1986 and 1988, the women provided information regarding lifestyle, subjective health, and function. Bone mineral density was measured in the proximal and distal parts of the radius and in the calcaneus. The women were followed for a mean of 10.2 years, during which time 301 of them had a foot fracture and 291 had an ankle fracture. The fractures were classified with use of a modification of the Orthopaedic Trauma Association's guidelines. Results: The incidence of foot fractures was 3.1 per 1000 woman-years, and the incidence of ankle fractures was 3.0 per 1000 woman-years. The most common ankle fracture was an isolated fibular fracture (prevalence, 57.6%), and the most common foot fracture was a fracture of the fifth metatarsal (56.9%). Women who sustained an ankle fracture had been slightly younger at the time of study enrollment than the women who did not sustain such a fracture (71.0 compared with 71.7 years), they had a higher body mass index (27.6 compared with 26.5), and they were more likely to have fallen within the twelve months prior to filling out the original questionnaire (38.1% compared with 29.7%). The appendicular bone mineral density was not significantly different between these two groups of subjects. Women who sustained a foot fracture had a lower bone mineral density in the distal part of the radius (0.345 g/cm 2 compared with 0.363 g/cm 2 ) and a lower calcaneal bone mineral density (0.394 g/cm 2 compared with 0.404 g/cm 2 ) than the women without a foot fracture, they were less likely to be physically active (62.3% compared with 67.8%), and they were more likely to have had a previous fracture after the age of fifty (45.5% compared with 36.8%) and to be using either long or short-acting benzodiazepines. Conclusions: Overall, foot fractures appeared to be typical osteoporotic fractures, whereas ankle fractures occurred in younger women with a relatively high body mass index. Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.

Outpatient knee surgery has come to involve increasingly complex procedures. The authors present observational data from a nerve block algorithm designed for the care of outpatients undergoing knee surgery. The aim of this report is to demonstrate differences in pain and unplanned hospital admission associated with surgical complexity and nerve blocks used.Day-of-surgery outcomes were studied for 1,200 consecutive outpatients undergoing routine arthroscopy or one of six complex outpatient knee procedures. Nerve blocks were administered on the basis of anticipated pain from open incisions in the femoral and sciatic nerve distributions. Regression analysis was used to determine factors associated with postoperative pain and unplanned hospital admissions, and patients were categorized as having received femoral and sciatic nerve blocks (FSB), femoral nerve block only (FNB), or no nerve blocks.Patients undergoing more complex (vs. less invasive) knee surgery were at greater risk for pain (P/= 0.004), whereas the use of FSB (vs. FNB or no block) was associated with less pain (P0.01). When no nerve blocks were used, more complex (vs. less invasive) knee surgery was associated with a 10-fold greater risk of hospital admission (P = 0.001). In the regression analyses, more complex surgery (P0.001) was associated with increased risk of admission, and the use of FNB or FSB (vs. no block) was associated with a 2.5-fold reduction in unplanned admissions (P = 0.009).For complex knee surgery, the use of FSB was associated with less pain; the use of FNB or FSB (vs. no block) was associated with fewer hospital admissions.

Study objective To track the incidence of in-hospital postoperative nausea and vomiting (PONV) requiring postoperative parenteral nursing interventions after outpatient reconstruction of the anterior cruciate ligament (ACL) with one of two types of regional anesthesia to determine the extent to which various anesthetic techniques, preemptive antiemetics, and other factors were associated with the lowest probability of PONV. Design Retrospective chart (database) review of all ACL procedures at the University of Pittsburgh Medical Center from August 1997 through June 1999. Setting University medical center. Measurements We reviewed our institutional database of 347 consecutive patients undergoing ACL reconstruction with either spinal with femoral nerve block (SPI-FNB) or lumbar plexus and sciatic nerve block (LUM-SCI). Recorded variables and outcomes included gender, history of PONV, intravenous (IV) fentanyl before and during surgery, preemptive antiemetics given, and parenteral nursing interventions for PONV performed. Chi-square tests and logistic regression were used to determine factors associated with PONV. Main results For SPI-FNB, PONV incidence was 13% (26/208), but it was higher for LUM-SCI [25%, 34/139, p=0.002; odds ratio (OR) = 2.2]. Regression modeling demonstrated that women (OR = 2.8, p=0.003) and LUM-SCI patients (OR = 3.0, p=0.005) were at greater risk for PONV. The combination of dexamethasone (4 to 10 mg IV) and perphenazine (1.2 to 2.0 mg IV) was associated with less PONV (OR = 0.3, p=0.005). Type of local anesthetic used for lumbar plexus block was not associated with PONV incidence. Conclusions For ACL reconstruction with regional anesthesia, use of LUM-SCI was associated with a higher rate of PONV, whereas combination antiemetic prophylaxis with perphenazine and dexamethasone was associated with less PONV.

Twenty patients with persistent symptoms of medial elbow pain after previous cubital tunnel surgery were evaluated during reoperation, for injury of the medial antebrachial and medial brachial cutaneous nerves at the time of reoperation. Abnormalities of the medial cutaneous nerves were found in 65 percent of the patients. A neuroma was found in 40 percent of the patients. The neuromas were treated surgically by excision, stump cauterization, and relocation into muscle. All patients had revision release of the cubital tunnel. The results were analyzed after a mean follow-up of 26 months. The results of the 13 patients with injured cutaneous nerves tended to be worse ( p=0.065) than the results of seven patients without such findings.

Study design A retrospective review of medical records and imaging studies of children diagnosed with spinal cord injury without radiographic abnormality (SCIWORA) or SCIWORA-like symptoms at Children's Hospital of Pittsburgh between 1965 and 1999 was undertaken. Objectives To evaluate the existence of occult segmental spinal instability and a role for bracing as treatment for SCIWORA, we contrasted the Children's Hospital of Pittsburgh experience with literature reports on SCIWORA. Summary of background data There is a great deal of confusion and conflicting evidence regarding pediatric SCIWORA in the literature. Previous reports from our institution reported unique findings, including the only description of serious, recurrent SCIWORA in the literature. These findings have frequently been cited as the justification for long-term immobilization in all cases of SCIWORA. Methods All records on patients coded as spinal cord injury without fracture or dislocation (ICD-9 code 952.xx) were reviewed. Children 17 years of age or younger with traumatic spinal cord injury and normal plain radiographic findings were included. Penetrating trauma, infection, or metabolic diseases were excluded. Results A total of 189 patients were diagnosed with SCIWORA at our institution over the 35-year review period. These patients differed from those reported in the literature with respect to a higher incidence, older age, less involved neurologic injury, and more low-energy mechanisms, such as sports and falls. There were no cases of a patient with SCIWORA who deteriorated and developed a permanent neurologic deficit after having either recovered or plateaued from an initial SCIWORA. All recurrent SCIWORA recovered to normal neurologic function. Bracing did not demonstrate any benefit in preventing these minor recurrent SCIWORAs. Conclusion We identified no cases of serious, recurrent SCIWORA at our institution from 1965 to 1999. A case-by-case evaluation is required for the treatment of spinal cord injury without apparent spinal column injury, and bracing is not uniformly indicated.

Background The authors recently proposed a recovery scoring system for outpatients receiving regional anesthesia (RA) or general anesthesia (GA). This scoring system was designed to allow qualifying patients to be directly routed to the phase II (step-down) recovery unit instead of the traditional postanesthesia care unit (PACU). We report PACU bypass rates using these criteria, and the extent to which PACU bypass was associated with (1) required nursing interventions in the step-down recovery unit, and (2) successful same-day discharge. Methods Day-of-surgery outcomes were studied for 894 outpatients undergoing outpatient sports medicine surgery on the lower extremity. We determined PACU-bypass rates, nursing interventions in the step-down recovery unit for common symptoms, and unplanned hospital admissions. Using logistic regression, we analyzed step-down nursing interventions based on PACU requirement versus PACU bypass, and anesthesia techniques used (GA vs. not, peripheral nerve blocks vs. not). Results Eighty-seven percent (778/894) of all patients bypassed PACU. Of PACU-bypass patients, 241/778 (31%) required step-down nursing interventions. Of patients requiring PACU, only 19/116 (16%) required additional interventions in step-down (P < 0.001). PACU-bypass patients were almost three times more likely (odds ratio 2.9,P < 0.001) to require at least one nursing intervention in the step-down unit, when compared with patients requiring PACU. Fewer unplanned admissions were required by patients who bypassed PACU (odds ratio = 0.3,P = 0.007). Conclusions For outpatient lower extremity surgery, applying our PACU-bypass criteria led to an 87% PACU bypass rate with no reportable adverse events.

Background. The objective of this study was to determine the prevalence of lower back pain and associated leg pain/ numbness in postmenopausal Caucasian women and the relationship of these symptoms to health status and function. Methods. A convenience sample of 573 white women enrolled in the Observational Study of the Women’s Health Initiative (WHI) in Pittsburgh completed a questionnaire on low back pain (LBP) and leg pain (LP) and its impact on their daily activity. For data analysis, this information was merged with that obtained under the standard WHI protocol. Results. Almost half of the women (49%) reported having had LBP during the previous month: 8% had LBP only, while 41% had both LBP and LP. In 9% of women, the leg and back symptoms were alleviated by sitting. Among women with LBP during the previous month, those who also had leg pain were five times more likely to have had functional limitations, two to four times more likely to have consulted a clinician or taken medications, and more likely to have had prior spinal surgery or hospitalization than the women with no LP. Based on the Short Form-36, women with LBP/LP had significantly lower scores for physical function, physical role, and bodily pain than women with no LBP or with LBP alone. Conclusions. Low back pain that radiates into the hip, buttock, or leg is relatively common in postmenopausal Caucasian women living in the community and is associated with decreased physical health status and with physical limitations.

The evaluation and treatment of the stiff elbow are described, as well as the lateral, medial, anterior, and posterior approaches for release of elbow contractures. The results after surgical release in 48 patients that failed nonoperative treatment for elbow contractures in our institution are reported. A literature review is provided.

OBJECTIVES: To determine the incidence of distal radius fractures and the characteristics of those fractures and to identify the key risk factors. DESIGN: Prospective cohort study, mean follow-up of 9.8 years. SETTING: Four clinical centers, one each in Baltimore, Maryland; Minneapolis, Minnesota; Pittsburgh, Pennsylvania; and Portland, Oregon. PARTICIPANTS: Nine thousand seven hundred four white women aged 65 and older, enrolled in the multicenter Study of Osteoporotic Fractures. METHODS: Five hundred twenty-seven distal radius fractures were confirmed by physician review of radiology reports; characteristics of the fractures were noted. Information was also collected on lifestyle, demographics, bone mineral density (BMD), and clinical and performance measures. RESULTS: The overall incidence of fracture was 7.3/1,000 person-years. Twenty-seven percent of the fractures were intra-articular; 73% were extra-articular. The independent predictors of fracture were decreased BMD (per 0.1 g/cm2) at the distal radius ( relative risk ( RR) = 1.8, 95%confidence interval ( CI) = 1.6–2.1), a history of recurrent falls ( RR = 1.6, 95%CI = 1.2–2.0), and having had a previous fracture since age 50 ( RR = 1.3, 95%CI = 1.1–1.6). Current use of oral estrogen was protective ( RR = 0.6, 95%CI = 0.4–0.8). For women aged 75 and older, poor cognitive status was also a predictor of wrist fracture. Intra-articular fractures occurred more than twice as frequently in women with diabetes mellitus. CONCLUSIONS: This is the first large long-term comprehensive study of distal radius fractures in older people. The results indicate that factors predictive of distal radius fractures can easily be assessed in routine clinical practice and can identify women at high risk for fracture. Selected preventive strategies could be designed to reduce the incidence of these fractures.

Study design A Cross-sectional study. Objectives To determine the prevalence of lumbar olisthesis among white women aged 65 years and older and its relation to low back pain and back function. Background Degenerative changes in the lumbar spine of elderly individuals may affect spinal stability, causing olisthesis (subluxation) of the lumbar spine. Neither the prevalence of this condition in the United States nor its relation to back symptoms has been studied previously. Methods Lateral radiographs of the lumbar spine for 788 women aged 65 years and older who were enrolled in the Study of Osteoporotic Fractures were digitized. Olisthesis (antero- and retro-) was assessed at L3-L4, L4-L5, and L5-S1. Back pain and function also were assessed. Results When olisthesis was defined as subluxation of 3 mm or more at any of the three levels studied, the overall prevalence of anterolisthesis was 29% and that of retrolisthesis was 14%. In 90% of women with anterolisthesis and 88% of women with retrolisthesis, subluxation occurred at a single vertebral level. The prevalence of anterolisthesis and retrolisthesis did not vary by smoking status, presence of diabetes, or history of oophorectomy. Anterolisthesis was not associated with the presence of back symptoms. Only retrolisthesis at L3-L4 was associated with a statistically significantly increased likelihood of lower back pain, greater severity of back pain, and impairment of back function. Conclusions Anterolisthesis of 3 mm or more in the lower lumbar spine is relatively common among elderly women but is not correlated with back problems. Retrolisthesis at L3-L4 is associated with increased back pain and impaired back function.

Study Design. A cross-sectional and prospective study of osteoporotic fractures. Objectives. To investigate the correlation between lower extremity arterial disease or history of cardiovascular disease and back pain, back function, osteoporosis, and vertebral fractures. Background. It has been postulated that atherosclerosis may compromise blood flow to bone and soft tissues in the back, causing pain and disability. Recent studies have presented conflicting results. Methods. At baseline, information on back pain and function, general functional status, cardiovascular history, and general lifestyle variables was obtained from 1492 elderly white women (mean age, 71 years) enrolled in the Study of Osteoporotic Fractures. Lateral radiographs of the lumbar-and thoracic spine were obtained, and lower extremity arterial disease was assessed. Follow-up information was obtained an average of 3.7 years later. Results. At baseline, 82 women had arterial disease, 443 had a history of cardiovascular disease, and 277 had vertebral fractures: 58 women had one or more additional vertebral fractures during the follow-up period. After adjustment for age, women with cardiovascular disease were more likely to have back pain and disability as a result of the back pain than women free of cardiovascular disease; at the follow-up examination, the back-related disability was more than twice as likely to have worsened in the cardiovascular disease group. No correlation was found between arterial disease and back problems. Neither the prevalence of vertebral fractures at baseline, nor the incidence of vertebral fractures was associated with the presence of arterial disease or cardiovascular disease. Conclusions. Results indicated that back problems in elderly women are associated with self-reported cardiovascular disease, but not with objectively assessed lower extremity arterial disease.