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ABSTRACT: Lumbar spinal stenosis is an irreversible and progressive process. If not recognized and managed appropriately, it can lead to substantial morbidity involving back pain and leg dysfunction. Because more [...]

• Steps/d at 6 weeks was associated with decreased disability and pain at 1 year. • Steps/d at 6 weeks was associated with no opioid use at 1 year after spine surgery. • Threshold of 3500 steps/d may serve as initial early postoperative recommendation after lumbar spine surgery. To investigate whether early postoperative walking is associated with "best outcome" and no opioid use at 1 year after lumbar spine surgery and establish a threshold for steps/day to inform clinical practice. Secondary analysis from randomized controlled trial. Two academic medical centers in the United States. We enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition (N=248). A total of 212 participants (mean age, 62.8±11.4y, 53.3% female) had valid walking data at baseline. Not applicable. Disability (Oswestry Disability Index), back and leg pain (Brief Pain Inventory), and opioid use (yes vs no) were assessed at baseline and 1 year after surgery. "Best outcome" was defined as Oswestry Disability Index ≤20, back pain ≤2, and leg pain ≤2. Steps/day (walking) was assessed with an accelerometer worn for at least 3 days and 10 h/d at 6 weeks after spine surgery, which was considered as study baseline. Separate multivariable logistic regression analyses were conducted to determine the association between steps/day at 6 weeks and "best outcome" and no opioid use at 1-year. Receiver operating characteristic curves identified a steps/day threshold for achieving outcomes. Each additional 1000 steps/d at 6 weeks after spine surgery was associated with 41% higher odds of achieving "best outcome" (95% confidence interval [CI], 1.15-1.74) and 38% higher odds of no opioid use (95% CI, 1.09-1.76) at 1 year. Walking ≥3500 steps/d was associated with 3.75 times the odds (95% CI, 1.56-9.02) of achieving "best outcome" and 2.37 times the odds (95% CI, 1.07-5.24) of not using opioids. Walking early after surgery may optimize patient-reported outcomes after lumbar spine surgery. A 3500 steps/d threshold may serve as an initial recommendation during early postoperative counseling. [ABSTRACT FROM AUTHOR]

Background: Spine surgery outcomes are variable. Patients who participate in and take responsibility for their recovery have improved health outcomes. Interventions to increase patient involvement in their care may improve health outcomes after a surgical procedure. We conducted a prospective interventional trial to compare the effectiveness of health behavior change counseling with usual care to improve health outcomes after lumbar spine surgical procedures.Methods: In this study, 122 patients with lumbar spinal stenosis undergoing a decompression surgical procedure from December 2009 through August 2012 were enrolled. Participants were assigned, according to enrollment date, to health behavior change counseling or usual care. Health behavior change counseling is a brief, telephone-based intervention intended to increase rehabilitation engagement through motivational interviewing strategies that elicit and strengthen motivation for change. Health behavior change counseling was designed to identify patients with low patient activation, to maximize postoperative rehabilitation engagement, to decrease pain and disability, and to improve functional recovery. Participants were assessed before the surgical procedure and for 3 years after the surgical procedure for pain intensity (Brief Pain Inventory), disability (Oswestry Disability Index), and physical health (12-Item Short-Form Health Survey, version 2). Differences in changes in health outcomes after the surgical procedure were compared between the health behavior change counseling group and the usual care group.Results: By 12 months, health behavior change counseling participants reported significantly greater reductions in pain intensity (p = 0.008) and disability (p = 0.028) and significantly greater improvement in physical health compared with usual care participants (p = 0.025). These differences were attenuated by 24 and 36 months after the surgical procedure. Early improvements in health outcomes were mediated by improvements in physical therapist-rated engagement and self-reported attendance at physical therapy sessions in the health behavior change counseling group.Conclusions: Health behavior change counseling improved health outcomes during the first 12 months after the surgical procedure through changes in rehabilitation engagement. Wider use of health behavior change counseling may lead to improved outcomes not only after lumbar spine surgery but also in other conditions for which rehabilitation is key to recovery.Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Widespread use of recombinant human bone morphogenetic protein (rhBMP) in cervical spine surgery has continued despite the U.S. Food and Drug Administration's 2008 notification regarding its adverse effects. Our study goals were to analyze how patient, surgical, and institutional factors influenced rhBMP use in cervical spinal fusion surgery and to examine the cervical-spine-specific in-hospital complications associated with rhBMP use. Methods: The Nationwide Inpatient Sample database was used to identify 1,064,372 patients eighteen years or older who had undergone cervical spinal fusion surgery from 2003 through 2010. Of these patients, 84,726 (7.96%) received rhBMP. Multivariate logistic regression models were used to analyze patient, surgical, and institutional factors associated with rhBMP use, and the relationship between rhBMP use and the development of in-hospital complications. Results: On multivariate analysis, patient age and sex, insurance type, surgical approach, use of autograft bone, and hospital teaching status, size, and region were significant predictors of rhBMP use. Use of rhBMP was a significant predictor of complications on univariate analysis and on multivariate analysis adjusted for patient age and sex, Charlson comorbidity score, insurance status, surgical approach, autograft bone use, and hospital teaching status, size, and region. Use of rhBMP was significantly associated with the development of dysphagia (prevalence, 2.0%; adjusted odds ratio [OR], 1.53), dysphonia (prevalence, 0.28%; adjusted OR, 1.48), hematoma/seroma formation (prevalence, 0.7%; adjusted OR, 1.24), and neurological complications (prevalence, 0.84%; adjusted OR, 2.0). These complications were most commonly found after anterior cervical fusion surgery. Wound infections and neurological complications were most commonly found after posterior cervical fusion surgery. Dysphagia was most commonly found after circumferential fusion surgery. Conclusions: Indications for rhBMP use for cervical spinal fusion are multifactorial. Its use is associated with a significantly higher likelihood of cervical-spine-specific complications. [ABSTRACT FROM AUTHOR]

This article describes a rare congenital abnormality of anterior and posterior C1 fusion failure presenting after an acute athletic injury to the fibrous nonunion. C1 congenital malformations are rare, occurring in approximately 2% of patients; even rarer are combined anterior and posterior arch malformations in the same patient. Posterior ring abnormalities are more common than anterior ring injuries (4.5:1, respectively). To the authors' knowledge, combined anterior and posterior ring congenital malformations with subsequent injury have not been previously described. In the current patient, a congenital failure of fusion of the anterior and posterior arches of C1 was identified. The anterior fibrous nonunion was injured while the patient played football, leading to transient neurologic injury and dysphagia from soft tissue swelling. The patient was initially diagnosed with an acute fracture at another facility; however, given advanced imaging, flexion and extension views, and a normal neurologic examination, the authors diagnosed a traumatized congenital defect. The injury healed with a short period of cervical collar immobilization and supportive measures. Such malformations are usually found incidentally, but they can be symptomatic after trauma. Images to distinguish these deficits can be difficult because the differences between chronic nonunions and congenital malformations are subtle. Surgery is rarely indicated for congenital malformations because they are often stable even after injury; however, they may predispose patients to neurologic injury in the future with high-risk activities. Because the current patient had an increased chance of future injury secondary to the lack of bone formation in the C1 vertebrae, he was restricted from participating in contact sports. [ABSTRACT FROM AUTHOR]

Background: Despite advances in surgical techniques, outcomes after spine surgery are highly variable. Recent research has highlighted the importance of individuals participating in, and taking responsibility for, their health and recovery. Patient activation, defined as an individual's propensity to engage in adaptive health behaviors leading to improved health outcomes, has been identified as a potentially important factor in this process. Our goal was to determine the association between preoperative patient activation and functional recovery after lumbar spine surgery. Methods: We prospectively followed sixty-five consecutive patients undergoing lumbar spine surgery from August 2005 through May 2006. Patient activation was assessed preoperatively as one of four stages. We assessed pain intensity, disability, and functional status preoperatively and postoperatively with use of a numeric rating scale for pain, the Oswestry Disability Index, and the Medical Outcomes Study Short Form-12 (version 2). Comparisons were made for disability and functional status as a function of patient activation. Repeated-measures linear regression models were used to test the association between patient activation and functional recovery over time. Results: Preoperatively, we rated participant activation as low (Stage I, fifteen patients), high (Stage IV, sixteen patients), and intermediate (Stage II, twelve patients; Stage III, twenty-two patients; total, thirty-four patients). Overall, pain and disability decreased after surgery (p < 0.05). Stage-IV participants experienced a greater degree of decrease in pain (p = 0.049) and disability (p = 0.035) than did Stage-I participants: Overall, physical and mental health improved after surgery (p < 0.05), but only physical health differed according to patient activation, with a significantly smaller improvement in Stage-I participants than in Stage-lV participants (p = 0.044). Conclusions: High patient activation was associated with better recovery after surgery. Increased patient activation may lead to improved functional recovery through increased physical therapy adherence after spine surgery in adults. [ABSTRACT FROM AUTHOR]

Background: The minimum clinically important difference is a clinically relevantthreshold of improvement. A substantial clinical benefit is a threshold of change that correlates with clinically important improvement. The Cervical Spine Out comes Questionnaire is a disease-specific, patient-reported outcomes instrument that was developed to be sensitive to changes associated with surgical treatment for degenerative cervical disc disease. To determine thresholds for change in these domain scores that are important from the patient's perspective, we estimated the minimum clinically important dtfference and substantial clinical benefit values for this questionnaires domain scores. Methods: We evaluated 252 patients from the Cervical Spine Reseamh Society Outcomes Study at their six-month follow-up visits after anterior cervical spine decompression and arthrodesis. Using a receiver operating characteristics curve, with the health transition item of the Short Fon-n-36 as an anchor, we determined that the minimum clinically important difference (the value that maximized sensitivity and specificity to differentiate the "somewhat better" and "much better' responses from others) and the substantial clinical benefit (the value that maximized sensitivity and specificity to differentiate the "much better response from others) for our questionnaire's domain scores. Responses were scaled between 0 and 1 point; higher scores denoted more severe impairment. Patient and clinical characteristics were tested to determine their influence on score changes. Results: The minimum clinically important difference ranged from 0.13 point (for functional disability) to 0,24 point (for arm/shoulder pain). The substantial clinical benefit score ranged from 0.20 point (for functional disability or physical symptoms otherthan pain)to 0.30 point (for neck or arm/shoulder pain). Age, sex, and duration of current symptoms were not associated with change in our questionnaire's domain scores. Conclusions: A O..13-point change in the functional disability domain score inchcated a clinically important difference in a self-reported outcome after anterior cervical spine surgery. A 0.30-point change in neck pain after surgery indicated a clinically important clinical benefit. This information, coupled with previous reports of the psychometric stability of the Cervical Spine Outcomes Questionnaire, should increase the clinical utility of this patient-reported outcomes instrument. [ABSTRACT FROM AUTHOR]

The article presents an overview of the specialized pulse sequences and imaging techniques that are available for evaluation of the human spine and the defining characteristics of the three compartments into which spinal tumors can be classified. A discussion of the types of tumors that are commonly encountered in the spine is presented. The process of magnetic resonance imaging is examined.

The article discusses pelvic bones fixation in spine surgery. Fusions of the lumbosacral spine continue to be a challenging area in spine surgery. The complex local anatomy, unique biomechanical forces, and poor bone quality of the sacrum are just a few of the many reasons why fusions of the lumbosacral spine have been notoriously difficult to perform. The sacrum, which functions as the keystone that unites the two hemipelves, consists of five fused vertebrae with transverse processes that merge into a thick, continuous lateral mass.

The altered mechanical environment due to a rigid fixation is considered as the cause of degeneration at the adjacent levels. A canine in vivo study was performed to investigate the long-term effects of spinal fusion with instrumentation across the L5-sacrum on the flexibility and viscoelastic properties of the adjacent L4–5 disc. Five experimental dogs underwent a posterior fusion with Isola transpedicular instrumentation from L5 to sacrum and were euthanized 30 weeks postoperatively. A solid fusion was achieved across L5–L7 levels, but substantial motion persisted at the L7-sacrum segment. Biomechanical tests were performed to measure the flexibility and viscoelastic properties of the intervertebral disc above the instrumented spinal fusion in the experimental and nonoperated control groups. No statistically significant differences in the flexibility and viscoelastic responses of the adjacent L4–L5 segment were found between the control and experimental groups. Fusion of the L5–L7 segments did not significantly affect the flexibility and viscoelastic properties of the L4–5 disc at 30 weeks postoperatively in the mongrel dog spine. [ABSTRACT FROM AUTHOR]

Focuses on educational opportunities of medical students and surgeons offered by the American Academy of Orthopedic Surgeons. Goal to meet the expectations in academic practice; Commitment to help young members to establish a relationship with the Academy; Formation of a resident liaison council accredited by the orthopedic residency program.

BACKGROUND CONTEXT The Affordable Care Act (ACA) aimed to (1) make affordable health insurance available to more people (2) expand Medicaid to cover all low-income adults and (3) lower health care costs. In practice, the effectiveness of the ACA has been highly debated. With implementation, the percent uninsured decreased in all race or ethnic groups – decreasing the White-Black and White-Hispanic coverage gap for both private and public health insurance. Using data from 2000 to 2009, we have demonstrated that Black and Hispanic patients undergo surgery at significantly reduced rates compared to White patients (0.59 and 0.34 vs. 1.07 per 1,000 persons, respectively) after adjusting for age, gender, insurance coverage and geographic region. PURPOSE To determine whether ACA passage reduced the White-Black and White-Hispanic gap in rate of lumbar spine surgery. STUDY DESIGN/SETTING Nationwide Inpatient Sample and March Supplement of the Current Population Survey for 2006-2014. PATIENT SAMPLE Hospital discharge data for admissions meeting strict ICD-9CM based criteria for definite lumbar surgery – diagnosis of herniated disc, disc degeneration, spinal stenosis, instability or low back problems with procedure of laminectomy, discectomy or fusion – in the absence of primary cervical or thoracic pathology or procedure. OUTCOME MEASURES Rate of definite lumbar spine surgery calculated as number of hospital discharges divided by the population estimate, matched for socio-demographic characteristics. Calendar year was stratified for ACA passage: 2006-2010; 2011-2014. METHODS Using probability weights, Poisson regression was used to model the rate of hospital discharge for definite lumbar spine surgery as a function of race/ethnicity after adjusting for adjusting for age, gender, insurance coverage and geographic region. To determine the effect of ACA passage, we examined the interaction of calendar year (stratified before and after ACA passage) and race/ethnicity. Significant post-ACA passage interaction terms would indicate a change in White-Black or White-Hispanic gap. RESULTS Using our diagnostic criteria, there were 3.2 million hospital discharges (1.9 million before and 1.3 million after ACA passage). After ACA passage, the overall median discharge rate decreased (1.84 vs. 1.58, p<.001). Before ACA passage, median unadjusted discharge rates were 1.82 for White, 0.78 for Black and 0.54 for Hispanic patients. After ACA passage, unadjusted rates increased across all groups: 1.85 for White, 0.93 for Black and 0.65 for Hispanic. When adjusting for socio-demographic factors, the White-Black gap in hospital discharge decreased from 0.40:1 to 0.44:1 with ACA passage (p<.001). A similar narrowing of the White-Hispanic gap was observed (0.35:1 to 0.38:1, p<.001). Comparing states that did not expand Medicaid to those that did, there were differences in the post-ACA passage White-Black (0.41:1 vs. 0.45:1) and White-Hispanic (0.38:1 vs. 0.41:1) gap in hospital discharge. CONCLUSIONS Based on population-adjusted data, there were marked decreases in the White-Black and White-Hispanic gap in hospital discharge for definite lumbar spine surgery after ACA passage. The gap was further reduced among those states that expanded Medicaid coverage to all low income adults (income below 138% of federal poverty level). This preliminary evidence demonstrates the utility of expanding insurance coverage to allow equitable musculoskeletal care. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Context: Since implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, more Americans have health insurance, and many racial/ethnic disparities in healthcare have improved. We previously reported that Black and Hispanic patients undergo surgery for spinal stenosis at lower rates than do white patients.Purpose: To assess changes in racial/ethnic disparities in rates of lumbar spinal surgery after passage of the ACA.Study Design: Retrospective analysis.Patient Sample: Approximately 3.2 million adults who underwent lumbar spinal surgery in the US from 2006 through 2014.Outcome Measures: Racial disparities in discharge rates before versus after ACA passage.Methods: Using the Nationwide Inpatient Sample, the U.S. Census Bureau Current Population Survey Supplement, and International Classification of Diseases, Ninth Revision, Clinical Modification, criteria for definite lumbar spinal surgery, we calculated rates of lumbar spinal surgery as the number of hospital discharges divided by population estimates and stratified patients by race/ethnicity after controlling for sociodemographic characteristics. Calendar years were stratified as before ACA passage (2006-2010) or after ACA passage (2011-2014). Poisson regression was used to model hospital discharge rates as a function of race/ethnicity before and after ACA passage after adjustment for potential confounders.Results: All rates are expressed per 1,000 persons. The overall median discharge rate decreased from 1.9 before ACA passage to 1.6 after ACA passage (p < .001). After adjustment for sociodemographic factors, the Black:White disparity in discharge rates decreased from 0.40:1 before ACA to 0.44:1 after ACA (p < .001). A similar decrease in the Hispanic:White disparity occurred, from 0.35:1 before ACA to 0.38:1 after ACA (p < .001).Conclusion: Small but significant decreases occurred in racial/ethnic disparities in hospital discharge rates for lumbar spinal surgery after ACA passage. [ABSTRACT FROM AUTHOR]