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Study Design: Retrospective review. Objective: Previous literature demonstrates mixed results regarding the relationship between patient-reported allergies and pain, function, and satisfaction scores. The objective of this study was to investigate the correlation between patient-reported allergies and preoperative Oswestry Disability Index (ODI), Neck Disability Index (NDI), and Patient-Reported Outcomes Measurement System (PROMIS) scores. Methods: All patients undergoing elective cervical, lumbar procedures between May 2017 and October 2018 were included. Baseline demographic information was recorded, as well as all reported allergies or adverse reactions. Preoperative PROMIS, ODI, and NDI scores were recorded. Hierarchical multiple linear regressions were used to assess the relationship between total number of allergies and the preoperative pain and function scores. Results: A total of 570 patients were included (476 lumbar, 94 cervical). The mean number of allergies reported was 1.89 ± 2.32. The mean preoperative ODI and NDI scores were 46.39 ± 17.67 and 43.47 ± 16.51, respectively. The mean preoperative PROMIS Physical Health and PROMIS Mental Health scores were 37.21 ± 6.54 and 43.89 ± 9.26, respectively. Hierarchical multiple linear regression showed that total number of reported allergies shared a statistically significant negative relationship with all of the following scores: ODI ( B = 0.83, P = .02), NDI ( B = 1.45, P = .02), PROMIS Physical Health ( B = −0.29, P = .013), and PROMIS Mental Health ( B = −0.38, P = .024). Conclusions: Patient-reported allergies share a statistically significant negative relationship with preoperative pain and function scores; as patients have increasing total number of allergies, the ODI/NDI scores become worse (increase) and the PROMIS scores become worse (decrease).

Objective : Spinal epidural abscesses (SEA's) are a challenge to diagnose, particularly if there are non-contiguous (skip) lesions. There is also limited data to predict which patients can be treated with antibiotics alone and which require surgery. We sought to assess which demographics, clinical and laboratory findings can guide both diagnosis and management of SEA's. Methods All patients with SEA (ICD9 324.1, ICD10 G06.1) between April 2011-May 2019 at a single tertiary center were included. A retrospective EMR review was completed. Patient and disease characteristics were compared using appropriate statistical tests. Results 108 patients underwent initial surgical treatment versus 105 that were treated medically initially; 22 (21 %) of those failed medical management. Patients who failed medical management had significantly higher CRP, longer symptom duration, and had higher rates of concurrent non-spinal infections. 9% of patients had skip lesions. Patients with skip lesions had significantly higher WBC, ESR, as well as higher rates of bacteremia and concurrent non-spinal infections. Demographic characteristics and proportion with IVDU, smoking, malignancy, and immunosuppression were similar among the three treatment groups. Conclusions 21 % of SEA patients failed initial medical management; they had significantly greater CRP, longer symptom duration, more commonly had neurologic deficits, and concurrent non-spinal infections. 9% of patients had skip lesions; they had significantly higher WBC, ESR, rates of bacteremia and infections outside the spine. These variables may guide diagnostic imaging, and identify those at risk of failing of medical management, and therefore require more involved clinical evaluation, and consideration for surgical intervention.

Randomized trial with a concurrent observational cohort study.To compare 8-year outcomes between surgery and nonoperative care and among different fusion techniques for symptomatic lumbar degenerative spondylolisthesis (DS).Surgical treatment of DS has been shown to be more effective than nonoperative treatment out to 4 years. This study sought to further determine the long-term (8-year) outcomes.Surgical candidates with DS from 13 centers with at least 12 weeks of symptoms and confirmatory imaging were offered enrollment in a randomized controlled trial (RCT) or observational cohort study (OBS). Treatment consisted of standard decompressive laminectomy (with or without fusion) versus standard nonoperative care. Primary outcome measures were the Short Form-36 (SF-36) bodily pain and physical function scores and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and yearly up to 8 years.Data were obtained for 69% of the randomized cohort and 57% of the observational cohort at the 8-year follow up. Intent-to-treat analyses of the randomized group were limited by high levels of nonadherence to the randomized treatment. As-treated analyses in the randomized and observational groups showed significantly greater improvement in the surgery group on all primary outcome measures at all time points through 8 years. Outcomes were similar among patients treated with uninstrumented posterolateral fusion, instrumented posterolateral fusion, and 360° fusion.For patients with symptomatic DS, patients who received surgery had significantly greater improvements in pain and function compared with nonoperative treatment through 8 years of follow-up. Fusion technique did not affect outcomes.1.

Study Design: Retrospective observational study. Objective: There is marked variation in the management of nonoperative thoracolumbar (TL) compression and burst fractures. This was a quality improvement study designed to establish a standardized care pathway for TL fractures treated with bracing, and to then evaluate differences in radiographs, length of stay (LOS), and cost before and after the pathway. Methods: A standardized pathway was established for management of nonoperative TL burst and compression fractures (AOSpine classification type A1-A4 fractures). Bracing, radiographs, costs, complications, and LOS before and after pathway adoption were analyzed. Differences between the neurosurgery and orthopedic spine services were compared. Results: Between 2012 and 2015, 406 nonoperative burst and compression TL fractures were identified. A total of 183 (45.1%) were braced, 60.6% with a custom-made thoracolumbosacral orthosis (TLSO) and 39.4% with an off-the-shelf TLSO. The number of radiographs significantly reduced after initiation of the pathway (3.23 vs 2.63, P = .010). A total of 98.6% of braces were custom-made before the pathway; 69.6% were off-the-shelf after the pathway. The total cost for braced patients after pathway adoption decreased from $10 462.36 to $8928.58 ( P = .078). Brace-associated costs were significantly less for off-the-shelf TSLO versus custom TLSO ($1352.41 vs $3719.53, respectively, P < .001). The mean LOS and complication rate did not change significantly following pathway adoption. The orthopedic spine service braced less frequently than the neurosurgery service (40.7% vs 52.2%, P = .023). Conclusions: Standardized care pathways can reduce cost and radiation exposure without increasing complication rates in nonoperative management of thoracolumbar compression and burst fractures.

BACKGROUND: To evaluate charges, expenses, reimbursement, and hospital margins with noninstrumented posterolateral fusion in situ (PLF), posterolateral fusion with pedicle screws (PPS), and PPS with interbody device (PLIF) in degenerative spondylolisthesis with spinal stenosis. METHODS: A retrospective chart review was performed from 2010 to 2014 based on ICD-9 diagnoses of degenerative spondylolisthesis with spinal stenosis in patients undergoing single-level fusions. All charges, expenses, reimbursement, and margins were obtained through financial auditing. A multivariate linear regression model was used to compare demographics, charges, etc. A 1-way analysis of variance with Tukey post hoc analysis was used to analyze reimbursements and margins based upon insurances. RESULTS: Two hundred thirty-three patients met inclusion criteria. The overall charges and expenses for PLF were significantly less compared to both types of instrumented fusions (P

Objective Although the primary goal of treatment of type II odontoid fracture is bony union, some advocate continued nonsurgical management of minimally symptomatic older patients who have fibrous union or minimal fracture motion. The risk of this strategy is unknown. We reviewed our long-term outcomes after dens nonunion to define the natural history of Type II odontoid fractures in elderly patients managed nonoperatively. Methods A retrospective chart review of 50 consecutive adults aged 65 or older with Type II odontoid fracture initially managed nonsurgically from 1998 to 2012 at a single tertiary care institution was conducted. Particular attention was paid to patients who had orthosis removal despite absent bony fusion. Patients were contacted prospectively by telephone and followed until death, surgical intervention, or last known contact. Results Fifty patients initially were managed nonsurgically; of these, 21 (42.0%) proceeded to bony fusion, 3 (6%) underwent delayed surgery for persistent instability, and 26 (52%) had orthosis removal despite the lack of solid arthrodesis on imaging. The last group had a median follow-up of 25 months (range 4–158 months), with 20 of 26 (76.9%) followed until death. Of these patients, 1 patient developed progressive quadriplegia and dysphagia 11 months after initial injury. Compared with patients with spontaneous union, patients with nonunion had shorter life expectancy, despite no significant differences between the groups with respect to age, sex, injury mechanism, radiographic variables, or follow-up duration. Conclusions Orthosis removal despite fracture nonunion may be reasonable in elderly patients with Type II dens fractures.

BACKGROUND CONTEXT Surgical management of degenerative spondylolisthesis (DS) with spinal stenosis (SS) remains controversial, as studies reveal that fusion technique may not affect outcomes. Various considerations may drive the decision to which type of fusion to use, including patient, surgeon and economic factors. PURPOSE This study was designed to characterize different charges, expenses, reimbursement, and hospital margins with non instrumented fusion in situ (PLF), posterolateral fusion with pedicle screws (PPS), and PPS with interbody device (PLIF). STUDY DESIGN/SETTING Retrospective chart review with corresponding financial audit. PATIENT SAMPLE All patients undergoing single level fusions from 2009-2014 based on ICD-9 diagnoses of DS and spinal stenosis. Multilevel fusions were excluded. OUTCOME MEASURES Primary outcome measures included all service and procedural charges (what was billed to insurance), expenses (direct costs incurred by the hospital), reimbursement, and margins that were obtained through the financial audit for each surgery and hospital stay. Overall reimbursement and margins were then calculated based on this data. METHODS A retrospective chart review was performed from 2010-2014 based on ICD-9 diagnoses of DS with SS in patients undergoing single level fusions. All service and procedural charges, expenses, hospital reimbursement, and hospital margins were obtained through the financial audit for each surgery and hospital stay. A multivariate linear regression model was used to compare patient demographics, charges, expenses, etc. A one-way analysis of variance (ANOVA) with Tukey post hoc analysis was used to analyze different reimbursements and margins based upon insurance types. RESULTS A total of 233 patients met inclusion criteria for the study. There were no significant differences with BMI, ASA class, length of stay or gender distribution. Both types of instrumented fusions had longer operating room times and estimated blood loss (P CONCLUSIONS As more instrumentation is used, the more it costs both the hospital (expenses) and the insurance company (charges). Hospital margins varied depending on both fusion method and insurance type. While charges, expenses and reimbursement tend to increase with instrumentation, hospital margins did not correspondingly. This study highlights the importance in better aligning the economic interests of all parties involved (patient, surgeon, hospital, insurance, etc.) in order to help control spending and transition to a more cost effective system. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Combined prospective randomized controlled trial and observational cohort study of degenerative spondylolisthesis (DS) with an as-treated analysis.To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for DS using subgroup analysis.Spine Patient Outcomes Research Trial demonstrated a positive surgical TE for DS at the group level. However, individual characteristics may affect TE.Patients with DS were treated with either surgery (n = 395) or nonoperative care (n = 210) and were analyzed according to treatment received. Fifty-five baseline variables were used to define subgroups for calculating the time-weighted average TE for the Oswestry Disability Index during 4 years (TE = [INCREMENT] Oswestry Disability Index(surgery)- [INCREMENT] Oswestry Disability Index(nonoperative)). Variables with significant subgroup-by-treatment interactions (P0.05) were simultaneously entered into a multivariate model to select independent TE predictors.All analyzed subgroups that included at least 50 patients improved significantly more with surgery than with nonoperative treatment (P0.05). Multivariate analyses demonstrated that age 67 years or less (TE -15.7 vs.-11.8 for age67, P= 0.014); female sex (TE -15.6 vs.-11.2 for males, P= 0.01); the absence of stomach problems (TE -15.2 vs.-11.3 for those with stomach problems, P= 0.035); neurogenic claudication (TE -15.3 vs.-9.0 for those without claudication, P= 0.004); reflex asymmetry (TE -17.3 vs.-13.0 for those without asymmetry, P= 0.016); opioid use (TE -18.4 vs.-11.7 for those not using opioids, P0.001); not taking antidepressants (TE -14.5 vs.-5.4 for those on antidepressants, P= 0.014); dissatisfaction with symptoms (TE -14.5 vs.-8.3 for those satisfied or neutral, P= 0.039); and anticipating a high likelihood of improvement with surgery (TE -14.8 vs.-5.1 for anticipating a low likelihood of improvement with surgery, P= 0.019) were independently associated with greater TE.Patients who met strict inclusion criteria improved more with surgery than with nonoperative treatment, regardless of other specific characteristics. However, TE varied significantly across certain subgroups.3.

STUDY DESIGN Retrospective and prospective patient surveys and a physician survey using a sample from American Medical Association master file. OBJECTIVE To evaluate the performance of a new instrument designed to measure the quality of decisions about treatment of herniated disc. SUMMARY OF BACKGROUND DATA There is growing consensus on the importance of engaging and informing patients to improve the quality of significant medical decisions, yet there are no instruments currently available to measure decision quality. METHODS The herniated disc-decision quality instrument (HD-DQI) was developed with input from clinical experts, survey research experts, and patients. The HD-DQI produces 2 scores each scaled to 0% to 100%, with higher scores indicating better quality: (1) a total knowledge score and (2) a concordance score (indicating the percentage of patients who received treatments that matched their goals). We examined hypotheses relating to the acceptability, feasibility, validity, and reliability of the instrument, using data from 3 samples. RESULTS The HD-DQI survey was feasible to implement and acceptable to patients, with good response rates and low missing data. The knowledge score discriminated between patients who had seen a decision aid or no decision aid (55% vs. 38%, P < 0.001) and between providers and patients (73% vs. 46%, P < 0.001). The knowledge score also had good retest reliability (intraclass correlation coefficient = 0.85). Most patients (78%) received treatments that matched their goals. Patients who received treatments that matched their goals were less likely to regret the decision than those who did not (13% vs. 39%, P = 0.004). CONCLUSION The HD-DQI met several criteria for high-quality patient-reported survey instruments. It can be used to determine the quality of decisions for treatment of herniated disc. More work is needed to examine acceptability for use as part of routine patient care.

Cost-effectiveness analysis of a randomized plus observational cohort trial.Analyze cost-effectiveness of Spine Patient Outcomes Research Trial data over 4 years comparing surgery with nonoperative care for three common diagnoses: spinal stenosis (SPS), degenerative spondylolisthesis (DS), and intervertebral disc herniation (IDH).Spine surgery rates continue to rise in the United States, but the safety and economic value of these procedures remain uncertain.Patients with image-confirmed diagnoses were followed in randomized or observational cohorts with data on resource use, productivity, and EuroQol EQ-5D health state values measured at 6 weeks, 3, 6, 12, 24, 36, and 48 months. For each diagnosis, cost per quality-adjusted life year (QALY) gained in 2004 US dollars was estimated for surgery relative to nonoperative care using a societal perspective, with costs and QALYs discounted at 3% per year.Surgery was performed initially or during the 4-year follow-up among 414 of 634 (65.3%) SPS, 391 of 601 (65.1%) DS, and 789 of 1192 (66.2%) IDH patients. Surgery improved health, with persistent QALY differences observed through 4 years (SPS QALY gain 0.22; 95% confidence interval, CI: 0.15, 0.34; DS QALY gain 0.34, 95% CI: 0.30, 0.47; and IDH QALY gain 0.34, 95% CI: 0.31, 0.38). Costs per QALY gained decreased for SPS from $77,600 at 2 years to $59,400 (95% CI: $37,059, $125,162) at 4 years, for DS from $115,600 to $64,300 per QALY (95% CI: $32,864, $83,117), and for IDH from $34,355 to $20,600 per QALY (95% CI: $4,539, $33,088).Comparative effectiveness evidence for clearly defined diagnostic groups from Spine Patient Outcomes Research Trial shows good value for surgery compared with nonoperative care over 4 years.

Study design As-treated analysis of the Spine Patient Outcomes Research Trial. Objective To compare baseline characteristics and surgical and nonoperative outcomes in degenerative spondylolisthesis (DS) and spinal stenosis (SpS) patients stratified by predominant pain location (i.e., leg vs. back). Summary of background data Evidence suggests that DS and SpS patients with predominant leg pain may have better surgical outcomes than patients with predominant low back pain (LBP). Methods The DS cohort included 591 patients (62% underwent surgery), and the SpS cohort included 615 patients (62% underwent surgery). Patients were classified as leg pain predominant, LBP predominant, or having equal pain according to baseline pain scores. Baseline characteristics were compared between the 3 predominant pain location groups within each diagnostic category, and changes in surgical and nonoperative outcome scores were compared for 2 years. Longitudinal regression models including baseline covariates were used to control for confounders. Results Among DS patients at baseline, 34% had predominant leg pain, 26% had predominant LBP, and 40% had equal pain. Similarly, 32% of SpS patients had predominant leg pain, 26% had predominant LBP, and 42% had equal pain. DS and SpS patients with predominant leg pain had baseline scores indicative of less severe symptoms. Leg pain predominant DS and SpS patients treated surgically improved significantly more than LBP predominant patients on all primary outcome measures at 1 and 2 years. Surgical outcomes for the equal pain groups were intermediate to those of the predominant leg pain and LBP groups. The differences in nonoperative outcomes were less consistent. Conclusion. Predominant leg pain patients improved significantly more with surgery than predominant LBP patients. However, predominant LBP patients still improved significantly more with surgery than with nonoperative treatment.

Several randomized controlled trials (RCTs) and prospective observational cohort studies have compared surgical to conservative treatment for patients with sciatica caused by lumbar disc herniation. Whereas no RCT has been able to compare surgery with nonoperative treatment without substantial crossover between treatment groups, multiple RCTs and observational studies have suggested that surgery resulted in faster improvement and a greater degree of improvement compared with nonoperative treatment. However, many patients in these studies also experienced improvement with nonoperative care without adverse sequelae. This paper critically reviews the literature comparing surgery with nonoperative treatment for lumbar disc herniation.

STUDY DESIGN Clinical trial subgroup analysis. OBJECTIVE To compare outcomes of different fusion techniques treating degenerative spondylolisthesis (DS). Summary of Background Data. Surgery has been shown to be more effective than nonoperative treatment out to 4 years. Questions remain regarding the differential effect of fusion technique. METHODS Surgical candidates from 13 centers in 11 states with at least 12 weeks of symptoms and confirmatory imaging showing stenosis and DS were studied. In addition to standard decompressive laminectomy, 1 of 3 fusion techniques was employed at the surgeon's discretion: posterolateral in situ fusion (PLF); posterolateral instrumented fusion with pedicle screws (PPS); or PPS plus interbody fusion (360 degrees). Main outcome measures were the SF-36 bodily pain (BP) and physical function (PF) scales and the modified Oswestry Disability Index (ODI) assessed at 6 weeks, 3 months, 6 months, and yearly to 4 years. The as-treated analysis combined the randomized and observational cohorts using mixed longitudinal models adjusting for potential confounders. RESULTS Of 380 surgical patients, 21% (N = 80) received a PLF; 56% (N = 213) received a PPS; 17% (N = 63) received a 360 degrees; and 6% (N = 23) had decompression only without fusion. Early outcomes varied, favoring PLF compared to PPS at 6 weeks (PF: 12.73 vs. 6.22, P < 0.020) and 3 months (PF: 25.24 vs.18.95, P < 0.025) and PPS compared to 360 degrees at 6 weeks (ODI: -14.46 vs. -9.30, P < 0.03) and 3 months (ODI: -22.30 vs. -16.78, P < 0.02). At 2 years, 360 degrees had better outcomes: BP: 39.08 versus 29.17 PLF, P < 0.011; and versus 29.13 PPS, P < 0.002; PF: 31.93 versus 23.27 PLF, P < 0.021; and versus 25.29 PPS, P < 0.036. However, these differences were not maintained at 3- and 4-year follow-up, when there were no statistically significant differences between the 3 fusion groups. CONCLUSION In patients with DS and associated spinal stenosis, no consistent differences in clinical outcomes were seen among fusion groups over 4 years.

Concurrent, prospective, randomized, and observational cohort study.To assess the 4-year outcomes of surgery versus nonoperative care.Although randomized trials have demonstrated small short-term differences in favor of surgery, long-term outcomes comparing surgical to nonoperative treatment remain controversial.Surgical candidates with imaging-confirmed lumbar intervertebral disc herniation meeting SPORT eligibility criteria enrolled into prospective, randomized (501 participants), and observational cohorts (743 participants) at 13 spine clinics in 11 US states. Interventions were standard open discectomy versus usual nonoperative care. Main outcome measures were changes from baseline in the SF-36 Bodily Pain (BP) and Physical Function (PF) scales and the modified Oswestry Disability Index (ODI - AAOS/Modems version) assessed at 6 weeks, 3 months, 6 months, and annually thereafter.Nonadherence to treatment assignment caused the intent-to-treat analyses to underestimate the treatment effects. In the 4-year combined as-treated analysis, those receiving surgery demonstrated significantly greater improvement in all the primary outcome measures (mean change surgery vs. nonoperative; treatment effect; 95% CI): BP (45.6 vs. 30.7; 15.0; 11.8 to 18.1), PF (44.6 vs. 29.7; 14.9;12.0 to 17.8) and ODI (-38.1 vs. -24.9; -13.2; -15.6 to -10.9). The percent working was similar between the surgery and nonoperative groups, 84.4% versus 78.4% respectively.In a combined as-treated analysis at 4 years, patients who underwent surgery for a lumbar disc herniation achieved greater improvement than nonoperatively treated patients in all primary and secondary outcomes except work status.

Management of degenerative spondylolisthesis with spinal stenosis is controversial. Surgery is widely used, but its effectiveness in comparison with that of nonsurgical treatment has not been demonstrated in controlled trials.Surgical candidates from 13 centers in 11 U.S. states who had at least 12 weeks of symptoms and image-confirmed degenerative spondylolisthesis were offered enrollment in a randomized cohort or an observational cohort. Treatment was standard decompressive laminectomy (with or without fusion) or usual nonsurgical care. The primary outcome measures were the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36) bodily pain and physical function scores (100-point scales, with higher scores indicating less severe symptoms) and the modified Oswestry Disability Index (100-point scale, with lower scores indicating less severe symptoms) at 6 weeks, 3 months, 6 months, 1 year, and 2 years.We enrolled 304 patients in the randomized cohort and 303 in the observational cohort. The baseline characteristics of the two cohorts were similar. The one-year crossover rates were high in the randomized cohort (approximately 40% in each direction) but moderate in the observational cohort (17% crossover to surgery and 3% crossover to nonsurgical care). The intention-to-treat analysis for the randomized cohort showed no statistically significant effects for the primary outcomes. The as-treated analysis for both cohorts combined showed a significant advantage for surgery at 3 months that increased at 1 year and diminished only slightly at 2 years. The treatment effects at 2 years were 18.1 for bodily pain (95% confidence interval [CI], 14.5 to 21.7), 18.3 for physical function (95% CI, 14.6 to 21.9), and -16.7 for the Oswestry Disability Index (95% CI, -19.5 to -13.9). There was little evidence of harm from either treatment.In nonrandomized as-treated comparisons with careful control for potentially confounding baseline factors, patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and function during a period of 2 years than patients treated nonsurgically. (ClinicalTrials.gov number, NCT00000409 [ClinicalTrials.gov].).

Lumbar disk herniation is one of the most common problems encountered in orthopaedic practice. Despite the frequency of its occurrence, however, much about lumbar disk herniation is poorly understood. It is important to review the basic and clinical science underlying the pathophysiology and treatment, surgical and nonsurgical, of this disorder.

Study Design. This is an observational cross sectional study of 26,290 patients seen and avaluate in the 25 centers of the National Spine Network. Objective. To explore the correlation between medical and psychosocial comorbidities, and baseline Short-Form 36 Health Status questionnaire (SF-36) and Oswestry Disability Index (ODI) (Musculaskeletal Outcomes Data Evaluation and Management Systems version with sowies reversed so that a score of 100 represents no disability, and a score of 0 represents severe disability) scores in spine patients. of Background Data. It remains unclear whether general health questionnaires or condition-spe cific surveys are superior for evaluation spine patients (Spine 2000,25:3300-3). Most clinicians would suspect that comorbidities (medical and psychosocial) play a significant role in the presentation, treatment, and cotcome of spine patients. Yet, it has been difficult to quantify specifically the association of comorbidities with traditional health status-instrument scores for spine patients. Methods. Initial visit (baseline) health questionnaires were analyzed. Patients were stratified according to the number of self-reported comorbidities. Analysis of variance was performed to assese the difference in mean health status across comorbidity groups. Multiple linear regressions were used to identify the most influential individual comorbidities on baseline functional survey Results. There is an associated decrease. in baseline physical component summary (PCS) (from the SF-36) and ODI scores with the addition of each comorbidity. For the range of zero to ≥7 comorbidities, the PCS score decreases from 33.3 to 23.2 (P < 0.001). The average base line ODI scote for patients with zero comorbidities was 62.4 decreasing to 42.0 in the group with ≥7 comorbidities (P < 0.001. The strongess association was seen with the medical comorbidities of smoking, frequent head aches, osteoarthritis, and osteoporosis (P < 0.001). How ever, the association with psychosocial comorbidities (e.g., self-rated health, active compensation case, depression) (P < 0.001) was higher for both health status measures. Health status measures in patients with lumbar problems show that these patients are more impacted by their disease than patients with cervical or thoracic spine problems (P < 0.001), although the correlation with comorbidities is smaller for the lumbar group (P < 0.001). Conclusion. Traditional medical comorbidities correlate with both SF-36 (e.g., PCS) general health survey scores as well as disease-specific 001 scores. However, psychosocial comprbidities such as poor self-rated health (SF-1), an active compensation case, and low education level have a higher association than traditional medical comorbidities on these health status measures. The results show that the type of survey (disease-specific e.g., 001, vs. generic e.g., SF-36) used may be less important than the need to assess and control for psychosocial and medical comorbidities when any patient-reported health survey is used in the spine population.

STUDY DESIGN Prospective observational cohorts. OBJECTIVE To describe sociodemographic and clinical features, and nonoperative (medical) resource utilization before enrollment, in patients who are candidates for surgical intervention for intervertebral disc herniation (IDH), spinal stenosis (SpS), and degenerative spondylolisthesis (DS) according to SPORT criteria. SUMMARY OF BACKGROUND DATA Intervertebral disc herniation, spinal stenosis, and degenerative spondylolisthesis with stenosis are the three most common diagnoses of low back and leg symptoms for which surgery is performed. There is a paucity of descriptive literature examining large patient cohorts for the relationships among baseline characteristics and medical resource utilization with these three diagnoses. METHODS The Spine Patient Outcomes Research Trial (SPORT) conducts three randomized and three observational cohort studies of surgical and nonsurgical treatments for patients with IDH, SpS, and DS. Baseline data include demographic information, prior treatments received, and functional status measured by SF-36 and the Oswestry Disability Index (ODI-AAOS/Modems version). The data presented represent all 1,411 patients (743 IDH, 365 SpS, 303 DS) enrolled in the SPORT observational cohorts. Multiple logistic regression was used to generate independent predictors of utilization adjusted for sociodemographic variables, diagnosis, and duration of symptoms. RESULTS The average age was 41 years for the IDH group, 64 years for the SpS group, and 66 years for the DS group. At enrollment, IDH patients presented with the most pain as reported on the SF-36 (BP 26.3 vs. 33.2 SpS and 33.8 DS) and were the most impaired (ODI 51 vs. 42.3 SpS and 41.5 DS). IDH patients used more chiropractic treatment (42% vs. 33% SpS and 26% DS), had more Emergency Department (ED) visits (21% vs. 7% SpS and 4% DS), and used more opiate analgesics (49% vs. 29% SpS and 27% DS). After adjusting for age, gender, diagnosis, education, race, duration of symptoms, and compensation, Medicaid patients used significantly more opiate analgesics (58% Medicaid vs. 41% no insurance, 42% employer, 33% Medicare, and 32% private) and had more ED visits compared with other insurance types (31% Medicaid vs. 22% no insurance, 16% employer, 3% Medicare, and 11% private). CONCLUSION IDH patients appear to have differences in sociodemographics, resource utilization, and functional impairment when compared with the SpS/DS patients. In addition, the differences in resource utilization for Medicaid patients may reflect differences in access to care. The data provided from these observational cohorts will serve as an important comparison to the SPORT randomized cohorts in the future.

Descriptive analysis of cross-sectional data collected prospectively in 20 National Spine Network (NSN) centers.First, to summarize clinical and demographic characteristics of patients likely to need servicesfor psychosocial concerns. Second, to determine the rate and variability of referrals for behavioral medicine interventions (BMED) across the NSN.The prevalence of mental distress resulting from or coexisting with spinal pain is unclear. There is evidence that psychological treatments, particularly BMED, can aid the recovery of patients with symptoms of mental distress.From 1998 to 2001, 28,349 patients presenting to NSN centers completed the SF-36 General Health Survey. Patients were dichotomized by the mental component summary (MCS) score into two groups: 1) those scoringor=35 on the MCS scale (patients self-reporting significant signs of mental distress) and 2) those scoring35. Clinicians recorded a "treatment plan" comprised of a standard array of treatment options. For patients scoringor=35 on the MCS, the rate and variation of referrals to BMED was assessed.Baseline health status scores were lower across all SF-36 scales for the patients scoring an MCSor= 35. For mentally distressed patients, the overall average referral rate for any BMED service for patients scoring MCSor= 35 was 11.8%. The rate varied across NSN sites from 0 to 41%.With only 11.8% of mentally distressed NSN patients receiving a referral for any form of BMED, it appears that a large proportion of eligible patients are not receiving a potentially beneficial treatment. Wide variation across centers may indicate an inability to adequately assess mental distress via the usual clinical interview and examination for spinal conditions or a lack of consensus regarding BMED's availability and utility.

STUDY DESIGN Randomized trial with a concurrent observational cohort study. OBJECTIVE To compare 8-year outcomes of surgery with nonoperative care for symptomatic lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA Surgery for spinal stenosis has been shown to be more effective than nonoperative treatment during 4 years, but longer-term data are less clear. METHODS Surgical candidates from 13 centers in 11 US states with at least 12 weeks of symptoms and confirmatory imaging were enrolled in a randomized cohort or observational cohort. Treatment was standard, decompressive laminectomy versus standard nonoperative care. Primary outcomes were SF-36 (MOS 36-Item Short-Form Health Survey) Bodily Pain and Physical Function scales and the modified Oswestry Disability Index assessed at 6 weeks, 3 months, 6 months, and yearly up to 8 years. RESULTS Data were obtained for 55% of participants in the randomized group and 52% of participants in the observational group at the 8-year follow-up. Intent-to-treat analyses showed no differences between randomized cohorts; however, 70% of those randomized to surgery and 52% of those randomized to nonoperative had undergone surgery by 8 years. As-treated analyses in the randomized group showed that the early benefit for surgery out to 4 years converged over time, with no significant treatment effect of surgery seen in years 6 to 8 for any of the primary outcomes. In contrast, the observational group showed a stable advantage for surgery in all outcomes between years 5 and 8. Patients who were lost to follow-up were older, less well-educated, sicker, and had worse outcomes during the first 2 years in both surgical and nonoperative arms. CONCLUSION Patients with symptomatic spinal stenosis show diminishing benefits of surgery in as-treated analyses of the randomized group between 4 and 8 years, whereas outcomes in the observational group remained stable. Loss to follow-up of patients with worse early outcomes in both treatment groups could lead to overestimates of long-term outcomes but likely not bias treatment effect estimates.

Study Design. A case report is presented. Objective. To highlight the potential for spontaneous resolution of large extruded intervertebral lumbar disc herniations in a patient with three independent herniations. Summary of Background Data. The most effective methods of treatment for lumbar intervertebral disc herniations remain in question. This is partly because the potential for intrinsic spontaneous resolution is not understood, and because many believe that large extruded lumbar intervertebral disc herniations require surgical intervention. This case report addresses both issues. Methods. A case is reported and the literature is reviewed. Results. In the patient described, multiple independent lumbar intervertebral disc herniations resolved spontaneously both clinically and radiographically with nonoperative treatment. Conclusions. Not only is the question concerning the cause of disc herniation unresolved, but the best methods of treatment also are generally unclear. This case report documents a patient with the intrinsic capability not only to herniate multiple lumbar intervertebral discs, but also to resolve them clinically and anatomically. Extruded lumbar intervertebral disc herniations may be treated without surgery, as highlighted by this case report. The immunohistologic pathomechanism for resorption remains unclear.

Study Design. A cross-sectional study of 16,974 protiants with spine disease from 26 members of the National Spine Network. Objectives. To une functional status measures and clinical parameters to evaluate the association between obesity and health status among patients with spine conditions. of Background Data. With 22.5% of Americans overweight, obesity is a significant health concern, However, the functional impact caused by obesity in spine patients remains unknown. Methods. Functional status was measured on 16,974 patients on an initial visit using a general physical health measure (SF-38 Physical Component Summary score) and a disease-specific measure (Oswestry Disability index). Obesity was measured using body mass index (kg/ m 2 ). Patients were categorized into four groups according to body mass index: normal range (

The Spine Patient Outcomes Research Trial aimed to determine the comparative effectiveness of surgical care versus nonoperative care by measuring longitudinal values: outcomes, satisfaction, and costs.This paper aims to summarize available evidence from the Spine Patient Outcomes Research Trial by addressing 2 important questions about outcomes and costs for 3 types of spine problem: (1) how do outcomes and costs of spine patients differ depending on whether they are treated surgically compared with nonoperative care? (2) What is the incremental cost per quality adjusted life year for surgical care over nonoperative care?After 4 years of follow-up, patients with 3 spine conditions that may be treated surgically or nonoperatively have systematic differences in value endpoints. The average surgical patient enjoys better health outcomes and higher treatment satisfaction but incurs higher costs.Spine care is preference sensitive and because outcomes, satisfaction, and costs vary over time and between patients, data on value can help patients make better-informed decisions and help payers know what their dollars are buying.

COMMENTARY ON: Meredith DS, Huang RC, Nguyen J, Lyman S. Obesity increases the risk of recurrent herniated nucleus pulposus after lumbar microdiscectomy. Spine J 2010;10:575–580 ( in this issue ). Yadla S, Malone J, Campbell PG, et al. Obesity and spine surgery: reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures. Spine J 2010;10:581–587 ( in this issue ).

Study Design. A prospective study of 17,774 patients who consulted spine centers in which the impact of spinal disorders and comorbidities on physical functional status were evaluated. Objectives. To quantify the effect spinal diagnoses have on patients' physical functional status (SF-36 Physical Component Summary [PCS] score) compared with other common conditions and to quantify the effects of comorbidities on physical functional status in spine patients. Summary of Background Data. The burden of spinal conditions on a patient's function and the role that comorbidities play in this affliction are poorly quantified in the literature. Methods. Data from the Health Survey Questionnaire were prospectively gathered through the National Spine Network, a nonprofit consortium of spine-focused practices. Each patient's SF-36 score was summarized into a single PCS score. The correlation between diagnosis and comorbidity and PCS score was assessed using multivariate linear regression. Results. The study patients were a mean of 47.5 years of age, 54.7% were female, 52.3% had lumbosacral diagnoses, and 82.0% had had 3 or more months of pain. The population had a mean PCS score of 30.4 ± 9.95 (SD) compared with 50.0 ± 10.00 for the general United States population. The more comorbidities in a patient, the lower the PCS score (Spearman rank correlation = -0.27). The five comorbid conditions that lowered the PCS the most included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), renal failure, rheumatoid arthritis, and lupus (all P

Study design Concurrent prospective randomized and observational cohort studies. Objective To assess the 8-year outcomes of surgery versus nonoperative care. Summary of background data Although randomized trials have demonstrated small short-term differences in favor of surgery, long-term outcomes comparing surgical with nonoperative treatment remain controversial. Methods Surgical candidates with imaging-confirmed lumbar intervertebral disc herniation meeting Spine Patient Outcomes Research Trial eligibility criteria enrolled into prospective randomized (501 participants) and observational cohorts (743 participants) at 13 spine clinics in 11 US states. Interventions were standard open discectomy versus usual nonoperative care. Main outcome measures were changes from baseline in the SF-36 Bodily Pain and Physical Function scales and the modified Oswestry Disability Index-AAOS/Modems version assessed at 6 weeks, 3 months, and 6 months, and annually thereafter. Results Advantages were seen for surgery in intent-to-treat analyses for the randomized cohort for all primary and secondary outcomes other than work status; however, with extensive nonadherence to treatment assignment (49% patients assigned to nonoperative therapy receiving surgery versus 60% of patients assigned to surgery) these observed effects were relatively small and not statistically significant for primary outcomes (bodily pain, physical function, Oswestry Disability Index). Importantly, the overall comparison of secondary outcomes was significantly greater with surgery in the intent-to-treat analysis (sciatica bothersomeness [P > 0.005], satisfaction with symptoms [P > 0.013], and self-rated improvement [P > 0.013]) in long-term follow-up. An as-treated analysis showed significant surgical treatment effects for primary outcome measures (mean change, surgery vs. nonoperative care; treatment effect; 95% confidence interval): bodily pain (45.3 vs. 34.4; 10.9; 7.7 to 14); PF (42.2 vs. 31.5; 10.6; 7.7 to 13.5); and Oswestry Disability Index (-36.2 vs. -24.8; -11.3; -13.6 to -9.1). Conclusion Carefully selected patients who underwent surgery for a lumbar disc herniation achieved greater improvement than nonoperatively treated patients; there was little to no degradation of outcomes in either group (operative and nonoperative) from 4 to 8 years. Level of evidence 2.

Combined prospective randomized controlled trial and observational cohort study of spinal stenosis (SpS) with an as-treated analysis.To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for SpS using subgroup analysis.The Spine Patient Outcomes Research Trial demonstrated a positive surgical TE for SpS at the group level. However, individual characteristics may affect TE. No previous studies have evaluated TE modifiers in SpS.SpS patients were treated with either surgery (n = 419) or nonoperative care (n = 235) and were analyzed according to treatment received. Fifty-three baseline variables were used to define subgroups for calculating the time-weighted average TE for the Oswestry Disability Index (ODI) over 4 years (TE = ΔODIsurgery - ΔODInonoperative). Variables with significant subgroup × treatment interactions (P0.05) were simultaneously entered into a multivariate model to select independent TE predictors.Other than smokers, all analyzed subgroups including at least 50 patients improved significantly more with surgery than with nonoperative treatment (P0.05). Multivariate analysis demonstrated: baseline ODI ≤ 56 (TE -15.0 vs. -4.4, ODI56, P0.001), not smoking (TE -11.7 vs. -1.6 smokers, P0.001), neuroforaminal stenosis (TE -14.2 vs. -8.7 no neuroforaminal stenosis, P = 0.002), predominant leg pain (TE -11.5 vs. -7.3 predominant back pain, P = 0.035), not lifting at work (TE -12.5 vs. -0.5 lifting at work, P = 0.017), and the presence of a neurological deficit (TE -13.3 vs. -7.2 no neurological deficit, P0.001) were associated with greater TE.With the exception of smokers, patients who met strict inclusion criteria improved more with surgery than with nonoperative treatment, regardless of other specific characteristics. However, TE varied significantly across certain subgroups, and these data can be used to individualize shared decision making discussions about likely outcomes. Smoking cessation should be considered before surgery for SpS.

A high percentage of patients with grade IIIC open tibial fractures eventually undergo amputation. Maintaining an adequate residual limb length is advantageous with regard to biomechanics, energy expenditure, and prosthetic fitting. This case report presents new considerations for maintaining residual limb length in the presence of comminuted proximal tibial fractures. These considerations include (a) using an autogenous fibular strut graft for stabilizing the reconstructed residual limb and (b) determining the level of amputation based on soft-tissue integrity rather than on fracture level. We present one technique for preserving an adequate residual limb length in the face of significant proximal tibia comminution.

Randomized trial with concurrent observational cohort. A total of 1171 patients were divided into subgroups by educational attainment: high school or less, some college, and college degree or above.To assess the influence of education level on outcomes for treatment of lumbar disc herniation.Educational attainment has been demonstrated to have an inverse relationship with pain perception, comorbidities, and mortality.The Spine Patient Outcomes Research Trial enrolled surgical candidates (imaging-confirmed disc herniation with at least 6 weeks of persistent signs and symptoms of radiculopathy) from 13 multidisciplinary spine clinics in 11 US states. Treatments were standard open discectomy versus nonoperative treatment. Outcomes were changes from baseline for 36-Item Short Form Health Survey (SF-36), bodily pain (BP), and physical function (PF) scales and the modified Oswestry Disability Index (ODI) at 6 weeks, 3 months, 6 months, and yearly through 4 years.Substantial improvement was seen in all patient cohorts. Surgical outcomes did not differ by level of education. For nonoperative outcomes, however, higher levels of education were associated with significantly greater overall improvement over 4 years in BP (P = 0.007), PF (P = 0.001), and ODI (P = 0.003). At 4 years a "dose-response" type relationship was shown for BP (high school or less = 25.5, some college = 31, and college graduate or above = 36.3, P = 0.004) and results were similar for PF and ODI. The success of nonoperative treatment in the more educated cohort resulted in an attenuation of the relative benefit of surgery.Patients with higher educational attainment demonstrated significantly greater improvement with nonoperative treatment while educational attainment was not associated with surgical outcomes.

STUDY DESIGN Combined prospective randomized controlled trial and observational cohort study of intervertebral disc herniation (IDH), an as-treated analysis. OBJECTIVE To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for intervertebral disc herniation (IDH) using subgroup analysis. SUMMARY OF BACKGROUND DATA The Spine Patient Outcomes Research Trial demonstrated a positive surgical TE for IDH at the group level. However, individual characteristics may affect TE. No prior studies have evaluated TE modifiers in IDH. METHODS IDH patients underwent either discectomy (n = 788) or nonoperative care (n = 404) and were analyzed according to treatment received. Thirty-seven baseline variables were used to define subgroups for calculating the time-weighted average TE for the Oswestry Disability Index (ODI) across 4 years (TE = ΔODI(surgery) -ΔODI(nonoperative)). Variables with significant subgroup-by-treatment interactions (P < 0.1) were simultaneously entered into a multivariate model to select independent TE predictors. RESULTS All analyzed subgroups improved significantly more with surgery than with nonoperative treatment (P < 0.05). In minimally adjusted univariate analyses, being married, absence of joint problems, worsening symptom trend at baseline, high school education or less, older age, no worker's compensation, longer duration of symptoms, and an SF-36 mental component score (MCS) less than 35 were associated with greater TEs. Multivariate analysis demonstrated that being married (TE, -15.8 vs. -7.7 single, P < 0.001), absence of joint problems (TE, -14.6 vs. -10.3 joint problems, P = 0.012), and worsening symptoms (TE, -15.9 vs. -11.8 stable symptoms, P = 0.032) were independent TE modifiers. TEs were greatest in married patients with worsening symptoms (-18.3) vs. single patients with stable symptoms (-7.8). CONCLUSION IDH patients who met strict inclusion criteria improved more with surgery than with nonoperative treatment, regardless of specific characteristics. However, being married, without joint problems, and worsening symptom trend at baseline were associated with a greater TE.

Background Ketamine is an N-methyl-d-aspartate receptor antagonist that has been shown to be useful in the reduction of acute postoperative pain and analgesic consumption in a variety of surgical interventions with variable routes of administration. Little is known regarding its efficacy in opiate-dependent patients with a history of chronic pain. We hypothesized that ketamine would reduce postoperative opiate consumption in this patient population. Methods This was a randomized, prospective, double-blinded, and placebo-controlled trial involving opiate-dependent patients undergoing major lumbar spine surgery. Fifty-two patients in the treatment group were administered 0.5 mg/kg intravenous ketamine on induction of anesthesia, and a continuous infusion at 10 microg kg(-1) min(-1) was begun on induction and terminated at wound closure. Fifty patients in the placebo group received saline of equivalent volume. Patients were observed for 48 h postoperatively and followed up at 6 weeks. The primary outcome was 48-h morphine consumption. Results Total morphine consumption (morphine equivalents) was significantly reduced in the treatment group 48 h after the procedure. It was also reduced at 24 h and at 6 weeks. The average reported pain intensity was significantly reduced in the postanesthesia care unit and at 6 weeks. The groups had no differences in known ketamine- or opiate-related side effects. Conclusions Intraoperative ketamine reduces opiate consumption in the 48-h postoperative period in opiate-dependent patients with chronic pain. Ketamine may also reduce opioid consumption and pain intensity throughout the postoperative period in this patient population. This benefit is without an increase in side effects.

Lumbar degenerative spondylolisthesis (DS) and spinal stenosis (SPS) were originally described as separate pathoanatomic entities, though both cause narrowing of the spinal canal, compression of the nerve roots, and can lead to neurogenic claudication.1,2 Given these commonalities, DS was originally classified as a subgroup among other degenerative causes of stenosis.3 Because listhetic deformities were thought to be inherently unstable, it was debated if fusion in addition to decompression improved outcomes in DS patients. The most definitive answer to that question was provided by Herkowitz and Kurz, who demonstrated significantly improved outcomes when fusion was combined with decompression in a cohort of DS patients.4 As a result, fusion is performed routinely for most DS patients. Less debated has been the role of fusion in SPS. Although there has been no definitive study, two meta-analyses suggested that fusion in addition to decompression did not improve outcomes in SPS.5,6 Most clinicians continue to treat their SPS patients with decompression alone. Despite the fact that DS and SPS patients typically undergo different surgical treatments, investigators have traditionally combined DS and SPS patients in clinical studies.5,7-12 Prior studies that included both DS and SPS patients have analyzed small subgroups to evaluate the relationship between listhesis and outcomes, and most found that listhesis was not associated with surgical outcomes.12-15 However, a meta-analysis reported that studies including only DS patients had better surgical results than those that combined DS and SPS patients,5 and a recent trial including DS and SPS patients found better outcomes among patients who underwent fusion, 90% of whom had DS.10 Given the lack of consensus about whether DS and SPS patients actually differ clinically, a formal comparison of these two diagnostic groups is needed. Because DS patients and SPS patients are generally treated with different surgical techniques, the Spine Patient Outcomes Research Trial (SPORT) evaluated and reported results for these two patient groups separately.16,17 This allows us to address two important questions: “Apart from the listhetic deformity, are there clinically relevant differences between patients presenting with DS and SPS ?” and “Are there significant differences between the clinical outcomes of patients with these two conditions?”

The various methods for posterior cervical stabilization techniques allow successful fusion in almost all instances and indications. The choice is primarily dependent on the surgeon's training, experience, and preference, and is subsequently narrowed by the available intact and stable anatomy unique to each patient's injury. Despite the availability of multiple stabilization techniques and their widespread use, these techniques should be performed only by surgeons familiar and comfortable with the approach, anatomy, and stabilization techniques, and with the care of patients with mechanical and neurological injuries to the cervical spine.

In working-age populations, sciatica due to an intervertebral disc herniation (IDH) is a common cause of low back problems resulting in disability. Among older persons in an aging workforce, spinal stenosis (SpS) is the most common cause of low back pain with radicular leg pain. For patients with these radicular pain syndromes, surgical treatment is frequently considered for persistent or severe symptoms. More than 400,000 nonfusion spine operations are performed each year in the United States, with discectomy for an IDH being the most common procedure.1,2 Although spine surgery is less common in older individuals, rates are rapidly increasing with SpS being the most common diagnosis.3 Despite being common conditions in working-age individuals, the extent to which treatment influences work-related disability is poorly understood. There is a widespread belief that patients receiving disability compensation have inferior clinical outcomes. For example, Harris et al examined surgical outcomes of patients with and without workers’ compensation (WC) for a variety of indications including back pain.4 Results from 129 studies involving 20,498 patients reported inferior outcomes for those individuals receiving WC.4 Often these outcomes are attributed to secondary gain, implying that the patient may be partly to blame. However, few studies adequately control for differences in clinical and demographic characteristics that may be related to outcomes and disability status.5 Harris et al identified many study limitations, including retrospective study design, use of unvalidated outcome measures, nonblinded physician reporting, and heterogeneous, poorly characterized clinical disorders.4 In addition, most studies were not designed to assess the impact of disability compensation status, and few controlled for baseline differences between patients receiving disability compensation or not.4,6–10 Differences in treatment outcomes for those receiving disability compensation might be explained by both clinical and nonclinical factors.11 Clinical factors can include potential differences in the disease entity itself, its severity, the presence of other medical conditions, and treatment(s) received.12–15 Nonclinical factors can include patient demographic, economic, work-related, and expectation/preference characteristics.13,16–20 Prior studies have identified many differences in clinical and nonclinical factors among patients who were receiving and not receiving WC at baseline.21–23 However, whether these results are generalizable is not clear since most involved a single institution or state, and WC is a state-based program with rules that vary considerably across the United States. This study seeks to address many of these limitations by examining baseline data for patients with disability compensation due to homogeneous, objectively defined spine conditions that were prospectively identified and evaluated at sites in different states. The goal is to identify baseline socioeconomic characteristics of patients with WC at study enrollment that distinguish them from patients who are not receiving disability compensation.

Lumbar disk herniation is one of the most common problems encountered in orthopaedic practice. Despite the frequency of its occurrence, however, much about lumbar disk herniation is poorly understood. It is important to review the basic and clinical science underlying the pathophysiology and treatment, surgical and nonsurgical, of this disorder.

Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial.To assess the efficacy of surgery for lumbar intervertebral disk herniation.The Spine Patient Outcomes Research Trial, a randomized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states. Patients were 501 surgical candidates (mean age, 42 years; 42% women) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks.Standard open diskectomy vs nonoperative treatment individualized to the patient.Primary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version) at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment. Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status.Adherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes.Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis.clinicaltrials.gov Identifier: NCT00000410.

STUDY DESIGN: This is an observational study of 3482 patients undergoing lumbar spine surgery from the National Spine Network. OBJECTIVES: To explore the influence of medical and psychosocial comorbidities on the change in Short-form 36 (SF-36) general health survey and condition-specific Oswestry Disability Index (ODI) scores in patients undergoing lumbar spine surgery. SUMMARY OF BACKGROUND DATA: It remains unclear as to which type of health instrument is more appropriate for monitoring improvement in patients who undergo lumbar spine surgery. Most clinicians would suspect that comorbidities (medical and psychosocial) play a significant role in the outcome of spine patients. Yet, it has been difficult to quantify specifically the impact of comorbidities on the responsiveness of traditional health status instruments for spine patients. METHODS: Analysis of variance was performed to assess the difference in the change in survey scores across comorbidity groups for the population of National Spine Network patients who had undergone lumbar spine surgical intervention and completed 3-month and 1-year follow-up surveys. Multiple linear regressions were used to identify the most influential individual comorbidities on the change scores. RESULTS: Comorbidities had a significant impact on the change in scores at 3 months and 1 year. The average change in bodily pain, physical function, physical component summary scores of the SF-36, as well as ODI scores decreased in response to surgery as the number of comorbidities increased. Psychosocial comorbidities such as an active compensation case, self-rated poor health, and smoking exerted large effects on the change in survey scores after surgery (P < 0.003). Medical disorders such as headaches, depression, and nervous system disorders were also highly influential (P < 0.05). CONCLUSIONS: The negative impact of medical and psychosocial comorbidities on the change in SF-36 general health survey and condition-specific ODI scores, despite spine surgery, highlights the need for researchers and clinicians to consider these comorbidities when using these, and perhaps all, health survey instruments and interpreting these scores after surgery. Contrary to current assumptions regarding condition-specific health surveys, medical and psychosocial comorbidities similarly affect the generic SF-36 and condition-specific ODI. Further studiesare needed to determine if spine surgery outcomes can be improved by specifically addressing potentially modifiable comorbidities, which negatively impact survey scores, or whether comorbidity burden should play a role in the selection process for surgical intervention. Failure to incorporate consideration of medical and psychosocial comorbidities into preoperative discussions can be a failure to allow our patients (and ourselves) to have realistic expectations and, consequently, the best possible outcome from their treatment choice.

Background data Depression is a common co-morbidity for patients with complaints of spinal pain, yet often goes undiagnosed in clinical practice. Depressed patients who are not identified do not receive a referral or recommendation for treatments that may help ease their total illness burden. Relative to the total outcomes of spine care this may increase costs, decrease overall functional outcomes, and limit patient satisfaction. Some spine care settings track functional outcomes using a general health status survey. Although a specific and reliable survey to detect depression could be employed, an additional survey would unnecessarily increase responder and analyst burdens if the general health status survey could be used instead. Objective To identify the Mental Component Summary (MCS) cutoff score from the Short Form 36-item Health Survey (SF-36) that best predicts a positive depression score as measured by the Center for Epidemiological Study–Depression Survey (CES-D). Study design An analysis of the diagnostic properties of the SF-36 MCS Scale as a predictor of depressive symptoms as measured by the CES-D. Outcome measures The SF-36 is a general health survey that contains a MCS score that represents the psychological well-being and general health perception of the respondent. This composite score is norm-based (mean=50, SD=10) with lower scores representing poorer health. The CES-D has been well-studied in patients with chronic pain complaints and was used as the gold standard for determining the MCS cutoff score. A CES-D score of 19 or greater was considered positive for depressive symptoms. Patient sample All patients entering our facility routinely complete the SF-36. Between February 2002 and October 2002, all patients scoring 30 or less on the MCS (MCS≤30) also completed the CES-D. Patients who scored 2 standard deviations below the mean (MCS=30 or less) were considered most at risk for depression. Patients scoring above 30 on their MCS (MCS>30) were considered less likely to have depressive symptoms and were randomly chosen to complete the CES-D. There were 420 patients who completed both surveys of which there were 99 MCS≤30 patients and 321 MCS>30 patients. Methods Receiver operating characteristic (ROC) curves were used to assess the sensitivity and specificity of the SF-36 as a screening tool for detecting depressive symptoms. Results An MCS score of 35 has a sensitivity of 80% (76–83; 95% confidence interval), a specificity of 90% (87–93), an ROC area of 0.8517 (0.81–0.89), and correctly identified 87% of the sample. Conclusion The SF-36 provides the benefits of a general functional health status measure and additionally appears to provide a screening tool for depressive symptoms. A cutoff score of 35 or less on the MCS scale has a high degree of sensitivity and specificity and is able to identify depressive symptoms in patients with back pain, which can help identify patients who will benefit from mental health treatments.

Emerging techniques for management of degenerative disc disease include modern fusion interbody cage devices, intradiscal electrothermal therapy, and disc prostheses among others. The management of discogenic low back pain is controversial: its accurate diagnosis is difficult, and treatment is inconsistent. Before wide application, the advantages and disadvantages of each procedure must be considered in lieu of inadequate study design and the lack of sufficient long-term outcome studies.

Grisel’s syndrome, or nontraumatic atlantoaxial subluxation, is a rare complication of inflammatory processes in the head and neck. Children are most frequently affected and classically present with torticollis after an infectious process or otolaryngologic surgery. Distention and abnormal laxity of the ligaments surrounding the atlanto-axial articulation results from direct spread of inflammation from the pharynx and nasopharynx and can result in cervical spine instability with devastating neurologic sequelae. We describe a case of retropharyngeal cellulitis in a 7-yearold boy progressing to atlanto-axial subluxation with osteomyelitis of the dens. The pathogenesis, diagnosis, and treatment of Grisel’s syndrome are discussed.

Study design A case study was conducted. Objective To detail the successful nonoperative management of a distraction-flexion Salter-Harris Type 1 midcervical spine injury in a young child. Summary of background data Documented cases of neurologically intact pediatric patients with unstable flexion-distraction injuries of the midcervical spine are rare. Methods A case report and literature review are presented. Results A rare distraction-flexion injury was successfully treated nonoperatively. Conclusions Although distraction-flexion cervical spine injuries are common in adults and often occur with concomitant neurologic sequelae, they also can occur in the pediatric patient. Whereas these injuries require surgery in adults, they can be managed nonoperatively in the pediatric population.

Cervical spine tumors, whether primary bone tumors or metastatic tumors, are rare. The possibility of tumors existing must be considered in the differential diagnosis of patients with persistent neck pain, with or without neurologic symptoms, particularly in those with significant pain at night. The clinical presentation is extremely variable, though a history of malignancy should always raise the concern for recurrence. The evaluation and diagnostic assessment includes a thorough physical examination. Radiographic imaging is usually initiated with plain radiographs and additional advanced imaging obtained as indicated. Using appropriate biopsy principles and techniques, tissue is obtained for histologic determination of the suspected lesion before surgical intervention. Treatment options are extremely variable and depend on many factors, including tumor type, location, and patient preference. Treatment warrants a multidisciplinary approach from experienced physicians and is most successfully accomplished in referral centers. Oncologic staging using the Enneking staging system, followed by surgical staging using the Weinstein, Boriani, Biagini system, will aid in the accurate characterization of the tumor load, maximize surgical goals, assure use of appropriate terminology, and provide optimal communication among treatment centers regarding tumor characteristics, treatment efforts, and results.

Emerging techniques and technologies in treating spinal disorders appear to be very promising. Vertebroplasty and kyphoplasty are new techniques that have been developed for treating osteoporotic vertebral compression fractures with early promising clinical results. More sophisticated and technically advanced methods of surgical navigation are also being developed as spinal surgery moves toward less invasive or minimally invasive procedures. Cost effectiveness, complication rates, and clinical efficacy need to be better defined to determine the exact role of these emerging techniques and technologies.