Study Design. Retrospective study. Objective. The aim of this study was to determine risk factors for prolonged opioid use and to investigate whether opioid-tolerance affects patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) surgery. Summary of Background Data. There is a lack of consensus on risk factors that can affect continued opioid use after cervical spine surgery and the influence of opioid use on patient-reported outcomes. Methods. Ninety-two patients who underwent ACDF for degenerative cervical pathologies were retrospectively identified and their opioid usage before surgery was investigated using a state-sponsored prescription drug monitoring registry. Opioid-naïve and opioid tolerant groups were defined using criteria most consistent with the Federal Drug Administration (FDA) definition. Patient-reported outcomes were then collected, including the Short Form-12 (SF-12) Physical Component (PCS-12) and Mental Component (MCS-12), the Neck Disability Index (NDI), the Visual Analogue Scale Neck (VAS neck) and the Visual Analogue Scale Arm (VAS Arm) pain scores. Logistic regression was used to determine predictors for prolonged opioid use following ACDF. Univariate and multivariate analyses were conducted to compare change in outcomes over time between the two groups. Results. Logistic regression analysis demonstrated that opioid tolerance was a significant predictor for prolonged opioid use after ACDF (odds ratio [OR]: 18.2 [1.46, 226.4], P = 0.02). Duration of usage was also found to be a significant predictor for continued opioid use after surgery (OR: 1.10 [1.0, 1.03], P = 0.03). No other risk factors were found to be significant predictors. Both groups overall experienced improvements in patient-reported outcomes after surgery. Multiple linear regression analysis, controlling for patient demographics, demonstrated that opioid-tolerant user status positively affected change in outcomes over time for NDI (β = −13.7 [−21.8,−5.55], P = 0.002) and PCS-12 (β = 6.99 [2.59, 11.4], P = 0.003) but no other outcomes measured. Conclusion. Opioid tolerance was found to be a significant predictor for prolonged opioid use after ACDF. Additionally, opioid-naïve and opioid-tolerant users experienced overall improvements across PROMs following ACDF. Opioid-tolerance was associated with NDI and PCS-12 improvements over time compared to opioid-naïve users. Level of Evidence: 4
Background: Anterior cervical discectomy and fusion (ACDF) is a common surgery for patients with degenerative cervical disease and current interbody spacers utilized vary based on material composition, structure, and angle of lordosis. Currently, there is a lack of literature comparing subsidence rates or long-term radiographic outcomes with hyperlordotic and standard lordotic spacers. This study compares long-term radiographic outcomes, subsidence rate, and rate of fusion in patients who underwent ACDF with hyperlordotic or standard interbody placement. Materials and Methods: Patients who underwent 1–3-level ACDF with either a standard lordosis or hyperlordotic interbody were included. Standard radiographs were evaluated for C2–7 lordosis (CL), sagittal vertical axis, C2 slope (C2S), T1 slope (T1S), subsidence rate, and fusion. Results: Forty-five patients underwent ACDF with hyperlordotic interbody placement and after a 1:1 propensity match with standard lordotic patients, 90 patients were included. 1-year postoperative radiographs demonstrated the hyperlordotic cohort achieved higher CL (15.3° ± 10.6° vs. 9.58° ± 8.88°; P = 0.007). The change in CL (8.42° ± 9.42° vs. 0.94° ± 8.67°; P < 0.001), change in C2S (−4.02° ± 6.68° vs. −1.11° ± 5.42°; P = 0.026), and change in T1S (3.49° ± 7.30° vs. 0.04° ± 6.86°, P = 0.008) between pre- and postoperative imaging were larger in the hyperlordotic cohort. There was no difference in overall subsidence ( P = 0.183) and rate of fusion ( P = 0.353) between the cohorts. Conclusion: Hyperlordotic spacer placement in ACDF can provide increased CL compared to standard lordosis spacers, which can be considered for patients requiring restoration or maintenance of CL following ACDF.
Study Design: Narrative review. Objectives: To provide an updated overview of the management of acute traumatic central cord syndrome (ATCCS). Methods: A comprehensive narrative review of the literature was done to identify evidence-based treatment strategies for patients diagnosed with ATCCS. Results: ATCCS is the most commonly encountered subtype of incomplete spinal cord injury and is characterized by worse sensory and motor function in the upper extremities compared with the lower extremities. It is most commonly seen in the setting of trauma such as motor vehicles or falls in elderly patients. The operative management of this injury has been historically variable as it can be seen in the setting of mechanical instability or preexisting cervical stenosis alone. While each patient should be evaluated on an individual basis, based on the current literature, the authors’ preferred treatment is to perform early decompression and stabilization in patients that have any instability or significant neurologic deficit. Surgical intervention, in the appropriate patient, is associated with an earlier improvement in neurologic status, shorter hospital stay, and shorter intensive care unit stay. Conclusions: While there is limited evidence regarding management of ATCCS, in the presence of mechanical instability or ongoing cord compression, surgical management is the treatment of choice. Further research needs to be conducted regarding treatment strategies and patient outcomes.
Study Design. A retrospective study. Objective. To compare the perioperative and postoperative outcomes among lumbar fusion patients treated at an orthopaedic specialty hospital (OSH), a hybrid community hospital (HCH), and a conventional community hospital in comparison to a tertiary care hospital (TCH). Summary of Background data. In spine surgery, strategies to reduce length of stay (LOS) include a myriad of pre-, intra-, and postoperative strategies that require a multidisciplinary infrastructure. The sum of these efforts has led to the creation of orthopedic specialty hospitals and protocols that have been adopted by community hospitals as well. There is a notable lack of information regarding the results of these efforts across different healthcare institution models. Methods. This was a retrospective study of patients undergoing elective one or two-level lumbar fusion between 2017 and 2022 at a large urban TCH, an OSH, a HCH, and a conventional CH. Data was collected on patient characteristics, demographics, comorbidities, BMI, smoking status, surgical type, surgical levels, surgery duration, hospital length of stay, readmissions, reoperations, and discharge status within a year. Patients across the four surgical settings were matched based on age, BMI, CCI, type of procedure, and number of levels fused. Results. A total of 1435 patients met the inclusion criteria. Length of hospital stay was significantly longer at TCH compared to OSH, HCH, and CH by an average of 1-2 days ( P <0.001). 90-day readmissions were higher at TCH compared to OSH ( P =0.001). TCH patients also were less likely to be discharged home than OSH and HCH patients ( P =0.001 and P =0.016, respectively). No significant differences were noted in 1-year reoperation rates across all hospital models. Conclusion. Shorter lengths of stays and more home discharges at the orthopaedic specialty hospital and community hospital settings did not compromise surgical quality or postoperative outcomes.
In recent years, alternative forms of impact measurement, known as “altmetrics”, have been proposed as a potential supplement to the more traditional citation-based metric system in determining the influence of orthopaedic literature on the community. As social media grows increasingly more pervasive into mainstream society, so too does its presence in the health care field, especially in the realm of orthopaedics; therefore, it is necessary to determine the influence social media has both on orthopaedic care and the dissemination of orthopaedic literature to the academic community.
To evaluate patient-reported outcomes and return to sport after open fasciotomy for lower extremity chronic exertional compartment syndrome (CECS).Retrospective case series.Foot and ankle specialty service at a large multisite academic medical center.All patients undergoing lower extremity fasciotomy for CECS from 2009 to 2017 by one surgeon were eligible. Patients that underwent a fasciotomy for trauma, infection, or an acute pathologic process were excluded. Fifty-nine patients that underwent 63 procedures were included. The average age was 26.6 years, and 35 (59%) patients were women. Thirty-seven patients underwent simultaneous bilateral fasciotomies, 4 had staged bilateral fasciotomies, and 18 underwent unilateral fasciotomy. Four-compartment fasciotomy was performed 15 times.Retrospective email/telephone follow-up.Return to sports questionnaire, the Foot and Ankle Ability Measure-Sports subscale, and visual analog scale for pain.At a mean follow-up of 58.8 months, significant postoperative improvement was seen in patient-reported outcome scores compared with preoperative scores (P < 0.0001). Overall, 55 (93%) patients were able to return to sport, 42 (76%) returned to the same level of sport, and 13 (24%) returned to a lower level of competition. Bivariate regression analysis demonstrated that a higher preoperative body mass index [odds ratio: 0.829 (95% confidence interval: 0.688, 0.999); P = 0.049] was associated with a lower likelihood of return to sport.This study demonstrates that lower extremity fasciotomy for CECS results in improvement of patient-reported outcomes and a high rate of return to sport.
Objective: To evaluate the reasons for transfer as well as the 90-day outcomes of patients who were transferred from a high-volume orthopedic specialty hospital (OSH) following elective spine surgery. Materials and Methods: All patients admitted to a single OSH for elective spine surgery from 2014 to 2021 were retrospectively identified. Ninety-day complications, readmissions, revisions, and mortality events were collected and a 3:1 propensity match was conducted. Results: Thirty-five (1.5%) of 2351 spine patients were transferred, most commonly for arrhythmia ( n = 7; 20%). Thirty-three transferred patients were matched to 99 who were not transferred, and groups had similar rates of complications (18.2% vs. 10.1%; P = 0.228), readmissions (3.0% vs. 4.0%; P = 1.000), and mortality (6.1% vs. 0%; P = 0.061). Conclusion: Overall, this study demonstrates a low transfer rate following spine surgery. Risk factors should continue to be optimized in order to decrease patient risks in the postoperative period at an OSH.
1. John Mangan, MD*
2. Darshan Shah, MD*
3. April Troy, MD, MPH*
4. Dennis Dawgert, MD*
1. *The Commonwealth Medical College, Scranton, PA
An 18-year-old boy presents with right-sided jaw pain, migratory body pains, decreased appetite, pain on deep inspiration, severe odynophagia, and dark urine. He had no history of sick contacts or international travel. He was evaluated a week earlier for a sore throat, moderate dysphagia, fever, and decreased energy. On physical examination at that time he was found to have an erythematous posterior pharynx, moderately enlarged tonsils, and cervical lymphadenopathy. His streptococcal antigen and Monospot test results were negative. He was prescribed corticosteroids and naproxen for pain and severe tonsillar enlargement.
Physical examination shows an erythematous posterior pharynx without exudates, severely enlarged tonsils, pleuritic chest pain on deep inspiration, and right mid-thoracic paraspinal tenderness. Vitals on presentation are a temperature of 102.4°F (39.1°C) and a heart rate of 90 beats/min. The remaining physical examination results are normal.
He is hospitalized for further evaluation and treatment with ceftriaxone for concern for peritonsillar abscess.
Laboratory evaluation shows a white blood cell count of 24×103/μL with 60% neutrophils and 25% bands, a platelet count of 115×103/μL (115×109/L), a blood urea nitrogen level of 30 mg/dL (10.7 mmol/L), and a creatinine concentration of 1.1 mg/dL (97.2 μmol/L). Urinalysis shows trace ketones, 5 to 9 red blood cells per high-power field, a urobilinogen level of 8 mg/dL, 2+ bilirubin, and 1+ protein. A chest computed tomographic (CT) scan is performed because of pleuritic chest pain and shows interstitial pneumonia with possible septic …
Category: Sports; Other Introduction/Purpose: Chronic exertional compartment syndrome (CECS) of the lower leg is the result of increased pressure in intramuscular compartments that occurs during repetitive physical activity. Previous studies have demonstrated the effectiveness of lower extremity fasciotomies in treating CECS. However, not all patients have the same level of symptom improvement or ability to return to sport. The purpose of this study was to determine if any independent patient variables were predictive of outcomes following fasciotomy for CECS of the lower leg. Methods: A retrospective review of patients undergoing fasciotomy of the lower leg for treatment of CECS by a single fellowship-trained orthopaedic surgeon from 2009 to 2017 was performed. All patients had a diagnosis confirmed by pre- and post-exercise compartment pressure testing using the Pedowitz criteria. Patients that underwent a fasciotomy for trauma, infection, or an acute pathologic process or underwent revision fasciotomy were excluded. Preoperative measures of Foot and Ankle Ability Measure-Sport subscale (FAAM-Sport), FAAM-Sport single assessment numeric evaluation (SANE), and visual analog scale (VAS) for pain during sporting activities were collected. Patients with at least 12 months of follow-up were included. The primary outcomes of change (delta, Δ) in FAAM-Sport, FAAM-Sport SANE, and VAS during sporting activities were calculated. To determine significant predictors of outcomes, a generalized multivariate linear regression model developed based on univariate analysis and clinical experience was used. Statistical significance was set at p<0.05. Results: In total, 61 patients underwent 65 procedures, with outcome measures obtained on average 57.9 (range, 12-115) months postoperatively. Median age was 22, median BMI was 24.4, and 59.0% of the cohort was female. Of the 65 fasciotomies, 39 (60.0%) were simultaneous bilateral, 6 procedures (9.2%) performed on 3 patients were staged bilateral, and 18 (27.7%) were unilateral. There were 16 four-compartment fasciotomies performed (24.6%), while 49 (75.4%) involved 2 compartments. Twenty- two procedures involved deep posterior compartment pressures meeting the Pedowitz criteria. Patients had mean (+- standard deviation) improvement in FAAM-Sport of 40.4 +- 22.3 points (p<0.001), improvement in FAAM-Sport SANE of 57.3 +- 31.6 (p<0.001), and reduction of VAS pain of 56.4 +- 31.8 (p<0.001). Multivariate linear regression results are listed in Table 1. Conclusion:: Fasciotomy is an effective treatment of CECS, with our study identifying certain patient variables leading to greater improvement. Independent predictors of improvement of FAAM-Sport SANE following surgery included younger age, history of depression, and male sex. A history of depression was an independent predictor of greater VAS pain reduction following fasciotomy. Patients with deep posterior compartment pressure testing meeting the Pedowitz criteria was an independent predictor of increased improvement in FAAM-Sport. To our knowledge, this is the first study to investigate and identify independent patient variables predictive of greater functional improvement following fasciotomy for CECS. [Table: see text]
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