Study Design Systematic review. Clinical Questions (1) Is autologous local bone (LB) graft as safe and effective as iliac crest bone graft (ICBG) in lumbar spine fusion? (2) In lumbar fusion using ICBG, does a single-incision midline approach reduce postoperative iliac crest pain compared with a two-incision traditional approach? Methods Electronic databases and reference lists of key articles were searched up to October 2014 to identify studies reporting the comparative efficacy and safety of ICBG versus LB graft or comparing ICBG harvest site for use in lumbar spine surgery. Studies including allograft, synthetic bone, or growth factors in addition to ICBG and those with less than 80% of patients with degenerative disease in the lumbar spine were excluded. Two independent reviewers assessed the level of the evidence quality using the Grades of Recommendation Assessment, Development and Evaluation criteria, and disagreements were resolved by consensus. Results Seven studies were identified as using ICBG fusion for degenerative disease in the lumbar spine. There were no differences in the fusion, leg pain, low back pain, or functional outcomes between patients receiving LB versus ICBG. There was a higher incidence of donor site pain and sensory loss in patients receiving ICBG, with no donor site complications attributed to LB. Compared with patients with the graft harvested through the two-incision traditional approach, patients with the graft harvested through the single-incision midline approach had lower mean pain scores over the iliac crest, with a higher proportion reporting no iliac crest tenderness. In patients with ICBG harvested through the single-incision midline approach on either the right or the left side of the ilium, only 36% of the patients were able to correctly identify the side when asked whether they knew which iliac crest was harvested. Only 19% of the patients with ICBG harvested through the single-incision midline approach on either the right or the left side of the ilium reported pain that was concordant with the side that was actually harvested. Conclusions LB is as safe and efficacious as ICBG for instrumented fusion in the lumbar spine to treat degenerative disease. When ICBG is used, graft harvest through the single-incision midline approach reduces postoperative iliac crest pain compared with a two-incision approach.
Care of spinal conditions has become increasingly complex and confusing. Classification systems can help in understanding the subject matter at hand, but have exploded in numbers and complexity. Attempts at extracting classifications of spinal disorders are cumbersome and require careful study of numerous reference books without achieving a comprehensive overview in the end. This one of a kind reference text summarizes over 185 spine classification or severity easures with standardized art work, provides ratings and critical evaluations of pertinent strengths and weaknesses in a concise and systematic fashion and provides help in: * Studying spinal disease conditions * Preparing informed treatment decisions * Communicating individual patient disease severity * Evaluating publications regarding treatment results and success * Formulating spinal research projects * Providing a scientific reference tool The book is divided into two major systems Disease severity: * General disease severity * Instability * Osteoporosis * Stenosis * Spinal deformity * Degenerative disorders * Infection * Tumor * Heterotopic ossification Trauma severity: * General trauma scores * Spinal cord injury * Fracture classifications All identified measures within each category are formally reviewed and displayed in a unique visually friendly manner containing: * A one of a kind compendium of high quality diagrams for each severity measure or classification system with unrivaled specificity and detail * The content of each measure and whether it incorporates the critically important ABCDs of disease severity including: an anatomical component, a biomechanical component, a clinical component, and the degree of severity component * A summary of the measures validity, reliability, and predictive ability with corresponding patient populations * An evaluation of each measure using our scoring criteria focusing on methodological rigor and clinical utility * An overall score for each measure rating the instrument's strength with respect to methodology and clinical utility
Introduction The primary objective of this work was to define the neurological benefit conferred by surgical intervention to patients with degenerative cervical myelopathy (DCM). Secondary objectives included assessing how preoperative disease severity and duration impacted on that benefit and defining the surgical complications encountered by these patients. Material and Methods A search was undertaken for articles published until May 2015 evaluating the operative treatment of DCM using electronic databases. Prospective studies of adult surgical myelopathic patients were included. Extracted data included study design, patient demographics, diagnosis, surgical approach, preoperative and postoperative neurological status (mJOA, NDI, Nurick, VAS), and complications. Preoperative disease severity and duration of symptoms were recorded. Risk of bias (Newcastle-Ottawa Scale) and quality of evidence (Grades of Recommendation Assessment, Development and Evaluation) were assessed. Primary outcomes included assessment of change in neurological (graded by mJOA, NDI, and Nurick scores) and pain (graded by VAS score) following surgical intervention for myelopathic patients. Secondary outcomes were also assessed for dependency on preoperative duration of symptoms and preoperative disease severity. Safety of surgery was assessed by pooled estimates of perioperative complications encountered. Results Among 32 included studies, surgical intervention for DCM patients provided clinically-significant improvement in neurological dysfunction and pain. This improvement occurred at short-term assessment (fewer than 12 months) and was durable in longer-term (greater than 36 months), consistent over several different scoring systems. Shorter duration of symptoms may be associated with a higher likelihood of neurological recovery. Conclusion Surgical intervention for DCM is an appropriate evidence-based therapy with an acceptably low rate of perioperative complication. Further work is important to define optimal surgical approach and timing.
The randomized controlled trial (RCT) has become the standard by which studies of therapy are judged. The key to the RCT lies in the random allocation process. When done correctly in a large enough sample, random allocation is an effective measure in reducing bias. In this article we describe the random allocation process.
In the course of evaluating the patient with spinal disease, a myriad of measurements need to be performed before determining the diagnosis and the severity of the disease process. This text explicitly outlines the measurement of the spine from a clinical, laboratory, and radiographic approach. A detailed description of the actual technique of measurement and the clinical implication are presented with accompanying illustrations. This amalgamation of measurement tools for the spine is a beneficial reference for a wide spectrum of healthcare providers: students, nurses, residents, fellows, and established surgeons. In addition to its detailed illustrated presentation, each measurement technique has been graded for scientific and clinical utility with a score that specifically grades: Interobserver reliability Intraobserver reliability Universality Disease specificity Ease of application Simplicity Patient tolerability Expense The detail presented in this text will not only serve as a reference, but will also allow the reader to accurately reproduce measurement techniques, thus enhancing inter-physician communication, research of the spine, and improvement of patient care.
Background: Lateral mass screw fixation with plates or rods has become the standard method of posterior cervical spine fixation and stabilization for a variety of surgical indications. Despite ubiquitous usage, the safety and efficacy of this technique have not yet been established sufficiently to permit ‘‘on-label’’ U.S. Food and Drug Administration approval for lateral mass screw fixation systems. The purpose of this study was to describe the safety profile and effectiveness of such systems when used in stabilizing the posterior cervical spine.
Study Design Systematic review. Study Rationale The purpose of this review is to further define the published literature with respect to vertebral artery (VA) anomaly and injury in patients with degenerative cervical spinal conditions. Objectives In adult patients with cervical spine or degenerative cervical spine disorders receiving cervical spine surgery, what is the incidence of VA injury, and among resulting VA injuries, which treatments result in a successful outcome and what percent are successfully repaired? Materials and Methods A systematic review of pertinent articles published up to April 2013. Studies involving traumatic onset, fracture, infection, deformity or congenital abnormality, instability, inflammatory spinal diseases, or neoplasms were excluded. Two independent reviewers assessed the level of evidence quality using the Grades of Recommendation Assessment, Development and Evaluation criteria; disagreements were resolved by consensus. Results From a total of 72 possible citations, the following met our inclusion criteria and formed the basis for this report. Incidence of VA injuries ranged from 0.20 to 1.96%. None of the studies reported using preoperative imaging to identify anomalous or tortuous VA. Primary repair and ligation were the most effective in treating VA injuries. Conclusion The incidence of VA injuries in degenerative cervical spinal surgery might be as high as 1.96% and is likely underreported. Direct surgical repair is the most effective treatment option. The most important preventative technique for VA injuries is preoperative magnetic resonance imaging or computed tomography angiographic imaging to detect VA anomalies. The overall strength of evidence for the conclusions is low.
The objective of this guideline is to outline the role of magnetic resonance imaging (MRI) in clinical decision making and outcome prediction in patients with traumatic spinal cord injury (SCI).A systematic review of the literature was conducted to address key questions related to the use of MRI in patients with traumatic SCI. This review focused on longitudinal studies that controlled for baseline neurologic status. A multidisciplinary Guideline Development Group (GDG) used this information, their clinical expertise, and patient input to develop recommendations on the use of MRI for SCI patients. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest."Based on the limited available evidence and the clinical expertise of the GDG, our recommendations were: (1) "We suggest that MRI be performed in adult patients with acute SCI prior to surgical intervention, when feasible, to facilitate improved clinical decision-making" (quality of evidence, very low) and (2) "We suggest that MRI should be performed in adult patients in the acute period following SCI, before or after surgical intervention, to improve prediction of neurologic outcome" (quality of evidence, low).These guidelines should be implemented into clinical practice to improve outcomes and prognostication for patients with SCI.
