Faculty Bibliography

Low back pain is one of the most common reasons for physician visits, leading to high heath care costs and disability. Patients may present to primary care physicians, pain management physicians, chiropractors, physical therapists, or surgeons with these complaints. A thorough history and physical examination coupled with judicious use of advanced imaging studies will aid in determining the etiology of the pain. As most cases of low back pain are self-limited and will not develop into chronic pain, nonsurgical treatment is the mainstay. First-line treatment includes exercise, superficial heat, massage, acupuncture, or spinal manipulation. Pharmacologic treatment should be reserved for patients unresponsive to nonpharmacologic treatment and may include NSAIDs or muscle relaxants. Surgery is reserved for patients with pain nonresponsive to a full trial of nonsurgical interventions and with imaging studies which are concordant with physical examination findings.

BACKGROUND CONTEXT/BACKGROUND:Lumbar disc herniation and retrolisthesis have been shown to be significant degenerative changes that can be associated with back pain. Current literature has shown evidence that retrolisthesis is associated with similar baseline function in patients with L5-S1 disc herniation, but worse post-operative outcomes 2 years after lumbar discectomy. However, literature comparing long-term post-operative outcomes at 8-year follow-up in patients with L5-S1 disc herniation with retrolisthesis is lacking. PURPOSE/OBJECTIVE:The purpose of the present study is to compare long-term post-operative outcomes at 8-year follow-up in patients with retrolisthesis and L5-S1 disc herniations to patients with L5-S1 disc herniations without retrolisthesis. STUDY DESIGN/METHODS:Retrospective review of prospectively collected data from the Spine Patients Outcomes Research Trial (SPORT) database. PATIENT SAMPLE/METHODS:Sixty-five patients who underwent lumbar discectomy for L5-S1 disc herniations with 8-year follow-up from the SPORT. OUTCOME MEASURES/METHODS:Short Form (SF)-36 bodily pain scale, SF-36 physical function scale, Oswestry Disability Index (ODI), Sciatica Bothersomeness Index (SBI), and reoperation rate. METHODS:Baseline surgical parameters, length of stay, complication rates, re-operation rates, and outcome measures were recorded in the SPORT database. Follow-up data was collected at 6 weeks, 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, 5 years, 6 years, 7 years, and 8 years. Retrolisthesis was defined as posterior subluxation ≥ 8%. Patients with and without retrolisthesis were compared using a mixed-effects model of longitudinal regression. Outcomes were calculated as time-weighted averages over 8 years. Reoperation rates were compared using the log-rank test based on time to first reoperation. RESULTS:One hundred-twenty five patients met inclusion criteria for the present study, including 29 patients with retrolisthesis (23.3%) and 96 patients who did not have retrolisthesis (76.7%). The greatest difference in clinical outcome measures was found at 2 years post-operatively. This was the only point at which both the SF-36 BP and PF showed significant differences between the retrolisthesis and non-retrolisthesis group. At 3 years, SF-36 BP was significantly lower in patients with retrolisthesis (39.9 vs 52, p=0.046). At 8-year follow-up, the presence of retrolisthesis in patients undergoing L5-S1 discectomy was not associated with worse outcome measure scores based on the AUC analysis for any metric investigated (SF-36 BP 41.4 vs 47.1, p=0.18; SF-36 PF 38.9 vs 45.4, p=0.12; ODI -39.4 vs -34.8, p=0.23; -11.6 vs -10.4, p=0.25) or a difference in reoperation rate (retrolisthesis group 10%, non-retrolisthesis group 17%, p=0.41). CONCLUSIONS:While retrolisthesis can contribute to low back pain and dysfunction in patients undergoing lumbar discectomy for L5-S1 herniated nucleus pulposus in early follow-up, no significant difference was found in post-operative outcomes after 3 years. Additionally, retrolisthesis was not found to be associated with different reoperation rates at 8 years postoperatively.

STUDY DESIGN/METHODS:Cross-Sectional Study. OBJECTIVE:The goal of this study is to investigate how surgeons differ in collar and narcotic use, as well as return to driving recommendations following cervical spine surgeries and the associated medico-legal ramifications of these conditions. SUMMARY OF BACKGROUND DATA/BACKGROUND:Restoration of quality of life is one of the main goals of cervical spine surgery. Patients frequently inquire when they may safely resume driving after cervical spine surgery. There is no consensus regarding post-operative driving restrictions. This study addresses how surgeons differ in their recommendations concerning cervical immobilization, narcotic analgesia, and suggested timeline of return to driving following cervical spine surgery. METHODS:Surgeons at the Cervical Spine Research Society annual meeting completed anonymous surveys assessing postoperative patient management following fusion and non-fusion cervical spine surgeries. RESULTS:70% of surgeons returned completed surveys (n = 71). 80.3% were orthopaedic surgeons and 94.2% completed a spine fellowship. Experienced surgeons (>15y in practice) were more likely to let patients return to driving within 2 weeks than less experienced surgeons (47.1% vs 24.3%, p = .013) for multi-level ACDF and laminectomy with fusion procedures. There were no differences between surgeons practicing inside and outside the USA for prescribing collars or return to driving time. Cervical collars were used more for fusions than non-fusions (57.7% vs 31.0%, p = .001). Surgeons reported 75.3% of patients ask when they may resume driving. For cervical fusions, 31.4% of surgeons allowed their patients to resume driving while restricting them with collars for longer durations. Furthermore, 27.5% of surgeons allowed their patients to resume driving while taking narcotics post-operatively. CONCLUSIONS:This survey-based study highlights the lack of consensus regarding patient 'fitness to drive' following cervical spine surgery. The importance of establishing evidence-based guidelines is critical as recommendations for driving in the post-operative period may have significant medical, legal, and financial implications. LEVEL OF EVIDENCE/METHODS:5.

We conducted a thorough review of the literature to examine the risks and complications associated with the use of Gardner-Wells Tongs (GWT). Twenty-three articles were included in this review for final analysis. One article reported a 37.5% (6/16) incidence rate of minor complications with the usage of GWTs, which included pin loosening, asymmetrical pin positioning, and superficial infections. Various cases reported more serious yet rare complications, including perforation of the skull, brain abscesses, and neurovascular damage. Overall, the complication rate is low, and often associated with only minor and transient complications, which can be easily managed. Therefore, we conclude that GWT are safe and effective, with only rare, more serious complications reported in the literature.

BACKGROUND:Excessive radiation to health-care providers has been linked to risks of cancer and cataracts, but its negative effects can be substantially reduced by lead aprons, thyroid shields, and leaded glasses. Hospitals are required to provide education and proper personal protective equipment, yet discrepancies exist between recommendations and compliance. This article presents the results of a survey of U.S. orthopaedic surgery residents concerning attitudes toward radiation exposure and personal protective equipment behavior. METHODS:An invitation to participate in a web-based, anonymous survey was distributed to 46 U.S. allopathic orthopaedic surgery residency programs (1,207 potential resident respondents). The survey was conceptually divided into the following areas: demographic characteristics, training and attitudes concerning occupational hazards, personal protective equipment provision and use, and general safety knowledge. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated for the association between these characteristics and compliance with thyroid shield or lead gown wear. RESULTS:In this study, 518 surveys were received, with 1 survey excluded because of insufficient response, leaving 517 surveys for analysis (42.8% response rate). Ninety-eight percent of residents believed that personal protective equipment should be provided by the hospital or residency program. However, provision of personal protective equipment was not universal, with 33.8% reporting none and 54.2% reporting provision of a gown and thyroid shield. The prevalence of leaded glasses usage was 21%. Poor lead gown compliance and thyroid shield wear were associated with difficulty finding the corresponding equipment: PR, 2.51 (95% CI, 1.75 to 3.62; p < 0.001) for poor lead gown compliance and PR, 2.14 (95% CI, 1.46 to 3.16; p < 0.0001) for poor thyroid shield wear. Not being provided with personal protective equipment was also significantly associated with low compliance with both lead gowns (PR, 1.47 [95% CI, 1.04 to 2.08]; p = 0.03) and thyroid shields (PR, 1.69 [95% CI, 1.18 to 2.41]; p = 0.004). Respondents from the Southeast, West, or Midwest had lower compliance with lead gown usage. Forgetting was the number 1 reason to not wear a lead apron (42%). CONCLUSIONS:Radiation exposure is associated with increased risk of serious health problems. Our findings identified that the availability of lead personal protective equipment leads to increased compliance among residents surveyed. In addition to yearly occupational hazard training specific to orthopaedic surgery, greater efforts by residency programs and hospitals are needed to improve access to lead personal protective equipment and compliance for orthopaedic residents.

Background/UNASSIGNED:Anterior cervical discectomy and fusion (ACDF) may be performed using an interbody cage or graft with an anterior plate or with a stand-alone (SA) interbody device without the anterior plate. The pros and cons of each vary. This study examined the radiographic outcome of the two techniques with a focus on implant subsidence. Methods/UNASSIGNED:A retrospective review of cases of singe level ACDF by a single surgeon was undertaken. Medical and radiographic records were reviewed to determine subsidence, pre- and post-operative segmental and total lordosis in cohorts of both stand-alone and graft-and-plate constructs. Results/UNASSIGNED:The post-operative radiographs of 35 patients with a SA cage were compared with 41 patients with an allograft block and anterior plate (graft and plate; GP). There was no significant difference in overall subsidence between the two groups although there was a trend toward less clinically significant subsidence (2 mm) in the SA group. For single level ACDF, a SA device appears to be comparable in terms of undesired subsidence. Conclusions/UNASSIGNED:Further studies with different implants and materials may offer further insight.

Residency selection is a perennial multifactorial process that differs considerably from the recruitment processes that other professional occupations enjoy. The 2016 meeting of the American Orthopaedic Association's Council of Orthopaedic Residency Directors highlighted a series of symposia that sought to present a novel manner of resident selection. Specifically, the presenters for each symposium were asked to do the following: present some general recruitment best practices in industries outside of medicine, present how branding of a program may translate into a better interview season, investigate evidence that the applicant pool to orthopaedic surgery may have changed and that residency program brands may have to reflect this, and assess our current evaluation techniques for talent identification and resident selection with respect to a specific department's appearance or brand. The meeting concluded with an understanding of the level to which programs can successfully create or adopt a brand and how this may go a long way in focusing the entire match process and allow emphasis to be placed on applicants who possess desired traits. The goal for this meeting was that attendees would leave with tangible practices and techniques that could be adopted at their home institutions.

Spinal cord compression due to synovial facet cyst in thoracolumbar spine is rare. Several etiologies of juxtafacet cysts (JFCs) in this location have been discussed, particularly overload of the arthritic facet joints. Due to the narrow caliber of the thoracic spine, JFC in this location can present with radicular pain or progressive myelopathy. We report an interesting case of a 67 year-old woman who presented with the signs and symptoms of thoracic myelopathy. A left-sided T11/12 JFC was identified on MRI and CT scans correlating with her myelopathy. She experienced a substantial improvement in her myelopathic symptoms after surgical excision of the JFC. The presentation, etiology, and therapeutic aspects of JFC are discussed in detail.

The diagnosis and treatment of patients who have both hip and lumbar spine pathologies may be a challenge because overlapping symptoms may delay a correct diagnosis and appropriate treatment. Common complaints of patients who have both hip and lumbar spine pathologies include low back pain with associated buttock, groin, thigh, and, possibly, knee pain. A thorough patient history should be obtained and a complete physical examination should be performed to identify the primary source of pain. Plain and advanced imaging studies and diagnostic injections can be used to further delineate the primary pathology and guide the appropriate sequence of treatment. Both the surgeon and the patient should understand that although one pathology is managed, management of the other pathology may be necessary because of persistent pain. The recognition of both entities may help reduce the likelihood of misdiagnosis, and the management of both entities in the appropriate sequence may help reduce the likelihood of persistent symptoms.