Faculty Bibliography

Background: Interlaminar-interspinous implants have gained acceptance as motion preservation devices. There are a limited number of posterior dynamic stabilization implants approved by the FDA. The purpose of this study was to review the long-term clinical outcomes of patients that had placement of an interspinous implant. Methods: This is a retrospective study of 124 patients that underwent placement of a interlaminar-interspinous implant (coflex, Paradigm Spine, New York, NY, U.S.A.) with a mean follow-up of 6.3 years. Patients were treated for spinal stenosis, spinal stenosis and lumbar disc herniation, or lumbar disc herniation. Preoperatively and postoperatively, patients were asked to grade their back and leg pain using the pain severity scale: no pain (0), mild pain (1), moderate pain (2), or severe pain (3). Patient satisfaction was queried concerning their operative procedure. Results: The mean severity of low back pain was decreased at the 2-year follow-up (moderate to mild, P < 0.001) and remained decreased with at least 5 years follow-up (moderate to mild, P < 0.001). The mean severity of leg pain was decreased at the 2-year follow-up (severe to mild, P < 0.001) and with at least 5 years follow-up (severe to mild, P < 0.001). Overall patient satisfaction demonstrated 7% were unsatisfied, 46% were satisfied, and 46% were very satisfied with the clinical outcome. Conclusion: This study has demonstrated that interlaminar-interspinous implant by coflex provides pain relief for patients with low back pain and leg pain. Interlaminar-inter-spinous implant by coflex is an option in the selection for dynamic stabilization

Objectives: Interlaminar-interspinous implants have gained acceptance as motion preservation devices. Currently, there are a limited number of posterior dynamic stabilization implants approved by the FDA. The purpose of this study was to perform a review of the long-term device related issues of an interlaminar-interspinous implant. Methods: This is a retrospective study of 99 patients who underwent placement of an interlaminar-interspinous implant (coflex, Paradigm Spine, New York, NY, U.S.A.) with a mean follow-up of 7 years. Patients were seen pre-operatively and postoperatively by one orthopaedic spine surgeon. Patients received radiographic analysis at follow-up visits, which was assessed by the operating surgeon for any device related issues. Results: All 99 patients received radiographs at their follow-up with the operating surgeon. The complications were catgorized into the following groups with their respective percentages: no device related issues (92%) and device related issues (8%). The patients with device related issues were categorized into the following groups: Broken U portion of implant (0%); Broken wing of the implant (1%); Displaced U portion of implant less than 5 mm (2%); Displaced U portion of implant more than 5 mm (2%); Displaced U portion of implant with unknown distance (1%); Removed implant (2%); Spinous process fracture (0%); bone-implant interface remodeling (0%). Conclusions: Displacement of the U portion of the implant was the most common complication and could be due to instability at the level of insertion. The data has demonstrated that in the short and long term follow-up, there are very few device related complications

Introduction: The gold standard for the treatment of isthmic spondylolisthesis is posterior-lateral fusion. Few studies have evaluated the clinical outcomes of circumference fusion in the treatment if isthmic spondylolisthesis. The purpose of this study was to evaluate the surgical and clinical outcomes of anterior-posterior surgical treatment for low-grade isthmic spondylolisthesis. Methods: Retrospectively, 23 consecutive patients were enrolled that underwent surgical treatment for Isthmic Spondylolisthesis Grade 1 or 2. Basic demographic data was collected. Radiographic data that was collected included Meyerding Scale, disc height, and slip angle. Pre and post surgical clinical surveys which included VAS, ODI, and SF-36 surveys were collected. Results: There were 23 patients. All patients underwent anterior interbody fusion with a femoral ring allograft or iliac crest bone graft in addition to posterior lumbar decompression and fusion with instrumentation. The average slip percentage decreased from 23.2% to 19.0% (P = 0.24), slip angle increased from 9.8 to 17.9 (P < 0.001), and disc height decreased from 1.9 cm to 0.80 cm (P < .001). VAS scores decreased from 7.1 to 2.4 (P < 0.001). ODI scores decreased from 52.5 to 28.1 (P < 0.001). SF-36 scores demonstrated a significant increase in the Physical Component Scale (PCS) from 29.5 to 42.6 (P < 0.001). Conclusion: This study demonstrates that patients with isthmic spondylolisthesis that undergo circumferential fusion have a good clinical outcome. Patients demonstrated an improvement in the ODI and the physical component scores of the SF-36. These results demonstrate that patients improved in their physical functioning due to the surgery alone

STUDY DESIGN: Prospective inter-rater and intrarater reliability analysis. OBJECTIVE: To compare the inter-rater and intrarater reliability of magnetic resonance imaging (MRI) and computed tomography (CT) for grading of facet arthropathy as well as determining whether there is a contraindication to total disc replacement (TDR). SUMMARY OF BACKGROUND DATA: Several classifications attempted to evaluate lumbar facet joints and their degree of arthropathy. The Fujiwara-MRI and Pathrea-CT classifications remain the most commonly used. METHODS: A total of 10 fellowship-trained orthopedic spine surgeons and 3 orthopedic spine fellows evaluated 50 levels from L3-L4 through L5-S1 on parallel axial MRI (T1 and T2) and CT images. The degree of osteoarthritis was graded on a 4-point scale (Fujiwara-MRI and Pathrea-CT). Surgeons evaluated whether the degree of facet disease represented a contraindication to TDR. Grading was performed during 2 sessions. Weighted kappa statistics were used to describe inter- and intraobserver agreement. RESULTS: The inter-rater reliability for MRI was 0.21 and 0.07 (fair to slight) among attendings and fellows, respectively. inter-rater reliability for CT was 0.33 and 0.27 (fair), respectively. The mean intrarater reliability for MRI was fair, 0.36 (attendings) and 0.26 (fellows). The mean intrarater reliability for CT was moderate, 0.52 (attendings) and 0.51 (fellows). For possible TDR contraindication, the inter-rater reliability for MRI was 0.22 and 0.01 (fair to slight) among attendings and fellows, respectively. Inter-rater reliability for CT was 0.33 and 0.45 (fair), respectively. The mean intrarater reliability for MRI was fair, 0.36 (attendings) and 0.26 (fellows). The mean intrarater reliability for CT was moderate, 0.52 (attendings) and 0.51 (fellows). CONCLUSION: The current grading system for facet arthropathy has only fair agreement. CT is slightly more reliable for grading. Intrarater reliability was only fair for MRI and moderate for CT. Only limited agreement existed between surgeons as to the extent of facet disease that would pose as a contraindication for TDR

STUDY DESIGN: Retrospective outcome data analysis. OBJECTIVE: To evaluate if there is a significant difference between the midline rectus (MR) and the paramedian lateral rectus (PLR) approaches with regard to implant position for lumbar disc arthroplasty. To establish that a less than optimal implant position may influence clinical outcome. SUMMARY OF BACKGROUND DATA: Little is known about the impact of varying surgical approaches on lumbar artificial disc implant position and clinical outcome. METHODS: Fifty-seven patients were obtained from one center participating Food and Drug Administration study for the evaluation of the lumbar Prodisc-L. Two different surgical access techniques were compared; the MR and left PLR. Two independent evaluators calculated the postoperative radiographical displacement from the midline in the coronal and sagittal planes for each of the surgical techniques. Pre- and postoperative clinical outcomes were evaluated to determine which surgical access technique was associated with better outcomes and if there was a clinical correlation with technical accuracy. RESULTS: The PLR approach was associated with greater malalignment of the prosthesis in both the coronal and sagittal planes compared with the MR approach. However, the difference was significant only in the sagittal plane (P = 0.021). There was no significant difference in clinical outcome for either approach (P = 0.34). Patients with >or=5 mm prosthetic displacement from the midvertebral point had significantly worse Owestry disability index scores than patients with <3 mm malalignment in both the coronal and sagittal planes regardless of the surgical approach employed. CONCLUSION: The finding of a statistically significant more anteriorly displaced position in the sagittal plane of the total disc arthroplasty using the PLR approach may indicate a need to change to the MR approach. This study also demonstrates that patients with >or=5 mm prosthetic deviation from midline in either the coronal or sagittal planes had diminished clinical outcomes regardless of the approach used

STUDY DESIGN: Retrospective study of patients enrolled in prospective randomized Food and Drug Administration trial. OBJECTIVE: To evaluate the influence of pre- and postoperative disc height on postoperative motion and clinical outcomes. SUMMARY OF BACKGROUND DATA: Our understanding of the factors that influence motion and ultimately patient satisfaction after lumbar disc replacement continues to evolve. METHODS: Forty-two patients with a single level ProDisc-L at either the L4/5 or L5-S1 were selected. Pre- and postoperative disc height and range of motion (ROM) were measured from standing lateral and flexion-extension radiographs. Oswestry Disability Index and visual analog scale were also collected. Student t test and Spearman rho tests were performed to determine if there was any correlation or 'threshold' effect between the disc height and ROM or clinical outcome. RESULTS: The mean anterior and posterior disc height significantly increased from 10.8 mm to 17.6 mm and 4.4 mm to 7.9 mm, respectively (P < 0.01). The mean ROM decreased from 7.0 degrees to 5.7 degrees (P = 0.21). Patients with less than 9 mm of preoperative anterior disc height had an increase in their ROM (2.2 degrees) compared with a loss of ROM (-2.2 degrees) in patients with more than 9 mm of preoperative disc height (P = 0.02). Patients with between 16 mm and 18 mm of postoperative anterior disc height have greater ROM (7.5 degrees) than those above or below this range (3.6 degrees and 3.6 degrees respectively, P < 0.05). There was no correlation or threshold effect between clinical outcomes and disc height. CONCLUSION: Patients with greater disc collapse benefit more in ROM from a total disc replacement. The optimal range to maximize ROM for postoperative anterior disc height is 16 mm to 18 mm. This optimal range did not translate into better clinical outcome at 2 years follow-up

Degenerative disc disease is one of the leading causes of pain and disability. Various surgical treatments are available, but the literature does not provide a comparative overview of their long-term outcomes. This article synthesizes the available long-term evidence on the treatment of degenerative disc disease. Fusion for degenerative disc disease has recently shown good long-term clinical outcomes, yet several studies strongly suggest that it may accelerate the degenerative process at adjacent levels. Arthroplasty shows at least equivalent long-term outcomes and is not expected to accelerate adjacent degeneration, but speculative concern remains about its safety, especially in regard to wear debris and facet joint arthrosis. Many other treatment devices are in various stages of development, but long-term studies are not yet available for most of them. When making treatment decisions, physicians and patients must consider the long-term outcomes, because the devices remain implanted indefinitely, and back pain could recur at any time if the degeneration progresses or the device fails. Before making a treatment decision, surgeons and patients should thoroughly discuss the long-term clinical prognosis, the safety of various procedures, the degrees of certainty in our currently available medical knowledge, and the patient's preferences. No one solution will be right for every patient, but we are entering a golden era of choices, where most patients with degenerative disc disease should be able to find a treatment that substantially improves their condition

Spinal infections can arise in a variety of anatomical locations and structures and encompass vertebral osteomyelitis, discitis, disc space infection, epidural abscesses, and infecti= on of the adjacent soft tissue structures. Plain radiography, compute= d tomography, magnetic resonance imaging (MRI), and nuclear imagi= ng all have a role in the diagnosis of spinal infection. MRI conti= nues to be the gold standard for the imaging diagnosis of spinal infections. ⁶⁷Gallium citrate and Tc-99m-methylene diphosphonate scintigraphy have become the standard for nuclear imaging of the spine. Fluorine-18-fluorodeoxyglucose positron emission tomography, strepavidin/¹¹¹In-biotin, and ^99m-ciprofloxacin have shown promise for aiding in t= he diagnosis and evaluation of spinal infection but warrant furthe= r study