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Zoher Ghogawala, Daniel K. Resnick, Steven D. Glassman, James Dziura, Christopher I. Shaffrey and Praveen V. Mummaneni

spinal stenosis. Ghogawala et al. report a substantially higher revision rate in patients treated without fusion, whereas Försth et al. report equivalent revision rates. 5 , 7 Försth et al. suggest that the higher revision rate observed in the SLIP study reflects the surgeon's belief that a subsequent procedure, fusion, might address residual symptoms after decompression alone. While this explanation might be accurate in some instances, there are multiple alternative explanations, including cultural bias toward revision surgery or a more supportive social safety net

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Michael G. Kaiser, Jason C. Eck, Michael W. Groff, Zoher Ghogawala, William C. Watters III, Andrew T. Dailey, Daniel K. Resnick, Tanvir F. Choudhri, Alok Sharan, Jeffrey C. Wang, Sanjay S. Dhall and Praveen V. Mummaneni

demonstrated a positive impact on fusion rate; however, there is insufficient evidence regarding its impact on clinical outcome (single Level III study/multiple Level IV studies). Grade I There is insufficient evidence to recommend for or against the use of PEMFS as a treatment alternative to revision surgery in patients presenting with pseudarthrosis following posterior lumbar fusion (single Level IV study). Rationale Since the publication of the original “Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine,” 16 the

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Michael W. Groff, Andrew T. Dailey, Zoher Ghogawala, Daniel K. Resnick, William C. Watters III, Praveen V. Mummaneni, Tanvir F. Choudhri, Jason C. Eck, Alok Sharan, Jeffrey C. Wang, Sanjay S. Dhall and Michael G. Kaiser

The utilization of pedicle screw fixation as an adjunct to posterolateral lumbar fusion (PLF) has become routine, but demonstration of a definitive benefit remains problematic. The medical evidence indicates that the addition of pedicle screw fixation to PLF increases fusion rates when assessed with dynamic radiographs. More recent evidence, since publication of the 2005 Lumbar Fusion Guidelines, suggests a stronger association between radiographic fusion and clinical outcome, although, even now, no clear correlation has been demonstrated. Although several reports suggest that clinical outcomes are improved with the addition of pedicle screw fixation, there are conflicting findings from similarly classified evidence. Furthermore, the largest contemporary, randomized, controlled study on this topic failed to demonstrate a significant clinical benefit with the use of pedicle screw fixation in patients undergoing PLF for chronic low-back pain. This absence of proof should not, however, be interpreted as proof of absence. Several limitations continue to compromise these investigations. For example, in the majority of studies the sample size is insufficient to detect small increments in clinical outcome that may be observed with pedicle screw fixation. Therefore, no definitive statement regarding the efficacy of pedicle screw fixation as a means to improve functional outcomes in patients undergoing PLF for chronic low-back pain can be made. There appears to be consistent evidence suggesting that pedicle screw fixation increases the costs and complication rate of PLF. High-risk patients, including (but not limited to) patients who smoke, patients who are undergoing revision surgery, or patients who suffer from medical conditions that may compromise fusion potential, may appreciate a greater benefit with supplemental pedicle screw fixation. It is recommended, therefore, that the use of pedicle screw fixation as a supplement to PLF be reserved for those patients in whom there is an increased risk of nonunion when treated with only PLF.

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Zoher Ghogawala, Robert G. Whitmore, William C. Watters III, Alok Sharan, Praveen V. Mummaneni, Andrew T. Dailey, Tanvir F. Choudhri, Jason C. Eck, Michael W. Groff, Jeffrey C. Wang, Daniel K. Resnick, Sanjay S. Dhall and Michael G. Kaiser

rhBMP-2 or ICBG. Outcomes &costs were assessed at 2 yrs. SF-6D was used for utility measurements. Follow-up was 96%. Nosensitivity analysis. The cost of fusion using rhBMP-2 was $39,967. Fusion w/ ICBG cost $42,286. In the ICBG group, there were 5 revision surgeries; in the rhBMP-2 cohort, 1 revision surgery. The 2 cohorts had similar improvement in SF-6D scores. The cost of using rhBMP-2 is comparable to the cost of autograft for lumbar fusion surgery pts. Glassman et al., 2008 IV 106 pts >60 yrs old randomized to either rhBMP-2 vs ICBG for anterior 1-level

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Sanjay S. Dhall, Tanvir F. Choudhri, Jason C. Eck, Michael W. Groff, Zoher Ghogawala, William C. Watters III, Andrew T. Dailey, Daniel K. Resnick, Alok Sharan, Praveen V. Mummaneni, Jeffrey C. Wang and Michael G. Kaiser

. of levels = 2). Heterogeneous: variable no. of levels, half w/ degenerative spondylolisthesis, some had previous surger, some smokers, age range 44–82 yrs. Used SF-36 & dynamic radiographs; 100% follow-up. Pseudarthrosis in 13 pts, leading to revision surgery in 1. Reports “nearly identical maximum improvement on SF-36” & no correlation btwn fusion & clinical outcome. Found no correlation btwn pseudarthrosis & clinical results. The lesser quality prospective study was downgraded to Level III because of the heterogeneous pt population. Djurasovic et al., 2011

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Jeffrey C. Wang, Andrew T. Dailey, Praveen V. Mummaneni, Zoher Ghogawala, Daniel K. Resnick, William C. Watters III, Michael W. Groff, Tanvir F. Choudhri, Jason C. Eck, Alok Sharan, Sanjay S. Dhall and Michael G. Kaiser

of Odom's criteria. Patients undergoing a fusion demonstrated significantly better outcomes with respect to low-back pain. The frequency of revision surgery was significantly higher in patients who did not receive a fusion, but met the criteria for fusion. Interestingly, those patients who did not fulfill the criteria for fusion but had a fusion surgery also had significantly better results in terms of low-back pain scores compared with those without fusions. The authors concluded with this Level IV study that patients with disc herniations and instability or

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Michael G. Kaiser, Michael W. Groff, William C. Watters III, Zoher Ghogawala, Praveen V. Mummaneni, Andrew T. Dailey, Tanvir F. Choudhri, Jason C. Eck, Alok Sharan, Jeffrey C. Wang, Sanjay S. Dhall and Daniel K. Resnick

surgery. Significant improvement compared w/ preop scores was maintained at 6 yrs after surgery. 25 revision surgeries were performed over the 6-yr follow-up period & 7 btwn the 2- & 6-yr time points. The authors concluded that this technique was an effective method of obtaining an ALIF & maintaining long-term, significant clinical improvements. The efficacy of rhBMP-2 as a substitute for autologous bone w/ tapered cages in 1-level ALIF was previously established w/ the prior studies. The results reported in this case series are limited by the significant no. of pts

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surgery following single-level transforaminal lumbar interbody fusion (TLIF). Methods: All patients who underwent a single-level TLIF at either L4/5 or L5/S1 at our institution for between July 2006 and December 2012 were analyzed for pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), lumbar lordosis (LL), and PI-LL mismatch. Using univariate and multivariate logistic regression analysis, we compared the spinopelvic parameters of patients who required revision surgery for symptomatic ALD against those who did not. The sensitivities and specificities for

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SF-36. Utility modeled over the lifetime and quality-adjusted-life-years (QALY) determined using the median 5-year health status data. Primary outcome measure, cost per QALY gained, calculated by estimating the mean incremental lifetime costs and QALYs for each diagnosis group after discounting costs and QALYs at 3%. Sensitivity analyses adjusting for, + 25% primary and revision surgery cost, + 25% revision rate, upper and lower confidence interval utility score, variable inpatient rehabilition rate for THA/TKA and discounting at 5%, were conducted to determine

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010

medial (32.8%) or superior (2.5%). T4 (4.1%) and T6 (4.0%) experienced the highest breach rate, while L5 and S1 had the lowest (Figure 4). Eight patients (0.8%) underwent a revision surgery to correct a malpositioned screw. Conclusions: Free-hand pedicle screw placement based on external anatomy alone can be performed with acceptable safety and accuracy and allows avoidance of radiation exposure encountered in fluoroscopic techniques. Image-guided assistance may be most valuable when placing screws between T4–T6 where breach rates are highest. J Neurosurg