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Editorial: Separation surgery

Charles Fisher and Juliet Batke

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The quality of quality of life publications in the spinal literature: are we getting any better?

Clinical article

John Street, Brian Lenehan, and Charles Fisher

Object

Criteria for methodological quality have been widely accepted in many fields of surgical practice. These criteria include those of Velanovich and Gill and Feinstein. No such analysis of the spine surgery literature has ever been reported. This study is a systematic review of the quality of life (QOL) publications to determine if the recent interest in QOL measurements following spinal surgery has been accompanied by an improvement in the quality of the papers published.

Methods

The archives of the journals Journal of Neurosurgery: Spine, Spine, Journal of Spinal Disorders & Techniques, European Spine Journal, and The Spine Journal, for the years 2000–2004 inclusive, were examined, and all publications reporting QOL outcomes were analyzed. Each paper was scored according to the criteria of Velanovich and Gill and Feinstein, and the methodological quality of these manuscripts—and any time-dependent changes—were determined.

Results

During the study period, the total number of articles published increased by 36%, while the number of QOL articles increased by 102%. According to the criteria of Velanovich, there was a statistically significant improvement in the quality of the publications over the study period (p = 0.0394). In 2000, only 27% of outcome measures were disease specific, 77% were valid, and 77% were appropriate for the study design. In 2004, 43% were disease specific, 88% were valid, and 89% were appropriate. In 2000, 53% of studies used appropriate statistical analysis compared with 100 and 96% for 2003 and 2004, respectively. There was no demonstrable improvement in the fulfillment of the more rigorous Gill and Feinstein criteria for any of the 5 journals over the period of the study.

Conclusions

The authors' study illustrates a moderate improvement in the quality of these publications over the study period but much methodological improvement is required.

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Nonoperative Treatment

Stephen E. Natelson

Object

Despite extensive published research on thoracolumbar burst fractures, controversy still surrounds which is the most appropriate treatment. The objective of this study was to evaluate the scientific literature on operative and nonoperative treatment of patients with thoracolumbar burst fractures and no neurological deficit.

Methods

In their search of the literature, the authors identified all possible relevant studies concerning thoracolumbar burst fracture without neurological deficit. Two independent observers performed study selection, methodological quality assessment, and data extraction in a blinded and objective manner for all papers identified during the search. In a synthesis of the literature, the authors obtained evidence for both operative and nonoperative treatments.

Conclusions

There is a lack of evidence demonstrating the superiority of one approach over the other as measured using generic and disease-specific health-related quality of life scales. There is no scientific evidence linking posttraumatic kyphosis to clinical outcomes. The authors found that there is a strong need for improved clinical research methodology to be applied to this patient population.

Open access

Spinal metastasis of parotid acinic cell carcinoma followed by intradural extramedullary recurrence: illustrative case

Po Hsiang (Shawn) Yuan, Lukas Grassner, Charles Fisher, and Nicolas Dea

BACKGROUND

The diagnosis and management of acinic cell carcinoma (ACC) is often challenging given its similarity to benign tumors, high incidences of late recurrence and distant metastasis, and tendency to be resistant to systemic chemotherapy. A primary parotid ACC resulting in an intradural extramedullary mass has not been reported.

OBSERVATIONS

The authors describe such a case that presented as a progressive cervical myelopathy 29 years after initial diagnosis. The tumor, located at the C2–C3 level, infiltrated the dura and contained both extradural and intradural components. This occurred 18 months after the incomplete resection of an extradural metastasis at the same location.

LESSONS

Although intracranial and extradural metastases of various primary malignancies are well reported, secondary spinal intradural malignancies are rare. As a result, there are no established guidelines for the surgical management of intradural extramedullary metastases and prognosis may be difficult to establish. In this case, treatment options were limited because systemic therapy options had been exhausted and repeated radiation to the area was not recommended. We report on this case to highlight the clinical course of a rare local recurrence after spinal metastasis leading to an intradural extramedullary tumor and to show that surgical intervention can lead to improvement of neurological symptoms.

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Anterior cervical plate fixation: biomechanical effectiveness as a function of posterior element injury

Tobias Pitzen, Chris Lane, Darrell Goertzen, Marcel Dvorak, Charles Fisher, Dragos Barbier, Wolf-Ingo Steudel, and Thomas Oxland

Object

The primary goal of this study was to determine if the stabilization provided to the spine by anterior cervical fixation with plating (ACFP) was dependent on the degree of posterior element injury. The secondary goal was to evaluate the effectiveness of additional posterior screw/rod stabilization in these injuries.

Methods

Following ACFP with interbody bone graft and stepwise transection of the posterior ligaments and facets at C5–6, eight fresh-frozen human C4–7 spine segments were loaded using pure moments of ± 1.5 Nm in flexion—extension, axial rotation, and lateral bending in the intact state. Posterior screw/rod fixation was performed after complete ligamentous destruction and complete removal of the facets. Repeated-measures analysis of variance and pairwise Student-Newman-Keuls tests were used to detect changes in the range of motion (ROM) and neutral zone (NZ). Statistical significance was assumed at a 95% level.

Significant increases in ROM occurred in each loading direction after transection of the capsular ligaments (p < 0.001) and again following facetectomy (p < 0.001) compared with the ACFP condition. Additional posterior fixation resulted in a significant decrease in ROM in all loading directions (p < 0.001). There was a significant increase in NZ for complete ligamentous destruction compared with ACFP (p < 0.05) and facetectomy compared with ACFP (p < 0.05) for flexion—extension. In lateral bending, a significant increase in NZ was found for facetectomy compared with ACFP (p < 0.05).

Conclusions

Capsular ligaments and articular facets are important structures in limiting three-dimensional vertebral motion in the presence of an anterior plate. Supplementary posterior fixation does reduce motion for all injury conditions.

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Long-term health-related quality of life outcomes following Jefferson-type burst fractures of the atlas

Marcel F. Dvorak, Michael G. Johnson, Michael Boyd, Garth Johnson, Brian K. Kwon, and Charles G. Fisher

Object. The primary goal of this study was to describe the long-term health-related quality of life (HRQOL) outcomes in patients who have suffered Jefferson-type fractures. These outcomes were compared with matched normative HRQOL data and with the patient's perceptions of their HRQOL prior to the injury. Variables that potentially influence these HRQOL outcomes were analyzed.

No standardized outcome assessments have been published for patients who suffer these fractures; their outcomes have long thought to be excellent following treatment. Determining the optimal surrogate measure to represent preinjury HRQOL in trauma patients is difficult.

Methods. A retrospective review, radiographic analysis, and cross-sectional outcome assessment were performed. The Short Form (SF)—36 and the American Academy of Orthopaedic Surgeons/North American Spine Society (AAOS/NASS) outcome instruments were filled out by patients at final follow-up examination (follow-up period 75 months, range 19–198 months) to represent their current status as well as their perceptions of preinjury status.

In 34 patients, the SF-36 physical component score and the AAOS/NASS pain values were significantly lower than normative values. There was no significant difference between normative and preinjury values. Spence criteria greater than 7 mm and the presence of associated injuries predicted poorer outcome scores during the follow-up period.

Conclusions. Long-term follow-up examination of patients with Jefferson fractures indicated that patients' status does not return to the level of their perceived preinjury health status or that of normative population controls. Those with other injuries and significant osseous displacement (≥ 7 mm total) may experience poorer long-term outcomes. Limitations of the study included a relatively low (60%) response rate and the difficulties of identifying an appropriate baseline outcome in a trauma population with which the follow-up outcomes can be compared.

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Effect of slosh mitigation on histologic markers of traumatic brain injury

Laboratory investigation

Ryan C. Turner, Zachary J. Naser, Julian E. Bailes, David W. Smith, Joseph A. Fisher, and Charles L. Rosen

Object

Helmets successfully prevent most cranial fractures and skull traumas, but traumatic brain injury (TBI) and concussions continue to occur with frightening frequency despite the widespread use of helmets on the athletic field and battlefield. Protection against such injury is needed. The object of this study was to determine if slosh mitigation reduces neural degeneration, gliosis, and neuroinflammation.

Methods

Two groups of 10 adult male Sprague-Dawley rats were subjected to impact-acceleration TBI. One group of animals was fitted with a collar inducing internal jugular vein (IJV) compression prior to injury, whereas the second group received no such collar prior to injury. All rats were killed 7 days postinjury, and the brains were fixed and embedded in paraffin. Tissue sections were processed and stained for markers of neural degeneration (Fluoro-Jade B), gliosis (glial fibrillary acidic protein), and neuroinflammation (ionized calcium binding adapter molecule 1).

Results

Compared with the controls, animals that had undergone IJV compression had a 48.7%–59.1% reduction in degenerative neurons, a 36.8%–45.7% decrease in reactive astrocytes, and a 44.1%–65.3% reduction in microglial activation.

Conclusions

The authors concluded that IJV compression, a form of slosh mitigation, markedly reduces markers of neurological injury in a common model of TBI. Based on findings in this and other studies, slosh mitigation may have potential for preventing TBI in the clinical population.

Free access

Defining the inherent stability of degenerative spondylolisthesis: a systematic review

Andrea M. Simmonds, Y. Raja Rampersaud, Marcel F. Dvorak, Nicolas Dea, Angela D. Melnyk, and Charles G. Fisher

OBJECT

A range of surgical options exists for the treatment of degenerative lumbar spondylolisthesis (DLS). The chosen technique inherently depends on the stability of the DLS. Despite a substantial body of literature dedicated to the outcome analysis of numerous DLS procedures, no consensus has been reached on defining or classifying the disorder with respect to stability or the role that instability should play in a treatment algorithm. The purpose of this study was to define grades of stability and to develop a guide for deciding on the optimal approach in surgically managing patients with DLS.

METHODS

The authors conducted a qualitative systematic review of clinical or biomechanical analyses evaluating the stability of and surgical outcomes for DLS for the period from 1990 to 2013. Research focused on nondegenerative forms of spondylolisthesis or spinal stenosis without associated DLS was excluded. The primary extracted results were clinical and radiographic parameters indicative of DLS instability.

RESULTS

The following preoperative parameters are predictors of stability in DLS: restabilization signs (disc height loss, osteophyte formation, vertebral endplate sclerosis, and ligament ossification), no disc angle change or less than 3 mm of translation on dynamic radiographs, and the absence of low-back pain. The validity and magnitude of each parameter’s contribution can only be determined through appropriately powered prospective evaluation in the future. Identifying these parameters has allowed for the creation of a preliminary DLS instability classification (DSIC) scheme based on the preoperative assessment of DLS stability.

CONCLUSIONS

Spinal stability is an important factor to consider in the evaluation and treatment of patients with DLS. Qualitative assessment of the best available evidence revealed clinical and radiographic parameters for the creation of the DSIC, a decision aid to help surgeons develop a method of preoperative evaluation to better stratify DLS treatment options.

Free access

Expectations of recovery and functional outcomes following thoracolumbar trauma: an evidence-based medicine process to determine what surgeons should be telling their patients

Rowan Schouten, Peter Lewkonia, Vanessa K. Noonan, Marcel F. Dvorak, and Charles G. Fisher

OBJECT

The aim of this study was to define the expected functional and health-related quality of life outcomes following common thoracolumbar injuries on the basis of consensus expert opinion and the best available literature. Patient expectations are primarily determined by the information provided by health care professionals, and these expectations have been shown to influence outcome in various medical and surgical conditions. This paper presents Part 2 of a multiphase study designed to investigate the impact of patient expectations on outcomes following spinal injury. Part 1 demonstrated substantial variability in the information surgeons are communicating to patients. Defining the expected outcomes following thoracolumbar injury would allow further analysis of this relationship and enable surgeons to more accurately and consistently inform patients.

METHODS

Expert opinion was assembled by distributing questionnaires comprising 4 cases representative of common thoracolumbar injuries to members of the Spine Trauma Study Group (STSG). The 4 cases included a thoracolumbar junction burst fracture treated nonoperatively or with posterior transpedicular instrumentation, a low lumbar (L-4) burst fracture treated nonoperatively, and a thoracolumbar junction flexion-distraction injury managed with posterior fusion. For each case, 5 questions about expected outcomes were posed. The questions related to the proportion of patients who are pain free, the proportion who have regained full range of motion, and the patients' recreational activity restrictions and personal care and social life limitations, all at 1 year following injury, as well as the timing of return to work and length of hospital stay. Responses were analyzed and combined with the results of a systematic literature review on the same injuries to define the expected outcomes.

RESULTS

The literature review identified 38 appropriate studies that met the preset inclusion criteria. Published data were available for all injuries, but not all outcomes were available for each type of injury. The survey was completed by 31 (57%) of 53 surgeons representing 24 trauma centers across North America (15), Europe (5), India (1), Mexico (1), Japan (1) and Israel (1). Consensus expert opinion supplemented the available literature and was used exclusively when published data were lacking.

For example, 1 year following cast or brace treatment of a thoracolumbar burst fracture, the expected outcomes include a 40% chance of being pain free, a 70% chance of regaining pre-injury range of motion, and an expected ability to participate in high-impact exercise and contact sport with no or minimal limitation. Consensus expert opinion predicts reemployment within 4–6 months. The length of inpatient stay averages 4–5 days.

CONCLUSIONS

This synthesis of the best available literature and consensus opinion of surgeons with extensive clinical experience in spine trauma reflects the optimal methodology for determining functional prognosis after thoracolumbar trauma. By providing consistent, accurate information surgeons will help patients develop realistic expectations and potentially optimize outcomes.

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Pelvic reconstruction after subtotal sacrectomy for sacral chondrosarcoma using cadaveric and vascularized fibula autograft

Technical note

Christopher C. Gillis, John T. Street, Michael C. Boyd, and Charles G. Fisher

A novel method of spinopelvic ring reconstruction after partial sacrectomy for a chondrosarcoma is described. Chondrosarcoma is one of the most common primary malignant bone tumors, and en bloc resection is the mainstay of treatment. Involvement of the pelvis as well as the sacrum and lumbar spine can result in a technically difficult challenge for en bloc resection and for achievement of appropriate load-bearing reconstruction.

After en bloc resection in their patient, the authors achieved reconstruction with a rod and screw construct including vascularized fibula graft as the main strut from the lumbar spine to the pelvis. Additionally, a cadaveric allograft strut was used as an adjunct for the pelvic ring. This is similar to a modified Galveston technique with vascularized fibula in place of the Galveston rods. The vascularized fibula provided appropriate biomechanical support, allowing the patient to return to independent ambulation. There was no tumor recurrence; neurological status remained stable; and the allograft construct integrated well and even increased in size on CT scans and radiographs in the course of a follow-up longer than 7 years.