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Edgar F. Fincher, Bronson S. Ray, Harold J. Stewart, Edgar F. Fincher, T. C. Erickson, L. W. Paul, Franc D. Ingraham, Orville T. Bailey, Frank E. Nulsen, James W. Watts, Walter Freeman, C. G. de Gutiérrez-Mahoney, Frank Turnbull, Carl F. List, William J. German, A. Earl Walker, J. Grafton Love, Francis C. Grant, I. M. Tarlov, Thomas I. Hoen and Rupert B. Raney

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Christopher S. Bailey, Marcel F. Dvorak, Kenneth C. Thomas, Michael C. Boyd, Scott Paquett, Brian K. Kwon, John France, Kevin R. Gurr, Stewart I. Bailey and Charles G. Fisher

Object

The authors compared the outcome of patients with thoracolumbar burst fractures treated with and without a thoracolumbosacral orthosis (TLSO).

Methods

As of June 2002, all consecutive patients satisfying the following inclusion criteria were considered eligible for this study: 1) the presence of an AO Classification Type A3 burst fractures between T-11 and L-3, 2) skeletal maturity and age < 60 years, 3) admission within 72 hours of injury, 4) initial kyphotic deformity < 35°, and 5) no neurological deficit. The study was designed as a multicenter prospective randomized clinical equivalence trial. The primary outcome measure was the score based on the Roland-Morris Disability Questionnaire assessed at 3 months postinjury. Secondary outcomes are assessed until 2 years of follow-up have been reached, and these domains included pain, functional outcome and generic health-related quality of life, sagittal alignment, length of hospital stay, and complications. Patients in whom no orthotic was used were encouraged to ambulate immediately following randomization, maintaining “neutral spinal alignment” for 8 weeks. The patients in the TLSO group began being weaned from the brace at 8 weeks over a 2-week period.

Results

Sixty-nine patients were followed to the primary outcome time point, and 47 were followed for up to 1 year. No significant difference was found between treatment groups for any outcome measure at any stage in the follow-up period. There were 4 failures requiring surgical intervention, 3 in the TLSO group and 1 in the non-TLSO group.

Conclusions

This interim analysis found equivalence between treatment with a TLSO and no orthosis for thoracolumbar AO Type A3 burst fractures. The influence of a brace on early pain control and function and on long-term 1- and 2-year outcomes remains to be determined. However, the authors contend that a thoracolumbar burst fracture, in exclusion of an associated posterior ligamentous complex injury, is inherently a very stable injury and may not require a brace.

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Navjot Chaudhary, Bill H. Wang, Kevin R. Gurr, Stewart I. Bailey and Christopher S. Bailey

Atlantooccipital dislocation (AOD) is a rare and often fatal injury. In cases of survival, residual deficits are severe and often include cranial nerve palsy, quadriplegia, or respiratory issues. Occipitalization is defined as partial or complete congenital fusion of the occiput to the atlas and is exceptionally rare.

The authors present a rare case of AOD superimposed on a congenital occipitalization of the atlas. This 39-year-old man had AOD following a motor vehicle collision. On examination, his overall motor score on the American Spinal Injury Association scale was 5/100, and his rectal tone was absent. Computed tomography demonstrated AOD in an area of occipitalization. Magnetic resonance imaging revealed ligamentous injury leading to C1–2 instability.

Intervention included occipital cervical instrumentation fusion from the occiput to C-3. Six months postoperatively, imaging revealed fusion of the graft and consolidation of the fractured occipitalization. At the 2-year follow-up, the patient's strength was 3/5 for wrist extension and handgrip on the right side and full strength in the rest of the myotomes. Bladder and bowel function was also normalized.

A high-velocity collision led to disruption of the atlantooccipital ligaments and fracture of the occipitalized lateral masses in this patient. Internal fixation and fusion led to good fusion postoperatively. Occipitalization probably led to abnormal joint mechanics at the C1-occiput junction, which might have altered the amount of force required to fracture the occipitalization and produce AOD. This difference may partially account for the favorable neurological outcome in the featured patient compared with traditional cases of AOD.

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Ingrid Radovanovic, Jennifer C. Urquhart, Venkat Ganapathy, Fawaz Siddiqi, Kevin R. Gurr, Stewart I. Bailey and Christopher S. Bailey

OBJECTIVE

The object of this study was to determine the association between postoperative sagittal spinopelvic alignment and patient-rated outcome measures following decompression and fusion for lumbar degenerative spondylolisthesis.

METHODS

The authors identified a consecutive series of patients who had undergone surgery for lumbar degenerative spondylolisthesis between 2008 and 2012, with an average follow-up of 3 years (range 1–6 years). Surgery was performed to address the clinical symptoms of spinal stenosis, not global sagittal alignment. Sagittal alignment was only assessed postoperatively. Patients were divided into 2 groups based on a postoperative sagittal vertical axis (SVA) < 50 mm (well aligned) or ≥ 50 mm (poorly aligned). Baseline demographic, procedure, and outcome measures were compared between the groups. Postoperative outcome measures and postoperative spinopelvic parameters were compared between groups using analysis of covariance.

RESULTS

Of the 84 patients included in this study, 46.4% had an SVA < 50 mm. Multiple levels of spondylolisthesis (p = 0.044), spondylolisthesis at the L3–4 level (p = 0.046), and multiple levels treated with fusion (p = 0.028) were more common among patients in the group with an SVA ≥ 50 mm. Patients with an SVA ≥ 50 mm had a worse SF-36 physical component summary (PCS) score (p = 0.018), a worse Oswestry Disability Index (ODI; p = 0.043), and more back pain (p = 0.039) than those with an SVA < 50 mm after controlling for multiple levels of spondylolisthesis and multilevel fusion. The spinopelvic parameters differing between the < 50-mm and ≥ 50-mm groups included lumbar lordosis (LL; 56.4° ± 4.7° vs 49.8° ± 4.3°, respectively, p = 0.040) and LL < pelvic incidence ± 9° (51% vs 23.1%, respectively, p = 0.013) after controlling for type of surgical procedure.

CONCLUSIONS

Data in this study revealed that patient-rated outcome is influenced by the overall postoperative sagittal balance as defined by the SVA.

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Jennifer C. Urquhart, Osama A. Alrehaili, Charles G. Fisher, Alyssa Fleming, Parham Rasoulinejad, Kevin Gurr, Stewart I. Bailey, Fawaz Siddiqi and Christopher S. Bailey

OBJECTIVE

A multicenter, prospective, randomized equivalence trial comparing a thoracolumbosacral orthosis (TLSO) to no orthosis (NO) in the treatment of acute AO Type A3 thoracolumbar burst fractures was recently conducted and demonstrated that the two treatments following an otherwise similar management protocol are equivalent at 3 months postinjury. The purpose of the present study was to determine whether there was a difference in long-term clinical and radiographic outcomes between the patients treated with and those treated without a TLSO. Here, the authors present the 5- to 10-year outcomes (mean follow-up 7.9 ± 1.1 years) of the patients at a single site from the original multicenter trial.

METHODS

Between July 2002 and January 2009, a total of 96 subjects were enrolled in the primary trial and randomized to two groups: TLSO or NO. Subjects were enrolled if they had an AO Type A3 burst fracture between T-10 and L-3 within the previous 72 hours, kyphotic deformity < 35°, no neurological deficit, and an age of 16–60 years old. The present study represents a subset of those patients: 16 in the TLSO group and 20 in the NO group. The primary outcome measure was the Roland Morris Disability Questionnaire (RMDQ) score at the last 5- to 10-year follow-up. Secondary outcome measures included kyphosis, satisfaction, the Numeric Rating Scale for back pain, and the 12-Item Short-Form Health Survey (SF-12) Mental and Physical Component Summary (MCS and PCS) scores. In the original study, outcome measures were administered at admission and 2 and 6 weeks, 3 and 6 months, and 1 and 2 years after injury; in the present extended follow-up study, the outcome measures were administered 5–10 years postinjury. Treatment comparison between patients in the TLSO group and those in the NO group was performed at the latest available follow-up, and the time-weighted average treatment effect was determined using a mixed-effects model of longitudinal regression for repeated measures averaged over all time periods. Missing data were assumed to be missing at random and were replaced with a set of plausible values derived using a multiple imputation procedure.

RESULTS

The RMDQ score at 5–10 years postinjury was 3.6 ± 0.9 (mean ± SE) for the TLSO group and 4.8 ± 1.5 for the NO group (p = 0.486, 95% CI −2.3 to 4.8). Average kyphosis was 18.3° ± 2.2° for the TLSO group and 18.6° ± 3.8° for the NO group (p = 0.934, 95% CI −7.8 to 8.5). No differences were found between the NO and TLSO groups with time-weighted average treatment effects for RMDQ 1.9 (95% CI −1.5 to 5.2), for PCS −2.5 (95% CI −7.9 to 3.0), for MCS −1.2 (95% CI −6.7 to 4.2) and for average pain 0.9 (95% CI −0.5 to 2.2).

CONCLUSIONS

Compared with patients treated with a TLSO, patients treated using early mobilization without orthosis maintain similar pain relief and improvement in function for 5–10 years.