Thirty-day readmissions after elective spine surgery for degenerative conditions among US Medicare beneficiaries

Background context

Readmissions within 30 days of hospital discharge are undesirable and costly. Little is known about reasons for and predictors of readmissions after elective spine surgery to help plan preventative strategies.

Purpose

To examine readmissions within 30 days of hospital discharge, reasons for readmission, and predictors of readmission among patients undergoing elective cervical and lumbar spine surgery for degenerative conditions.

Study design

Retrospective cohort study.

Patient sample

Patient sample includes 343,068 Medicare beneficiaries who underwent cervical and lumbar spine surgery for degenerative conditions from 2003 to 2007.

Outcome measures

Readmissions within 30 days of discharge, excluding readmissions for rehabilitation.

Methods

Patients were identified in Medicare claims data using validated algorithms. Reasons for readmission were classified into clinically meaningful categories using a standardized coding system (Clinical Classification Software).

Results

Thirty-day readmissions were 7.9% after cervical surgery and 7.3% after lumbar surgery. There was no dominant reason for readmissions. The most common reasons for readmissions were complications of surgery (26%–33%) and musculoskeletal conditions in the same area of the operation (15%). Significant predictors of readmission for both operations included older age, greater comorbidity, dual eligibility for Medicare/Medicaid, and greater number of fused levels. For cervical spine readmissions, additional risk factors were male sex, a diagnosis of myelopathy, and a posterior or combined anterior/posterior surgical approach; for lumbar spine readmissions, additional risk factors were black race, Middle Atlantic geographic region, fusion surgery, and an anterior surgical approach. Our model explained more than 60% of the variability in readmissions.

Conclusions

Among Medicare beneficiaries, 30-day readmissions after elective spine surgery for degenerative conditions represent a target for improvement. Both patient factors and operative techniques are associated with readmissions. Interventions to minimize readmissions should be specific to surgical site and focus on high-risk subgroups where clinical trials of interventions may be of greatest benefit.     

Intraosseous ganglion cyst within the L4 lamina causing spinal stenosis

Background context

There are rare reports of intraosseous ganglion cysts in the cervical spine. However, to our knowledge, there are no previous reports of these cysts occurring in the lumbar spine.

Purpose

To report a case of symptomatic lumbar spinal stenosis caused by an intraosseous ganglion cyst of the L4 lamina that communicated with the spinal canal.

Study design

Case report.

Methods

An 86-year-old woman was referred to our spine service for a 2-year history of anterior thigh and leg pain. Magnetic resonance imaging revealed a benign-appearing intraosseous cyst in the left L4 lamina communicating with a posterior epidural cyst at L4–L5 causing marked spinal stenosis. The patient was treated successfully with a laminectomy and resection.

Results

The patient underwent partial laminectomies of L4 and L5 preserving the interspinous ligaments between L5–S1 and L3–L4. The cyst was removed en bloc without violation of the cyst wall. Histopathologic examination revealed focal myxoid changes without a cellular lining of the cyst wall, confirming the diagnosis of intraosseous ganglion cyst.

Conclusions

This is the first report to describe an intraosseous ganglion cyst occurring in the lumbar spine. Although spinal stenosis is commonly a result of degenerative joint or disc disease, it occasionally may result from more obscure causes. This case illustrates a patient with an intraosseous ganglion cyst within the spinal lamina resulting in spinal stenosis, treated successfully with a laminectomy and resection.     

Early depth assessment of local burns by videomicroscopy: a novel proposed classification

Purpose

Videomicroscopy is very useful for burn depth assessment in an early phase; however, there is no practical classification that includes complicated anatomic, pathologic, and morphologic findings of burn wounds.The aim of this study was to propose a novel classification to assess burn depth in its early phase easily and reliably by videomicroscopy.

Methods

Forty-four patients with 56 intermediate-depth burn wounds were included. Burn depth was divided into each grade according to our proposed classification, which is composed of five categories based on dermal capillary integrity patterns. The intrarater and interrater reliabilities of the assessment by the second and third authors were evaluated by Cohen's unweighted κ-value.

Results

The results of the measurements according to the proposed classification showed an accuracy of 92.9%, sensitivity of 81.8%, and specificity of 100.0%.The intrarater reliability of the second and third authors showed substantial agreement (κ = 0.719 and 0.729, respectively). The interrater reliability of the sum of each observer's variable also showed substantial agreement (κ = 0.636).

Conclusion

This pattern analysis system is easy to use even for inexperienced personnel, and is reliable with high accuracy and specificity. Intrarater and interrater statistics also support its reliability and reproducibility.     

Reoperation rate after surgery for lumbar spinal stenosis without spondylolisthesis: a nationwide cohort study

Background context

Lumbar spinal stenosis is one of the most common degenerative spine diseases. Surgical options are largely divided into decompression only and decompression with arthrodesis. Recent randomized trials showed that surgery was more effective than nonoperative treatment for carefully selected patients with lumbar stenosis. However, some patients require reoperation because of complications, failure of bony fusion, persistent pain, or progressive degenerative changes, such as adjacent segment disease. In a previous population-based study, the 10-year reoperation rate was 17%, and fusion surgery was performed in 10% of patients. Recently, the lumbar fusion surgery rate has doubled, and a substantial portion of the reoperations are associated with a fusion procedure. With the change in surgical trends, the longitudinal surgical outcomes of these trends need to be reevaluated.

Purpose

To provide the longitudinal reoperation rate after surgery for spinal stenosis and to compare the reoperation rates between decompression and fusion surgeries.

Study design/setting

Retrospective cohort study using national health insurance data.

Patient sample

A cohort of patients who underwent initial surgery for lumbar stenosis without spondylolisthesis in 2003.

Outcome measures

The primary end point was any type of second lumbar surgery. Cox proportional hazards regression modeling was used to compare the adjusted reoperation rates between decompression and fusion surgeries.

Methods

A national health insurance database was used to identify a cohort of patients who underwent an initial surgery for lumbar stenosis without spondylolisthesis in 2003; a total of 11,027 patients were selected. Individual patients were followed for at least 5 years through their encrypted unique resident registration number. After adjusting for confounding factors, the reoperation rates for decompression and fusion surgery were compared.

Results

Fusion surgery was performed in 20% of patients. The cumulative reoperation rate was 4.7% at 3 months, 7.2% at 1 year, 9.4% at 2 years, 11.2% at 3 years, 12.5% at 4 years, and 14.2% at 5 years. The adjusted reoperation rate was not different between decompression and fusion surgeries (p=.82). The calculated reoperation rate was expected to be 22.9% at 10 years.

Conclusions

The reoperation rate was not different between decompression and fusion surgeries. With current surgical trends, the reoperation rate appeared to be higher than in the past, and consideration of this problem is required.     

Comparative in-hospital morbidity and mortality after revision versus primary thoracic and lumbar spine fusion

Background context

Despite increasing utilization of surgical spine fusions, a paucity of literature addressing perioperative complications after revision posterior spinal fusion (RPSF) versus primary posterior spine fusion (PPSF) of the thoracic and lumbar spine exists.

Purpose

To examine demographics of patients undergoing PPSF and RPSF of the thoracic and lumbar spine, assess the incidence of perioperative morbidity and mortality, and determine independent risk factors for in-hospital death.

Study design/setting

Analysis of nationally representative data collected for the National Inpatient Sample (NIS).

Patient sample

All discharges included in the NIS with a procedure code for posterior thoracic and lumbar spine fusion from 1998 to 2006.

Outcome measures

In-hospital mortality and morbidity.

Methods

Data collected for each year between 1998 and 2006 for the NIS were analyzed. Discharges with a procedure code for thoracic and lumbar spine fusion were included in the sample. The prevalence of patient- as well as health care–related demographics was evaluated by procedure type (primary vs. revision). Frequencies of procedure-related complications and in-hospital mortality were analyzed. Independent predictors for in-hospital mortality were determined.

Results

We identified 222,549 PPSF and 12,474 RPSF discharges between 1998 and 2006. Patients undergoing PPSF were significantly younger (51.23 years; confidence interval [CI]=51.16, 51.31) and had lower average comorbidity indices (0.40; CI=0.39, 0.41) than those undergoing RPSF (52.69 years; CI=52.43, 52.97) and (0.44; CI=0.43, 0.45), p<.0001. The incidence of procedure-related complications was 16.02% among RPSF compared with 13.44% in PPSF patients (p<.0001). In-hospital mortality rates after PPSF were approximately twice those of RPSF (0.28% vs. 0.15%, p=.006). Adjusted risk factors for increased in-hospital mortality included PPSF compared with RPSF, male gender, and increasing age. A number of comorbidities, complications, and specific surgical indications increased the risk for perioperative death.

Conclusion

Despite being performed in generally younger and healthier patients and having lower perioperative morbidity, PPSF procedures are associated with increased mortality compared with RPSF procedures. The findings of this study can be used for risk stratification, accurate patient consultation, and hypothesis formation for future research.     

Radiological analysis of lumbar degenerative kyphosis in relation to pelvic incidence

Background context

Lumbar degenerative kyphosis (LDK) is characterized by sagittal imbalance resulting from a loss of lumbar lordosis (LL). The pelvic incidence (PI) regulates the sagittal alignment of the spine and pelvis.

Purpose

The purpose of this study is to evaluate the spinopelvic parameters in patients with LDK and to compare them with those of a normal population.

Study design/setting

A cross-sectional study.

Patient sample

The selected patients showed characteristic clinical features of LDK. As control group, asymptomatic volunteers without spinal pathology were recruited.

Outcome measures

Full-length radiographs of the spine in the anteroposterior and lateral planes were taken, extending from the base of the skull to the proximal femur. Pelvic incidence, sacral slope (SS), pelvic tilt (PT), main thoracic kyphosis (TK), thoracolumbar junction (TLJ), LL, and sagittal vertical axis (SVA) were evaluated.

Methods

In terms of PI, the patient and control groups were divided into three groups: low (PI≤45°), middle (45°<PI≤60°), and high PI groups (PI>60°). All the spinopelvic parameters were compared between each group and between the patient and control groups in each group. The correlations between each of the parameters were analyzed.

Results

We evaluated 172 patients with symptomatic LDK and 39 healthy volunteers. The number of LDK patients with low, middle, and high PI groups were 44 (25.6%), 72 (44.8%), and 51 (29.6%), respectively. In the control group, the number of low, average, and high PI patients were 18 (46.2%), 15 (38.5%), and 6 (15.4%), respectively. In the control group, PI determined all spinopelvic parameters except SVA. In the LDK group, PI also determined spinopelvic parameters except for TK and SVA. Lumbar degenerative kyphosis with low PI was associated with pronounced kyphosis in LL and TLJ; LDK with a high PI was associated with relatively preserved lordosis in LL with a flat or lordotic TLJ. In terms of pelvic parameters, low PI showed flattened SS and low PT, whereas high PI showed steep SS and high PT.

Conclusions

The results of this study suggest the importance of the key anatomical parameter, PI, in the determination of sagittal contour in symptomatic LDK patients and normal population. Spinopelvic parameters and pelvic compensatory mechanisms in LDK patients differ according to PI. Identifying the spinopelvic parameters is useful when correcting deformities.     

Modic type I change may predict rapid progressive, deforming disc degeneration: a prospective 1-year follow-up study

Introduction

This prospective magnetic resonance imaging (MRI) study in chronic low-back pain (CLBP) patients evaluated the natural course of degenerative lumbar spine changes in relation to Modic 1 type changes (M1) within 1 year.

Materials and methods

From 3,811 consecutive CLBP patients referred to lumbar spine MRI 54 patients with a large M1 were selected using strict exclusion criteria to exclude specific back disorders. Follow-up MRI was obtained within 11–18 months.

Results

At baseline M1 was associated with an adjacent endplate lesion in 96% of the cases. In follow-up, an unstable M1 was associated both with an increase of endplate lesions, decrease of disc height and change in disc signal intensity, most found at L4/5 or L5/S1. In disc spaces without M1, progression of degenerative changes was rare.

Conclusion

Endplate deformation, decreasing disc height and change of disc signal intensity appear essential features of accelerated degenerative process associated with M1.     

Long-term follow-up of a case of aneurysmal bone cyst in the lumbar spine

Background context

Aneurysmal bone cyst (ABC) in the spine is relatively rare, so little is known about the natural history of the disease.

Purpose

The purpose of this study was to describe a spinal ABC that was followed for an extended period from lesion enlargement to spontaneous regression.

Study design

Case report.

Methods

A 63-year-old woman had a 1-year-long history of mild low back and bilateral leg pain without any significant neurologic deficits caused by lumbar spinal stenosis. At her first visit to our hospital, magnetic resonance imaging (MRI) showed a small cystic lesion on the left side of the L5 vertebral body. The patient's clinical symptom progression and MRI and computed tomography evaluations were reported for >13 years.

Results

After 6 years, the cystic lesion enlarged significantly and extended into the left pedicle and transverse process of the L5 vertebra. The lesion was diagnosed as an ABC based on multilocular cysts with fluid-fluid levels on MRI and bony septations on computed tomography. Thirteen years after the first visit, the lesion regressed spontaneously without a clear reason, such as biopsy or fracture, and most of the lesion was replaced by fatty marrow. The patient's symptoms stabilized without neurologic deterioration during the follow-up period.

Conclusions

Although spinal ABC is an expandable cystic lesion, we should consider that such a lesion in an elderly patient could spontaneously regress.     

Reliability assessment of AOSpine thoracolumbar spine injury classification system and Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries: results of a multicentre study

Purpose

The aim of this multicentre study was to determine whether the recently introduced AOSpine Classification and Injury Severity System has better interrater and intrarater reliability than the already existing Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries.

Methods

Clinical and radiological data of 50 consecutive patients admitted at a single centre with a diagnosis of an acute traumatic thoracolumbar spine injury were distributed to eleven attending spine surgeons from six different institutions in the form of PowerPoint presentation, who classified them according to both classifications. After time span of 6 weeks, cases were randomly rearranged and sent again to same surgeons for re-classification. Interobserver and intraobserver reliability for each component of TLICS and new AOSpine classification were evaluated using Fleiss Kappa coefficient (k value) and Spearman rank order correlation.

Results

Moderate interrater and intrarater reliability was seen for grading fracture type and integrity of posterior ligamentous complex (Fracture type: k = 0.43 ± 0.01 and 0.59 ± 0.16, respectively, PLC: k = 0.47 ± 0.01 and 0.55 ± 0.15, respectively), and fair to moderate reliability (k = 0.29 ± 0.01 interobserver and 0.44+/0.10 intraobserver, respectively) for total score according to TLICS. Moderate interrater (k = 0.59 ± 0.01) and substantial intrarater reliability (k = 0.68 ± 0.13) was seen for grading fracture type regardless of subtype according to AOSpine classification. Near perfect interrater and intrarater agreement was seen concerning neurological status for both the classification systems.

Conclusions

Recently proposed AOSpine classification has better reliability for identifying fracture morphology than the existing TLICS. Additional studies are clearly necessary concerning the application of these classification systems across multiple physicians at different level of training and trauma centers to evaluate not only their reliability and reproducibility, but also the other attributes, especially the clinical significance of a good classification system.

     

Is magnetic resonance imaging in addition to a computed tomographic scan necessary to identify clinically significant cervical spine injuries in obtunded blunt trauma patients?

Background

Guidelines are in place directing the clearance of the cervical spine in patients who are awake, alert, and oriented, but a gold standard has not been recognized for patients who are obtunded. Our study is designed to determine if magnetic resonance imaging (MRI) detects clinically significant injuries not seen on computed tomographic (CT) scans.

Methods

The trauma registry was used to identify and retrospectively review medical records of blunt trauma patients from January 1, 2005, to March 30, 2012. Only obtunded patients with a CT scan and MRI of the cervical spine were included.

Results

The study cohort consisted of 277 patients. In 13 (5%) patients, MRI detected clinically significant cervical spine injuries that were missed by CT scans, and in 7 (3%) these injuries required intervention. The number needed to screen with MRI to prevent 1 missed injury was 21.

Conclusions

The findings suggest that the routine use of MRI in clearing the cervical spine in the obtunded blunt trauma patient.     

Inter- and Intra-observer Reliability of MRI for Lumbar Lateral Disc Herniation

Background

The authors analyzed inter- and intra-observer agreement with respect to interpretation of simple magnetic resonance T1- and T2-weighted axial and sagittal images for the diagnosis of lumbar lateral disc herniation, including foraminal and extraforaminal disc herniations.

Methods

Forty-two patients in whom lumbar lateral disc herniation was suspected or confirmed by simple magnetic resonance imaging at one institute between May 2003 and December 2004 were included. The magnetic resonance images consisting of T1- and T2-weighted axial and sagittal images, and these were reviewed blindly and independently by three orthopaedic spine surgeons in a random manner. The images were interpreted as positive or negative for lateral disc herniation on 2 different occasions 3 months apart. Results were analyzed using Cohen''s kappa statistic, and strengths of agreements were determined using the Landis and Koch criteria.

Results

The kappa values for inter-observer agreement averaged 0.234 (0.282, 0.111, and 0.308 respectively) on the first occasion, and 0.166 (0.249, 0.111, and 0.137 respectively) on the second occasion, with an overall mean value of 0.200. Thus, the strength of agreement was only slight-to-fair according to the Landis and Koch criteria. Kappa values for intra-observer agreement averaged 0.479 (0.488, 0.491, and 0.459 respectively), indicating moderate agreement.

Conclusions

The present study indicates that simple magnetic resonance imaging is not a reliable imaging modality for diagnosing lumbar lateral disc herniation. Another imaging study with improved diagnostic values should be developed to diagnose this pathologic finding.     

Kinetic magnetic resonance imaging analysis of lumbar segmental mobility in patients without significant spondylosis

Purpose

The purpose of this study was to examine lumbar segmental mobility using kinetic magnetic resonance imaging (MRI) in patients with minimal lumbar spondylosis.

Methods

Mid-sagittal images of patients who underwent weight-bearing, multi-position kinetic MRI for symptomatic low back pain or radiculopathy were reviewed. Only patients with a Pfirrmann grade of I or II, indicating minimal disc disease, in all lumbar discs from L1–2 to L5–S1 were included for further analysis. Translational and angular motion was measured at each motion segment.

Results

The mean translational motion of the lumbar spine at each level was 1.38 mm at L1–L2, 1.41 mm at L2–L3, 1.14 mm at L3–L4, 1.10 mm at L4–L5 and 1.01 mm at L5–S1. Translational motion at L1–L2 and L2–L3 was significantly greater than L3–4, L4–L5 and L5–S1 levels (P < 0.007). The mean angular motion at each level was 7.34° at L1–L2, 8.56° at L2–L3, 8.34° at L3–L4, 8.87° at L4–L5, and 5.87° at L5–S1. The L5–S1 segment had significantly less angular motion when compared to all other levels (P < 0.006). The mean percentage contribution of each level to the total angular mobility of the lumbar spine was highest at L2–L3 (22.45 %) and least at L5/S1 (14.71 %) (P < 0.001).

Conclusion

In the current study, we evaluated lumbar segmental mobility in patients without significant degenerative disc disease and found that translational motion was greatest in the proximal lumbar levels whereas angular motion was similar in the mid-lumbar levels but decreased at L1–L2 and L5–S1.     

Degenerative lumbar spinal canal stenosis: intra- and inter-reader agreement for magnetic resonance imaging parameters

Purpose

To assess the inter- and intra-reader agreement of commonly used quantitative and qualitative image parameters for the assessment of degenerative lumbar spinal canal stenosis (LSS) by magnetic resonance imaging (MRI).

Methods

In this ethical board approved cross-sectional multicenter study, MRI of 100 randomly selected patients (median age 72.5 years, 48 % female) of the prospective Lumbar Stenosis Outcome Study (LSOS) were evaluated by two independent readers. A set of five previously published core imaging parameters as well as nine qualitative and five quantitative additional parameters regarding LSS and degenerative changes of the lumbar spine were assessed to calculate κ and intraclass correlation coefficients (ICC) for the inter-reader agreement. Additional repeated image evaluations were performed by one reader to calculate the intra-reader agreement.

Results

κ values for the core image parameters ranged between 0.42 (compromise of the foraminal zone) and 0.77 (relation between fluid and cauda equina) for inter-reader agreement and between 0.59 (compromise of the foraminal zone) and 0.8 (compromise of the central zone) for intra-reader agreement. The inter-reader agreement for the non-core parameters showed κ values of 0.27–0.69 and ICC values of 0.46–0.85. The intra-reader agreement showed κ values of 0.53–0.69 and ICC values of 0.81–0.88.

Conclusions

The inter- and intra-reader agreement of commonly used quantitative and qualitative image parameters for the assessment of LSS showed quite a variability with previously defined core parameters having good to excellent inter- and intra-reader agreements.

     

Primary amyloidoma in epidural and paravertebral space of the lumbar spine

Background context

Localized amyloid deposits result in a mass, that is, so-called amyloidoma; it has been reported in every anatomic site, although systemic amyloid deposition is much more common. However, primary lumbar epidural amyloidoma without bony involvement is extremely rare. To the best of our knowledge, only one case has been reported previously.

Purpose

To report and review the clinical presentations, imaging studies, and treatment of epidural and paravertebral amyloidoma.

Study design

A case report and review of the literature.

Methods

Lumbar epidural and paravertebral amyloidoma in a 75-year-old man with neurologic compromise is presented. Laminectomy with mass resection was performed.

Results

After surgery, almost complete neurologic improvement was observed. Histologically, definite diagnosis was obtained only after the specific staining of tissue. No sign of local recurrence was evident 1 year after surgery.

Conclusions

Primary amyloidoma, although rare, should be included in the differential diagnosis of epidural mass of the spine. Diagnosis before surgery is difficult as there were no characteristic findings in clinical and imaging studies. Special histologic technique and stains are useful to make a definite diagnosis.     

Reproducibility and Precision of CT Scans to Evaluate Tibial Component Rotation

Background

Component rotation likely plays a greater role on the survivorship and outcomes of total knee arthroplasties than is currently known. Our goal was to evaluate the precision, interobserver reliability, and intrarater reliability of tibial component rotation as measured by computed tomography (CT) scan, regardless of measurement technique.

The influence of subgroup diagnosis on radiographic and clinical outcomes after lumbar fusion for degenerative disc disorders revisited: a systematic review of the literature

Background Context

Understanding the influence of preoperative diagnosis on outcomes for lumbar fusion surgery improves the quality of research and outcomes data, and helps guide treatment decisions.

The effects of a temporarily manipulated dental occlusion on the position of the spine: a comparison during standing and walking

Background context

The relationship between dental occlusion and body posture or even the spine position is often analyzed and confirmed. However, this relationship has not been systematically investigated for standing and walking.

Purpose

To examine whether a symmetric or asymmetric dental occlusion block, using 4 mm thick silicon panels, can significantly change the spine position (cervical, thoracic, or lumbar region) during standing and walking.

Study design

The following study is a cross-sectional study.

Patient sample

This study was carried out with 23 healthy subjects (18 women, 5 men) without discomfort in the temporomandibular system or body movement apparatus.

Outcome measures

Position changes (millimeter) of the spine (cervical, thoracic, lumbar) in frontal, sagittal, and transverse planes of motion.

Methods

The upper spine position was quantified with an ultrasonic distance measurement system (sonoSens Monitor). Every subject placed the 4 mm thick silicon panel systematically between the left/right premolars or the front teeth. Differences between the habitual and manipulated occlusion positions were determined by the Friedman test, followed by pairwise comparisons with applied Bonferroni-Holm correction.

Results

During standing and walking there were significant (p≤.05) differences between the occlusion block conditions and the habitual dental position in all body planes except in the right lumbar region during walking. In addition, differences within the manipulated occlusion position could be detected. Significant differences were also shown between the standing and walking trials in the frontal, sagittal, and transverse planes, particularly with respect to the lumbar region (p≤.001).

Conclusions

Symmetrical and asymmetrical occlusion blocks in the premolar region can be associated with changes in all three spine regions during standing and walking. The results showed highly similar reaction patterns in all spine positions, regardless of the location of the silicon panel. Between standing and walking, the main differences were in the lumbar spine. The results suggest a relationship between the chewing and the movement system. However, it must be stated that this study has no direct clinical impact. The study design cannot determine the causality of the observed associations; also the clinical significance of the small postural changes remains unknown.     

Analysis of the clinical picture in patients with osteoarthritis of the spine depending on the type and severity of lesions on magnetic resonance imaging

Objectives

Spondyloarthritis is the most common pathological change in the spine. In a significant number of cases, it leads to compression of the nervous structures of the spinal canal, causing pain and neurological symptoms. Intervertebral disc pathology is a common cause of root deficits in neurological examination of all types of degenerative changes of the spine structures. Disc herniation is pathologically divided into 4 stages of herniated nucleus pulposus: 1) bulging, 2) protrusion, 3) extrusion, 4) sequestration. The aim of this study is to analyze the correlation between the type and severity of degenerative changes in the spine and the incidence of neurological deficits.

Material and methods

The study included 100 patients: 74 men and 26 women aged 50.2 ±10.43 years with pain of the spine in the cervical and/or lumbosacral segments and with degenerative changes in the plain radiographs. The mean value of body mass index (BMI) was 27.8 ±3.95 kg/m². Each patient underwent neurological examinations and 1.5 T magnetic resonance imaging MRI of the cervical and/or lumbar spine.

Results

Every patient was diagnosed with herniated nucleus pulposus affecting on average 4 ±2 segments of the spine. The most frequently observed degree of severity of disc herniation was the second (protrusion, 71.9% of all disc disease in 89 patients). Much less frequently found was the third degree (extrusion, 45 patients, 20.1% slipped disc), the first (bulging, 14 patients, 6.3% slipped disc), and least often only a small percentage of fourth degree (sequestration, 4 patients, 1.7% slipped disc). Neurological symptoms (deficits) were observed in 34 patients. They were accompanied by disc herniations in 23.7% of patients. In remaining patients with neurological deficits there was spinal stenosis. No correlation was observed between neurological deficits and stage 1 of disc herniation.

Conclusions

The incidence rate of neurological deficits is correlated with the degree of changes in the spine, as visualized by MRI.     

Predictors and prevalence of patients undergoing additional kyphoplasty procedures after an initial kyphoplasty procedure

Background context

Vertebral cement augmentation, including kyphoplasty, has been shown to be a successful treatment for pain relief for vertebral compression fracture (VCF). Patients can sustain additional symptomatic VCFs that may require additional surgical intervention.

Purpose

To examine the prevalence and predictors of patients who sustain additional symptomatic VCFs that were treated with kyphoplasty.

Study design

A retrospective review of patients who previously underwent kyphoplasty for VCFs and had additional VCFs that were treated with kyphoplasty.

Patient sample

A total of 256 patients underwent kyphoplasty for VCFs from 2000 to 2007 at a single medical center.

Outcome measures

The outcome measure of interest was the need for an additional kyphoplasty procedure for a symptomatic VCF.

Methods

Risk factors such as age, sex, smoking status, and steroid use were assessed, as well as bisphosphonate use. Sagittal spinal alignment via Cobb angles for thoracic, thoracolumbar, and lumbar regions was assessed.

Results

About 22.2% of the patients had an additional symptomatic VCF that was treated with a kyphoplasty procedure. Steroid use was the only significant risk factor for predicting patients with additional symptomatic VCFs who underwent additional kyphoplasty. The average time to the second VCF was 33 days. Adjacent-level VCFs were most common in the thoracic and thoracolumbar spine. Bisphosphonate use was not shown to be protective of preventing additional VCFs during this follow-up period.

Conclusion

This is the first single-center review of a large cohort of patients who underwent additional-level kyphoplasty for symptomatic VCFs after an index kyphoplasty procedure. Our results suggest that patients with a VCF who use chronic oral steroids should be carefully monitored for the presence of additional symptomatic VCFs that may need surgical intervention. Patients with prior thoracic VCFs who have additional back pain should be reevaluated for a possible adjacent-level fracture.