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Perioperative Complications of Anterior Procedures on the Spine*

MARK F. MCDONNELL, M.D., STEVEN D. GLASSMAN, M.D., JOHN R. DIMAR II, M.D., ROLANDO M. PUNO, M.D. and JOHN R. JOHNSON, M.D., LOUISVILLE, KENTUCKY

Investigation performed at the Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
We reviewed the operative and hospital records of 447 patients in order to determine the rates of perioperative complications associated with an anterior procedure on the thoracic, thoracolumbar, or lumbar spine. The anterior procedures were performed to treat spinal deformity or for débridement or decompression of the spinal canal. The diagnostic groups that we studied included idiopathic scoliosis in adolescents or young adults (100 patients), scoliosis in mature adults (sixty-three patients), kyphosis (sixty-one patients), neuromuscular scoliosis (sixty patients), fracture (forty-seven patients), a revision procedure (thirty-nine patients), congenital scoliosis (thirty-six patients), tumor (nineteen patients), vertebral osteomyelitis or discitis (eight patients), and miscellaneous (fourteen patients). Complications occurred in 140 (31 per cent) of the 447 patients and were classified as major or minor. Forty-seven patients (11 per cent) had at least one major complication and 109 (24 per cent) had at least one minor complication. Two patients died, both from pulmonary complications after the operation. The most common type of major complication was pulmonary; the most common type of minor complication was genito-urinary. The adolescent or young adult patients who had idiopathic scoliosis had the lowest rate of complications, and the patients who had neuromuscular scoliosis had the highest. An age of more than sixty years at the time of the operation was associated with a higher risk of complications. The duration of the procedures involving a thoracic approach was shorter than that of those involving a thoracolumbar or lumbar approach; however, the rate of complications was not significantly different among the three approaches. Vertebrectomies took longer to perform and were associated with a greater estimated blood loss than discectomies; however, there was no significant difference in the rate of complications between the two types of procedures. The patients who had a fracture or a tumor lost more blood than those from the other diagnostic groups. Blood loss increased as the duration of the operation increased for all procedures. Combined anterior and posterior procedures performed during the same anesthesia session were associated with a higher rate of major complications than were procedures that were staged. A logistical regression analysis showed that the variables that increased the risk of a major complication were an estimated blood loss of more than 520 milliliters and an anterior and posterior procedure performed sequentially under the same anesthesia session. This analysis also demonstrated that the diagnosis of idiopathic scoliosis in adolescents or young adults was associated with a reduced risk of major complications. Compared with other major operations, an anterior procedure on the thoracic, thoracolumbar, or lumbar spine performed for the indications mentioned in this study is relatively safe.

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion References

 
An anterior procedure on the spine is frequently performed in the treatment of a variety of spinal disorders. Although some surgeons avoid anterior procedures because of perceived risk, the actual risk factors have not been critically evaluated, to our knowledge. Some authors^{2-4,6,10,12,13,15-18} have discussed the perioperative complications of anterior or combined anterior and posterior procedures on the spine; however, a computer search of the English-language literature failed to recover any reports devoted entirely to the perioperative complications of anterior procedures on the spine. The purpose of the present study was to determine the prevalence and types of complications in a large series of patients who had had an anterior procedure on the spine through a thoracic, thoracolumbar, or lumbar approach.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
We reviewed the operative and hospital records of 447 patients who had had an anterior procedure on the spine for the treatment of a deformity, fracture, tumor, or infection between 1985 and 1992. Patients who had had a procedure on the cervical spine or an anterior interbody arthrodesis for the treatment of lumbar degenerative disc disease were excluded from the study.

The preoperative records were reviewed for the primary diagnosis, the extent of preoperative evaluation, and the preoperative blood hemoglobin value. The intraoperative records were reviewed for the type of procedure performed; the duration of the operation; the estimated blood loss; whether the procedure was combined, staged, or isolated; the operative approach; the need for intraoperative transfusion; and the intraoperative complications. The postoperative records were reviewed for the blood hemoglobin value, the need for transfusion, the number of days that the thoracostomy tube was in place, the duration of hospitalization before the second stage of a staged procedure, and any complications attributable to the anterior procedure.

Postoperative management was standardized and included early resumption of walking when feasible, daily checks of the blood hemoglobin value for three days, and removal of the thoracostomy tube when the rate of drainage was less than 300 milliliters in twenty-four hours. Urine specimens were obtained for culture from most patients when the Foley catheter was removed.

The anterior procedures were classified as combined, staged, or isolated. A combined procedure was an anterior procedure followed immediately by a posterior procedure performed under the same anesthesia session, a staged procedure was an anterior procedure followed by a posterior procedure at a later time but during the same period of hospitalization, and an isolated procedure was an anterior procedure with no subsequent posterior procedure. Complications that occurred after the second stage of a staged procedure were excluded from this analysis unless they were clearly related to the anterior procedure. All complications after a combined procedure were included unless the complication was specifically related to the posterior procedure, such as an infection of the posterior wound.

The complications were categorized as cardiac, related to the thoracostomy tube, hematological, neurological, operative, genito-urinary, gastroenterological, pulmonary, related to the operative wound, a drug reaction, miscellaneous, or death. The severity of a complication was also evaluated (Table I), by determination of the effect on the course of recovery in the hospital. Any complication that appeared to substantially alter an otherwise smooth and expected course of recovery was considered a major complication. A complication that was documented in the medical record but that did not, in our opinion, substantially alter the course of recovery was considered a minor complication. For example, cystitis that was manifested only by dysuria with or without a low-grade fever and that could be treated with oral administration of antibiotics was considered a minor genito-urinary complication. In contrast, gram-negative sepsis that originated in the bladder and necessitated intravenous administration of antibiotics, volume resuscitation, and transfer of the patient to the intensive-care unit was considered a major genito-urinary complication. In the case of complications related to the operative wound, a small area of superficial inflammation that responded to local measures such as moist heat and changes of the dressing but that did not necessitate formal débridement was considered a minor complication. A wound infection that was serious enough to necessitate intravenous administration of antibiotics and formal débridement in the operating room was considered a major complication.

The patients who had kyphosis had several different types, including Scheuermann (thirty patients), post-traumatic (eighteen patients), congenital (four patients), and various other types (nine patients). The types of neuromuscular scoliosis included cerebral palsy (thirty-three patients), myelomeningocele (fourteen patients), post-poliomyelitis (six patients), injury of the spinal cord (three patients), Arnold-Chiari malformation (one patient), and an unclassified neuromuscular disorder (three patients). Eight of the patients who had a miscellaneous diagnosis had a herniated thoracic disc, and the other six had scoliosis secondary to Marfan syndrome (four patients), arthrogryposis (one patient), or neurofibromatosis (one patient).

The age of the patient at the time of the operation, the operative approach, the type of procedure that was performed, the estimated blood loss during the anterior procedure, and the duration of the anterior procedure were analyzed in several ways according to clinical relevance.

The patients were divided into four age-groups: three to twenty years (213 patients), twenty-one to forty years (111 patients), forty-one to sixty years (ninety-eight patients), and sixty-one to eighty-five years (twenty-five patients). The operative approach was classified as thoracic if the procedure was performed entirely cephalad to the diaphragm, as thoracolumbar if the procedure involved incision of the diaphragm, and as lumbar if the procedure was performed entirely caudad to the diaphragm. The operative procedure was designated as a vertebrectomy if any bone was excised or an osteotomy was performed and as a discectomy if no bone was excised or no osteotomy was performed. Estimated blood loss was divided into four groups: less than 500 milliliters, 500 to 999 milliliters, 1000 to 1500 milliliters, and more than 1500 milliliters. The duration of the operation was classified as less than two hours, two to three hours, more than three to four hours, or more than four hours.

The estimated blood loss, the duration of the operation, and the age of the patient were also treated as continuous variables in the multivariate analysis.

A statistical analysis was performed with use of a general statistics data-analysis software package to evaluate the operative parameters and the rates of complications in relation to variables such as the diagnosis, the age of the patient at the time of the operation, the type of operative approach, the type of operative procedure, the estimated blood loss, and the duration of the operation.

	Results

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Over-All
One hundred and forty (31 per cent) of the 447 patients had at least one perioperative complication. There were sixty major complications and 124 minor complications. Forty-seven patients (11 per cent) had at least one major complication (Table II), 109 (24 per cent) had at least one minor complication (Table II), and sixteen (4 per cent) had both major and minor complications. Seven patients (2 per cent) had more than one major complication, and twelve patients (3 per cent) had more than one minor complication. There were two deaths in the series, for an over-all mortality rate of 0.4 per cent. Both deaths were the direct result of major pulmonary complications following the operation. No patient died as the result of a catastrophic intraoperative event.

The most common type of minor complication was genito-urinary (42 per cent of all minor complications). Fifty-two (11.6 per cent) of the 447 patients had such a complication (Table II). Thirteen patients (2.9 per cent) had a gastroenterological complication, twelve (2.7 per cent) had a complication related to the operative wound, twelve (2.7 per cent) had a complication related to the thoracostomy tube, ten (2.2 per cent) had a pulmonary complication, eight (1.8 per cent) had a neurological complication, six (1.3 per cent) had a miscellaneous complication, five (1.1 per cent) had an operative complication, four (0.9 per cent) had a cardiac complication, one (0.2 per cent) had a drug reaction, and one (0.2 per cent) had a hematological complication.

Diagnostic Group
A statistical analysis was performed to compare the diagnostic groups to determine any differences in either estimated blood loss or duration of the operation. The group that had a fracture and the group that had a tumor had a higher estimated blood loss, but with the numbers available the difference in the duration of the operation was not significantly different for any group (p > 0.05, analysis of variance and pairwise tests).

The rate of complications varied according to the diagnostic group; the group that had neuromuscular scoliosis had the highest over-all rate of complications (thirty-one of sixty patients; 52 per cent), and the adolescents and young adults who had idiopathic scoliosis had the lowest (sixteen of 100 patients; 16 per cent) (p < 0.05, pairwise testing). Although the rate of complications for the group that had vertebral osteomyelitis or discitis (five of eight patients) was higher than that for the group that had neuromuscular scoliosis, the small sample size of this group did not merit comparison.

The group that had neuromuscular scoliosis also had the highest rate of major complications (eleven patients; 18 per cent) and the highest rate of minor complications (twenty-three patients; 38 per cent) (p < 0.05, pairwise testing). (The group that had a tumor had a slightly higher rate of major complications [four of nineteen patients], but the sample size was too small to allow for comparison.) Similarly, the adolescents and young adults who had idiopathic scoliosis had the lowest rate of major complications (three patients; 3 per cent) and the lowest rate of minor complications (fourteen patients; 14 per cent) (p < 0.05, pairwise testing) (Table III). (The group that had a miscellaneous diagnosis also had a 14 per cent rate of minor complications, but the lack of homogeneity in this group did not allow for realistic comparison.) Again, the rates of major and minor complications were highest for the group that had vertebral osteomyelitis or discitis (three and four of eight, respectively), but the small sample size of this group did not allow for comparison.

Adolescents and Young Adults Who Had Idiopathic Scoliosis
There were enough adolescents and young adults who had idiopathic scoliosis to justify closer examination of that group. The mean age of the 100 patients in this group was sixteen years (range, eleven to twenty-nine years). The over-all rate of complications was 16 per cent (sixteen patients), the rate of major complications was 3 per cent (three patients), and the rate of minor complications was 14 per cent (fourteen patients). The mean estimated blood loss was 486 milliliters, and the mean duration of the operation was 181 minutes. There was one major complication each in the thoracostomy-tube, neurological, genito-urinary, pulmonary, and operative-wound categories. The most common type of minor complication was genito-urinary (ten patients).

This group was subdivided into adolescents (eighty-six patients) and young adults (fourteen patients). The rate of major complications for the adolescents was 3 per cent (three patients). None of the young adults had a major complication. The rate of minor complications was 12 per cent (eleven patients) for the adolescents and three of fourteen young adults. There was no significant difference between these two subgroups with regard to the rate of either major or minor complications (p > 0.05, Fisher exact test); therefore, the group was considered as a whole in the statistical analyses.

Age of the Patient
The age of the patient at the time of the operation was an important factor in this study. The patients ranged in age from three to eighty-five years (mean, twenty-eight years; median, twenty-two years).

The rates of complications were similar for the patients who were three to twenty years old and those who were twenty-one to forty years old, but there was a distinct rise in the over-all rate of complications for the patients who were forty-one to eighty-five years old. However, the patients who were sixty-one to eighty-five years old were the only group that had a significantly higher over-all rate of complications compared with the other three groups (p < 0.05, pairwise testing) (Table III).

The most common type of major complication for all patients except for the sixty-one to eighty-five-year-old group was pulmonary. For the patients who were sixty-one to eighty-five years old, the rate of pulmonary complications was equivalent to the rate of complications related to the thoracostomy tube. The most common type of minor complication in all age-groups was genito-urinary.

Operative Approach
One hundred and seventy-four patients had a thoracic approach, 248 had a thoracolumbar approach, and twenty-five had a lumbar approach. Over-all, complications occured in 28 per cent (forty-nine) of the patients who had a thoracic approach, 34 per cent (eighty-four) of the patients who had a thoracolumbar approach, and 28 per cent (seven) of the patients who had a lumbar approach. There were no significant differences in the rates of major or minor complications or in the over-all rate of complications among these groups.

The mean estimated blood loss was 589 milliliters for the 124 patients who had a thoracic approach and for whom this information was available, 636 milliliters for the 194 patients who had a thoracolumbar approach and for whom this information was available, and 922 milliliters for the twenty patients who had a lumbar approach and for whom this information was available. There was no significant difference between the patients who had a thoracic approach and those who had a thoracolumbar approach with regard to blood loss; however, the blood loss in these two groups was significantly different from that in patients who had a lumbar approach (p = 0.02, analysis of variance). Despite this finding, the size of the sample managed with a lumbar approach is small (twenty-five patients) compared with that of the other two groups; therefore, any more definitive statement must be made with caution.

The mean duration of the operation was 163 minutes for the 138 patients who had a thoracic approach and for whom this information was available, 181 minutes for the 194 patients who had a thoracolumbar approach and for whom this information was available, and 187 minutes for the twenty-one patients who had a lumbar approach and for whom this information was available. There was no significant difference between the patients who had a thoracolumbar approach and those who had a lumbar approach with regard to the duration of the operation, but the operation was significantly shorter for the patients who had a thoracic approach compared with those in the other two groups (p < 0.05, analysis of variance).

Thus, in this series of patients, an operation through a thoracic approach took less time to perform and more blood was lost when a lumbar approach was used, but no approach was significantly different with regard to the rate of complications (Table IV).

Operative Procedure
There were 125 vertebrectomies and 251 discectomies. The remaining seventy-one procedures could not be classified because of ambiguity or lack of information in the medical record. A rate of major complications of 12 per cent (fifteen of 125 procedures) and a rate of minor complications of 29 per cent (thirty-six of 125 procedures) was associated with the vertebrectomies. The rates were 12 per cent (thirty of 251 procedures) and 27 per cent (sixty-nine of 251 procedures), respectively, for the discectomies. The difference between the groups was not significant (p > 0.05, t test).

The mean duration of the discectomies was 158 minutes, and the mean duration of the vertebrectomies was 191 minutes; this difference was significant (p < 0.01, pairwise testing). Also, the mean estimated blood loss was significantly higher for the vertebrectomies (950 milliliters) than for the discectomies (482 milliliters) (p < 0.01, pairwise testing).

Therefore, the type of procedure had a significant effect on the estimated blood loss at the time of the operation and on the duration of the operation, but it did not affect the rate of complications (Table IV).

Estimated Blood Loss
The mean estimated blood loss for 338 of the patients was 635 milliliters. For the remaining 109 patients, it was not possible to separate the amount of estimated blood loss that was due to the anterior part of a combined procedure as only a combined estimated blood loss had been recorded; these patients were excluded from this analysis. Patients who did not have any complications appeared to have a lower mean estimated blood loss (609 milliliters) than those who did have complications (689 milliliters); however, this finding was not significant (p > 0.05).

One hundred and fifty-seven patients had an estimated blood loss of less than 500 milliliters, 117 lost 500 to 999 milliliters, forty-one lost 1000 to 1500 milliliters, and twenty-three lost more than 1500 milliliters. There was no significant difference among these four groups with respect to the rates of complications. However, when considered as a continuous variable, estimated blood loss was an important factor in the prediction of complications.

Duration of the Operation
The mean duration of the operation for 353 of the patients was 174 minutes. For the remaining ninety-four patients, it was not possible to determine the duration of the anterior part of a combined procedure as only a combined duration had been recorded; these patients were excluded from this analysis. There was no significant difference in the mean duration of the operation between the patients who had a complication (172 minutes) and those who did not (175 minutes).

The sixty-three patients for whom the operation lasted less that two hours had a mean estimated blood loss of 375 milliliters, the 134 patients for whom the operation lasted two to three hours lost a mean of 569 milliliters, the seventy-two patients for whom the operation lasted more than three to four hours lost a mean of 693 milliliters, and the thirty-eight patients for whom the operation lasted more than four hours lost a mean of 1202 milliliters. There was a significant correlation between the duration of the operation and the estimated blood loss (r = 0.45, p < 0.05). However, there was no correlation between an increase in the duration of the operation and an increase in the rate of complications.

Combined, Staged, or Isolated Procedures
There were 238 combined procedures, 109 staged procedures, and 100 isolated anterior procedures.

On the basis of many of the medical records, it was not possible to separate the estimated blood loss or the duration of the operation, or both, for the anterior approach of a combined procedure; only a combined estimated blood loss or duration of the operation, or both, was available. These patients were excluded from the analyses of estimated blood loss and duration of the operation.

At least one major complication was associated with 14 per cent (thirty-three) of the 238 combined procedures, 8 per cent (nine) of the 109 staged procedures, and 4 per cent (four) of the 100 isolated procedures. The difference in the rate of major complications among the three groups was significant (p < 0.01, chi-square test). The rate of major complications associated with the combined procedures was also significantly different from that associated with the staged procedures (p < 0.05, z test for two proportions). There were no significant differences in the rates of minor and over-all complications among the three groups. The age of the patient had no effect on the rate of complications for these groups (p = 0.43, chi-square test). The estimated blood loss and the duration of the operation for the combined procedures were significantly greater than those for the staged procedures (p < 0.05, chi-square test) (Table IV).

Sixty-six of the 100 isolated anterior procedures involved the addition of Zielke instrumentation. The isolated anterior procedures with instrumentation took much longer to perform than those without it (p = 0.0000001, analysis of variance) and were associated with greater estimated blood loss (p < 0.05, analysis of variance); however, there was no significant difference in the rate of complications between these two groups.

Multivariate Analysis
A logistic regression analysis was performed on the data for the 311 patients for whom complete information was available. The final variables for this analysis were chosen with use of a stepwise variable selection procedure known as backward elimination. Major complications alone were evaluated with this technique as these are of the most interest to clinicians. In this analysis, the variables that increased the risk of major complications were an estimated blood loss of more than 520 milliliters and combined procedures. The diagnosis of idiopathic scoliosis in adolescents or young adults seemed to reduce the risk of major complications.

In this type of analysis, the age of the patient could not be considered adequately because of the bias associated with the formation of the subsamples involved. For example, all of the adolescents and young adults who had idiopathic scoliosis were twenty-nine years old or less, while all of the mature adults who had scoliosis were more than twenty-nine years old. When examined as an individual variable, an age of sixty-one to eighty-five years was the only age that was associated with a significant increase in the over-all rate of complications as determined with pairwise testing.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
Anterior procedures on the spine are valuable for the treatment of various disorders^{2-4,6,10,12,13,15-18}. The decision to perform such a procedure depends in part on the perceived risks; however, we are not aware of any published studies in which the relative importance of these risks have been defined and evaluated. The sample size of the present study is sufficiently large to allow statistically valid conclusions to be drawn concerning the risks of anterior procedures on the spine.

Anderson et al. studied respiratory complications after an anterior procedure on the spine in eighty-eight patients who had non-idiopathic scoliosis (many of whom had neuromuscular scoliosis) and found a 35 per cent rate of complications. Our study confirms the higher rate of complications in patients who have non-idiopathic scoliosis, especially in those who have neuromuscular scoliosis.

Our data compare favorably with those of smaller studies. Byrd et al. reported a mean duration of the operation of 259 minutes, a mean estimated blood loss of 1229 milliliters, and an 8 per cent rate of major neurological complications (two of twenty-six) in association with the anterior procedure in adults in whom scoliosis was treated with staged anterior and posterior procedures. This compares well with our mean duration of 174 minutes, mean estimated blood loss of 635 milliliters, and 0.7 per cent rate of major neurological complications.

The results of the present study show that anterior procedures on the spine are relatively safe in comparison with other major operations. For example, the rate of mortality after elective operations on the hip has been reported to be 2 per cent (forty-two of 2091 patients)⁷, and the rate of mortality after coronary bypass has been reported as 1.4 per cent (fourteen of 1000 patients)¹⁴. The mortality rate of 0.4 per cent (two of 447 patients) in our series compares favorably with the rates in these studies.

The 11 per cent rate of major complications in the present study (forty of 447 patients) also compares favorably with the rates of morbidity reported for procedures on the lumbar spine as well as with the rates reported for other major orthopaedic and non-orthopaedic operative procedures. The over-all rate of complications during hospitalization (which most closely approximates the rate of major perioperative complications in our series) reported in one study after 18,122 operations on the lumbar spine was 9.1 per cent⁵. The reported rate of major complications after elective coronary artery bypass at the Cleveland Clinic Foundation was 18 per cent (184 of 1000 patients)¹⁴. The reported rate of urinary tract infection after total hip arthroplasty has ranged from 7 to 14 per cent⁹, which compares well with the 12 per cent rate of genito-urinary complications (fifty-four of 447 patients) in our study.

We emphasize that the high rate of minor complications in our study reflects our decision to report any event, however minor, as a complication. For example, we routinely obtain urine specimens for cultures at the time that the Foley catheter is removed. An asymptomatic urinary tract infection (a minor complication in this study) found in this fashion would be missed in any investigation that did not incorporate this protocol.

At first glance, there is an inconsistency in our results in the area of estimated blood loss, as shown by the statistical analyses; however, the apparent difference in the results of the two types of statistical analyses that were performed is easily explained by the method with which the data in each analysis were treated. In pairwise testing, groups of data were tested against each other. In the formation of those groups, for which arbitrary criteria (such as multiples of 500 milliliters for blood loss) were used in order to facilitate the handling of the information, the ranges selected could introduce bias. In this study, for example, when the same data for estimated blood loss were evaluated as a continuous variable in the multivariate analysis, 520 milliliters clearly was seen to be the threshold value for an increase in the rate of major complications.

Another criticism of the present study is the absence of complete data for every patient. In this retrospective study, some records did not provide an estimate of blood loss from the anterior portion of a combined procedure. Other records lacked documentation of the duration of the anterior part of a combined operation. The conclusions drawn for the combined procedures compared with the staged procedures, therefore, need to be viewed in light of this limitation. However, complete data were available for most of the patients.

This investigation helps to identify patients who are at greater-than-usual risk for complications, to establish guidelines for the assessment and treatment of complications, and to initiate protocols in an attempt to decrease the rate of certain complications. An increased risk of perioperative morbidity can be expected for patients who are more than forty years old and for those who have neuromuscular scoliosis. An increase in estimated blood loss can be expected as the duration of the operation increases. The high likelihood of pulmonary and genito-urinary complications should also be kept in mind. Vigorous pulmonary toilet and early removal of the Foley catheter are now part of our routine postoperative regimen for all patients who have had an anterior procedure on the spine.

With the advent of percutaneous procedures, we think that this information concerning the complications related to anterior procedures on the spine establishes a baseline with which to compare the results of future investigations.

In conclusion, we have documented the rates of complications associated with anterior procedures on the spine for a wide variety of diagnoses and age-groups in a series of 447 patients. A diagnosis of neuromuscular scoliosis, an age of sixty-one years or more, and an estimated blood loss of more than 520 milliliters were the greatest risk factors for major complications in this series. We also found a higher rate of major complications associated with combined (same-day, sequentially performed) anterior and posterior procedures than with staged anterior and posterior procedures. The rate of complications after anterior procedures on the spine compares favorably with those published^8,11,14 both for other major orthopaedic operative procedures and for non-orthopaedic operative procedures.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Read in part at the Annual Meetings of the Scoliosis Research Society, Dublin, Ireland, September 23, 1993, and the North American Spine Society, San Diego, California, October 15, 1993.

6410 Fannin Street, Suite 1100, Houston, Texas 77030.

Department of Orthopaedic Surgery, University of Louisville School of Medicine, 210 East Gray Street, Louisville, Kentucky 40202.

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