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The Journal of Bone and Joint Surgery (American). 2007;89:1654-1663. doi:10.2106/JBJS.G.00425 © 2007 The Journal of Bone and Joint Surgery, Inc. What's New in Spine Surgery
1 Department of Orthopaedic Surgery, Washington University School of Medicine,
One Barnes-Jewish Hospital Plaza, Suite 11300 West Pavilion, Campus Box 8233,
St. Louis, MO 63110. E-mail address:
bridwellk{at}wudosis.wustl.edu
Specialty Update has been developed in collaboration with the Council
of Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
The results of randomized controlled trials of several cervical arthroplasty devices are becoming available and are the focus of much attention. At the same time, secondary outcomes are being analyzed that may address socioeconomic concerns about the costs and observable benefits of arthroplasty. Since the introduction of a validated outcome tool to measure swallowing dysfunction, researchers have more critically analyzed postoperative dysphagia. With the continued expansion of the use of cervical laminoplasty, methods to reduce complications continue to be explored.
Disc Arthroplasty From outside the United States, there have been case reports of complications, including the late development of central stenosis secondary to osteophyte formation, fracture of a vertebral body during insertion, spontaneous fusion, expulsion of the device, and kyphotic angulation. Despite these cases, the results of disc arthroplasty are encouraging, but longer follow-up is needed. Early return to function is a hypothetical benefit of arthroplasty. In general, arthroplasty does not require immobilization and patients are allowed to rapidly return to full function. The median time to return to work is significantly better following arthroplasty than it is following fusion. This effect is even greater in patients receiving Workers' Compensation. From a socioeconomic perspective, this may mitigate the additional cost of the implant and the additional surgical time.
Complications Dysphagia is an under-recognized morbidity after anterior cervical surgery. Using an accepted outcome instrument, Lee et al. found that dysphagia was present in >50% of patients at one month and as many as 15% at two years. Risk factors included female gender, revision procedures, and multilevel procedures. Ischemia of the upper esophageal sphincter mucosa resulting from the use of soft-tissue retractors may be the cause of postoperative dysphagia. Maintaining the endotracheal balloon pressures at <20 mm Hg, intermittent relaxation of retractors, and cuff reinflation after the retractors are placed are all strategies that may decrease dysphagia.
Myelopathy In the study by Miyata, forty patients who had postoperative ossification of the posterior longitudinal ligament following a French-door type of laminoplasty were evaluated with dynamic magnetic resonance imaging. The author found that the cord had shifted posteriorly and was adequately decompressed. This study again validates that posterior decompression allows posterior cord translation away from the ventral pathology. Despite surgical treatment, ossification of the posterior longitudinal ligament appears to progress in the majority of patients and can lead to recurrent symptoms. No means to decrease this tendency have been developed. Furthermore, it is not known if fusion will likely increase or decrease this phenomenon. An important controversy is how to treat and counsel patients who have cervical stenosis but are asymptomatic. Recent reports from the Cervical Spine Research Society have shown that 30% of patients with stenosis experienced minor trauma and that half of those will deteriorate neurologically. Future studies should determine if a much more aggressive surgical approach can prevent neural damage.
Spinal Cord Monitoring
Biologic tools for reconstruction and regeneration continue to be an important focus of research related to the spine today. There are continued efforts to enhance the process of achieving spine fusion and to eliminate the need for autogenous iliac crest bone graft harvest. Since the United States Food and Drug Administration's (FDA) post-marketing approval of recombinant human bone morphogenetic protein-2 (rhBMP-2) in 2002 and the creation of a Humanitarian Device Exemption for rhBMP-7 late in 2004, the era of recombinant bone morphogenetic proteins for use in spine fusion has continued to blossom. Given the limited access (with only two companies producing approved BMPs) as well as their relatively high cost, there has been renewed interest in promoting less expensive and potentially unvalidated alternative bone-graft substitutes. Finally, while an increasing amount of research continues to be focused on understanding the biology of the intervertebral disc and on developing biologic strategies to retard or reverse degeneration, these treatments still seem to be quite far from clinical practice.
Recombinant Osteoinductive Proteins Although rhBMP-2 (INFUSE; Medtronic Sofamor Danek, Memphis, Tennessee) has been approved by the FDA for anterior lumbar interbody fusion, much physician-directed use has occurred in the posterolateral spine. A subset of data from an investigational device exemption study involving the use of a higher concentration of rhBMP-2 (20 mg BMP-2 per side) on a compression-resistant matrix (AMPLIFY; Medtronic) has been published. The report included ninety-eight patients from a prospective, randomized study in which AMPLIFY was compared with iliac crest bone graft in patients undergoing a single level instrumented posterolateral lumbar fusion. In this subset of patients, the radiographic fusion rate was 88% for the AMPLIFY group and 73% for the iliac crest bone graft group (p = 0.05). This was the first time that a recombinant BMP demonstrated superiority over autogenous bone graft. With the outcome measures used, no substantial clinical benefit was detected in association with the avoidance of harvesting an iliac crest bone graft. Readers should note that the BMP formulation comprising AMPLIFY is different (with respect to dose and carrier) than the currently available INFUSE formulation. In another study, the approved INFUSE kit was used in addition to iliac crest cancellous bone graft for instrumented posterolateral fusion. The use of INFUSE in combination with iliac crest bone improved the fusion success rate (as determined with thin-slice computed tomography scans) from 77% with iliac crest graft alone to 97% with iliac crest graft plus one large InFuse kit (6 mg BMP-2 per side) wrapped around local bone as a bulking agent. This finding suggests that the current kit, while likely not sufficient as a stand-alone graft substitute for the posterolateral spine, can provide a significant enhancer effect, improving the success of autogenous bone graft. A primary concern with off-label use of recombinant BMPs relates to local adverse events. The three most commonly reported local side effects have been heterotopic bone formation in the surgical approach track, transient bone resorption when used near exposed cancellous bone, and sterile seroma fluid collections and/or local edema. Most of these local side effects are believed to be related to the surgeon's use of too much BMP either by increasing the concentration of the growth factor or by overstuffing the defect, which can result in a higher concentration or leakage of BMP into the surrounding tissues. Two reports have described perioperative swelling in the cervical spine, again most often in association with excessive BMP doses and with the implant being placed outside the structural cage or ring. Surgeons who are encountering these local side effects with any regularity should carefully examine their technique to limit the exposure of BMP directly to cancellous bone (e.g., through less aggressive end plate decortication) and should avoid the use of excessive amounts of BMPs in small spaces or overpacking of the BMP implants.
Other Bone-Graft Substitutes A recently published animal study investigated the role of simvastatin in achieving posterolateral spine fusion in rabbits. Statins have been shown to increase the expression of BMPs and may enhance bone formation in certain situations. In this study, the systemic administration of simvastatin did not positively or negatively affect spine fusion. It is possible that local administration of statins may have more profound effects. Interest in mesenchymal stem cells has increased with the introduction of two mineralized allograft products that are claimed to have cryopreserved stem cells. These products are claimed to immunodeplete the non-stem cells from allograft and to provide a mineralized scaffold with allogeneic stem cells. Since these products are regulated as "minimally manipulated tissues," little outcome data are available. The studies that are under way may not include the proper controls to assess whether the stem cells are providing any increased healing in comparison with the allograft alone. These, as well as other, minimally manipulated products that are claimed to have bone-healing potential must be carefully evaluated by surgeons because the FDA does not require definitive proof of bone-enhancing capability. In general, the number of stem cells present in bone marrow is relatively small, and without specific signals (e.g., BMP) it is not clear whether sufficient numbers of cells are present to initiate bone formation de novo.
Biologic Treatments for Disc Degeneration
Over the past year, many articles and presentations addressed the etiology of adolescent idiopathic scoliosis and the treatment of early-onset scoliosis as well as congenital spinal deformity, particularly thoracic insufficiency syndrome. There also have been advances in the treatment of kyphosis, neuromuscular scoliosis, and spondylolisthesis. The Scoliosis Research Society (SRS) continues to be very interested in investigating complications of surgical treatment.
Etiology of Adolescent Idiopathic Scoliosis
Early-Onset Scoliosis
Congenital Spinal Deformity
Kyphosis
Neuromuscular Scoliosis
Spondylolisthesis
Adolescent Spinal Deformity
Adult Spinal Deformity Complications after surgery for the correction of spinal deformity are more common in adults than in adolescents. These complications include pseudarthrosis, proximal and distal junctional kyphosis, and an extended recovery. RhBMP is being considered as an alternative or adjunct to reduce the pseudarthrosis rate in adults with spinal deformity. However, use of these products for posterior surgery constitutes an offlabel use and is prohibitively expensive for many centers.
Complications
Research in the area of spinal cord injury is making strides in understanding the mechanisms of secondary injury and the factors inhibiting axonal regeneration. Cell death not only occurs at the time of injury but also is due to a cascade of secondary events that result in further neurologic dysfunction. Multiple biochemical processes, including the production of reactive oxygen species, excitotoxicity from neurotransmitter release, and imbalances in ion concentrations at a cellular level, culminate in the death of neurons and supporting glial cells. Spinal cord injury is followed by changes that inhibit the regrowth of axons and the reestablishment of neural connections. It was once thought that axonal regeneration could not occur within the central nervous system, but it is now understood that central nervous system axons can regenerate in the proper environment. Formation of a glial scar and production of inhibitory compounds in the extracellular matrix impede the regrowth of axons across the site of injury. As a result of a better understanding of the multiple biochemical processes that result in secondary cell injury and the inhibition of axonal regeneration, many new therapies are being studied. In addition, new strategies are being investigated to bridge the gap across a damaged spinal cord segment.
Therapies to Reduce Secondary Injury
Therapies to Promote Axonal Regeneration Although much research has been focused on reducing the immune response to spinal cord injury, other approaches have involved the utilization of immune cells (macrophages) to facilitate axonal regeneration. Animal testing with genetically modified autologous macrophages showed encouraging results in rodent models and prompted human clinical studies. ProCord (Proneuron Biotechnologies, Los Angeles, California) therapy, involving the injection of "activated" autologous macrophages into the contused area of a spinal cord injury, was begun as a Phase-II clinical study in the United States and Israel. The trial, which enrolled twenty-four patients, was suspended from further patient recruitment because of funding issues, but the patients who were managed are still being followed. Other investigations have targeted neurite growth inhibitory protein, Nogo-A, which is a cell surface protein, expressed after spinal cord injury, that inhibits neurite growth. Antibodies to Nogo-A have been administered intrathecally in rodent spinal cord injury models, with increasing axonal regeneration and improved neurologic recovery being noted. Rolipram, a specific inhibitor of phosphodiesterase 4, has also been shown to improve axonal regeneration after spinal cord injury in rodent models. Cell-based therapies involving Schwann cells, olfactory ensheathing cells, and stem cells as well as other forms of implantable scaffolding have been shown to facilitate axonal regeneration and remyelination after spinal cord injury in animal models. Lima et al. recently reported on the implantation of olfactory mucosa at the site of injury in seven patients with an acute complete spinal cord injury and noted an improvement in the ASIA grade in all patients, with two patients having two grades of improvement. Implantation of stem cells has received substantial attention in the media as a potential cure for spinal cord injury. However, as encouraging as the results in animal studies have been, human clinical trials have not proven that these therapies are currently effective.
Novel treatments and advances in the treatment of lumbar degenerative disorders continue to be of high interest to clinicians and researchers as these pathologies represent some of the more common musculoskeletal disorders. The development of novel technologies is very exciting, but we certainly need appropriate evidence of their efficacy.
Motion Preservation/Lumbar Disc Arthroplasty One group of investigators presented a systematic literature review on the efficacy and safety of intervertebral disc prostheses for the lumbar spine. This meta-analysis primarily examined two of the FDA-approved disc devices in comparison with fusion. The conclusions were that the scientific evidence presently available for these devices was not sufficient to recommend the use of either one for the treatment of lumbar disc pain in routine clinical practice. The authors recommended additional studies with larger numbers of patients.
Adjacent Segment Degeneration Two studies have examined the fate of the L5-S1 level following spine fusion to L5. One study evaluated nineteen patients with fusion to L5 and showed that 32% of the patients required revision of the fusion to the sacrum at the time of the five-year follow-up, and the investigators predicted a 60% survival rate at ten years of follow-up. Another center presented a study of thirty patients after five years of follow-up. The investigators noted a high rate (68%) of progressive degeneration at the L5-S1 level and noted a 20% rate of revision to the sacrum.
Biological Promoters of Fusion Vaccaro et al. presented their results after the use of rhBMP-7 for uninstrumented posterolateral spinal fusion. Twenty-six patients were followed to the five-year time-point, and the five-year results were compared with the earlier (two-year) results presented for a larger group. The authors reported that the fusion rates and clinical outcomes were maintained at the longer-term follow-up. Angevine et al. studied the cost-effectiveness of the use of rhBMP-2 for the primary surgical treatment of adult scoliosis. This retrospective cohort cost-offset analysis examined the charges for each hospitalization at one institution for all adults undergoing this procedure. The investigators found that the use of rhBMP-2 increased the cost of the index procedure for adult idiopathic scoliosis, but was cost-neutral when controlling for the type of surgery, the number of levels, and the number of pedicle screws used. Furthermore, when taking into account the differential rate of pseudarthrosis and the associated costs, the use of rhBMP-2 was more cost-effective.
Nonoperative Care One group reported on a prospective series of 346 patients receiving nerve root injections for the treatment of a variety of degenerative lumbar disorders. The investigators demonstrated efficacy and the avoidance of surgery in a large percentage of patients (in increasing order of efficacy) who had moderate disc herniations, degenerative spondylolisthesis, spinal stenosis, isthmic spondylolisthesis, foraminal stenosis, degenerative scoliosis, and failed back syndrome. Poor outcomes were found in association with stenosis, extraforaminal disc herniations, recurrent disc herniations, and failed back surgery when combined with instability.
Complications
The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 medical journals were reviewed to identify these articles, which all have high-quality study design. In addition to articles published previously in this journal or cited already in this Update, sixteen level-I articles were identified that were relevant to spine surgery. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help guide your further reading, in an evidence-based fashion, in this subspecialty area.
The forty-second annual meeting of the Scoliosis Research Society (SRS) will be held on September 5 through 8, 2007, at the Edinburgh International Conference Center, Edinburgh, Scotland. It will be preceded by a one-day course entitled "Update on Congenital Spinal Deformity," to be held on September 4, 2007. Web site: www.srs.org The twenty-second annual meeting of the North American Spine Society (NASS) will be held on October 23 through 27, 2007, at the Austin Convention Center in Austin, Texas. It will be preceded by several precourses and two half-day meetings of the Biologics Research Section and the Motion Preservation Section, which are being developed by the society. Web site: www.spine.org The thirty-fifth annual meeting of the Cervical Spine Research Society (CSRS) will be held on November 29 through December 1, 2007, at the Palace Hotel in San Francisco, California. It will be preceded by an Instructional Course sponsored by the Society on November 28, 2007. Web site: www.csrs.org The Federation of Spine Associations will present the spine program at Specialty Day at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), to be held on Saturday, March 8, 2008, in San Francisco, California. Web site: www.aaos.org The annual meeting of the International Society for the Study of the Lumbar Spine (ISSLS) will be held May 25 though 31, 2008, in Geneva, Switzerland. Web site: www.issls.org The thirty-fourth annual meeting of the American Spinal Injury Association (ASIA) will be held on June 19 through 22, 2008, at Loews Coronado Bay Resort in San Diego, California. Web site: www.asia-spinalinjury.org The fifteenth annual International Meeting on Advanced Spinal Techniques (IMAST) will be held on July 8 through 11, 2008, at the Hong Kong Convention Center in Hong Kong, China. Web site: www.imastonline.com
Brox JI, Reikerås O, Nygaard Ø, Sørensen R, Indahl A, Holm I, Keller A, Ingebrigtsen T, Grundnes O, Lange JE, Friis A. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain. 2006;122:145-55. In this study from Norway, spinal fusion was compared with a cognitive intervention and exercise program following the "failure" of a previous disc herniation operation to relieve back pain. There was a 50% success rate in the fusion group and a 48% success rate in the cognitive intervention/exercise group. Depending on one's perspective, either both modalities were equally effective or equally ineffective in this very difficult group of patients. This study suggests there is no "one answer" to the patient who has continued chronic low-back pain after previous surgery for the treatment of a disc herniation. Clarke J, van Tulder M, Blomberg S, de Vet H, van der Heijden G, Bronfort G. Traction for low back pain with or without sciatica: an updated systematic review within the framework of the Cochrane collaboration. Spine. 2006; 31:1591-9. This study was a review of the literature on traction. There was not sufficient evidence to recommend traction for patients with low-back pain or sciatica. Because most studies were underpowered, the literature does not allow a negative conclusion that traction is not effective. Clarke JA, van Tulder MW, Blomberg SE, de Vet HC, van der Heijden GJ, Bronfort G. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev. 2005;(4):CD003010. This paper identified twenty-four randomized clinical trials involving >2000 patients. Five of the trials were considered "high quality." The authors concluded that there was conflicting evidence regarding the short-term effectiveness of either continuous or intermittent traction as compared with placebo, sham treatment, or other treatments when managing patients who have either chronic low-back pain or a mixture of low-back pain and sciatica. This finding suggests that there is nothing "magical" about employing traction when physical therapy is being used to treat low-back pain. de Graaf I, Prak A, Bierma-Zeinstra S, Thomas S, Peul W, Koes B. Diagnosis of lumbar spinal stenosis: a systematic review of the accuracy of diagnostic tests. Spine. 2006;31:1168-76. This was a review of the literature for published articles examining diagnostic studies for spinal stenosis. The authors found twenty-four articles (fifteen on imaging tests, seven on clinical tests, and two on other diagnostic studies). The authors found that the published studies were of poor quality and were not directly comparable, and they concluded that no firm conclusions could be made regarding the different tests. The results of this study are not surprising as spinal stenosis is a clinical syndrome with a large number of varying symptoms that may all not be present in any particular patient. The diagnosis of spinal stenosis is determined by the clinician on the basis of a combination of the test results, the clinical information and history, and the imaging studies. Finckh A, Zufferey P, Schurch MA, Balagué F, Waldburger M, So AK. Shortterm efficacy of intravenous pulse glucocorticoids in acute discogenic sciatica. A randomized controlled trial. Spine. 2006;31:377-81. The authors performed a randomized controlled trial evaluating the use of a single intravenous bolus of methylprednisolone (500 mg) for the treatment of acute sciatica (duration of symptoms, less than six weeks). The authors noted a significant decrease in sciatic pain in association with the intravenous administration of methylprednisolone over the first twenty-four hours but noted that the effects were transient and of small magnitude. This study demonstrates that a high-dose intravenous bolus of steroids may provide some short-term pain relief and, thus, may allow patients to better participate in physical therapy and other conservative modalities to relieve the symptoms of sciatica. Freeman BJ, Fraser RD, Cain CM, Hall DJ, Chapple DC. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine. 2005;30:2369-78. This was a randomized controlled study comparing intradiscal electrothermal therapy (IDET) with sham treatment for patients with chronic low back pain. Thirty-eight patients were randomized to IDET, and nineteen were randomized to sham treatment. All patients had one or two-level degenerative low-back pain confirmed with magnetic resonance imaging and discography. At six months, no improvement from baseline was observed in either group, and no differences were present between the IDET and sham groups. This was a well-done study that contradicted a previous randomized controlled study that had demonstrated a slight to moderate effect of IDET as compared with sham treatment. Taking these studies together, IDET appears to have little clinical efficacy. Gibson JN, Waddell G. Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine. 2005;30:2312-20. The authors performed an extensive review of the literature on the surgical treatment of degenerative lumbar spondylosis and concluded that there is a paucity of good studies on this topic. There is limited evidence to support some aspects of surgical practice. The authors underscored the importance of critical appraisal of the literature when formulating individual practice behaviors. Kääpä EH, Frantsi K, Sarna S, Malmivaara A. Multidisciplinary group rehabilitation versus individual physiotherapy for chronic nonspecific low back pain: a randomized trial. Spine. 2006;31:371-6. This was a prospective randomized trial, from two different centers, that included 120 women who were employed as health-care and social-care professionals and had low-back pain. The women were randomized to either a multidisciplinary group rehabilitation program for seventy hours or individual therapy for ten hours. The authors found no differences between the two groups at the time of the two-year follow-up, with both groups demonstrating favorable effects from the therapy that held up at the time of the final followup. The study shows that group therapy that is comprehensive is as effective as individual therapy and that both demonstrate positive effects at the time of two-year follow-up. Khadilkar A, Milne S, Brosseau L, Wells G, Tugwell P, Robinson V, Shea B, Saginur M. Transcutaneous electrical nerve stimulation for the treatment of chronic low back pain: a systematic review. Spine. 2005;30:2657-66. The authors set out to perform a meta-analysis of the literature on transcutaneous electrical nerve stimulation (TENS) for the treatment of low-back pain but only found two studies that met criteria to include in this analysis. They concluded that evidence to support the use of TENS treatment for low-back pain is limited. Korhonen T, Karppinen J, Paimela L, Malmivaara A, Lindgren KA, Järvinen S, Niinimäki J, Veeger N, Seitsalo S, Hurri H. The treatment of disc herniation-induced sciatica with Infliximab: results of a randomized, controlled, 3-month follow-up study. Spine. 2005;30:2724-8. This was a prospective randomized controlled study of forty patients with sciatica due to a lumbar disc herniation. Patients were managed with either a single infusion of the medication (antibody against TNF-alpha) or placebo. Both groups showed a significant reduction in leg pain, without any significant differences between the two groups. The authors concluded that there was no support for the use of this medication for lumbar disc herniation-induced sciatica. With the recent interest in TNF-alpha blockers for the treatment of sciatic pain, this study demonstrates that there was no difference between the medication and the placebo, which may reflect the positive natural history of the disorder itself. Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005;366:643-8. Patients with isolated epidural spinal metastases were randomized to radiation therapy or surgical decompression followed by postoperative irradiation. The primary end point was the ability to walk. The study was discontinued before full enrollment because the surgical group had significantly better results, including the percentage of patients who remained able to walk, the duration of walking, the number of patients who regained the ability to walk, and a decreased need for corticosteroids and opioids. This convincing study demonstrates that for patients with isolated epidural spinal cord compression, surgery followed by radiation therapy is associated with a better outcome than radiation alone. This was true for patients with significant neurologic deficits and for those who were neurologically intact. Rosenfeld M, Seferiadis A, Gunnarsson R. Active involvement and intervention in patients exposed to whiplash trauma in automobile crashes reduces costs: a randomized, controlled clinical trial and health economic evaluation. Spine. 2006;31:1799-1804. This randomized study demonstrated that for patients exposed to whiplash trauma in a motor-vehicle collision, active involvement and intervention were both less costly and more effective than a standard intervention. There was reduced pain and less sick leave in the active involvement group. Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA. Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2005;143:849-56. In this randomized controlled study of patients with prior episodic low-back pain, Viniyoga was compared with group exercise taught by a physical therapist or through an instructional booklet. Viniyoga is a safe technique that emphasizes breathing and posture for the treatment of low-back pain symptoms. At twenty-six weeks of follow-up, there was significant improvement in both the exercise and yoga groups. The yoga group had superior outcomes, but the differences were not significant compared with the exercise group. Both therapeutic groups had significantly better results than did the subjects who used the booklet. The conclusions of the study are limited in that the results cannot be generalized because the treatment population was poorly defined. Furthermore, instructions were given in each group by one practitioner who may have biased the outcome. The duration of follow-up was short, and it is unknown if the observed effect will be lasting. Finally, compliance with the program was not reported. Singh K, Samartzis D, Strom J, Manning D, Campbell-Hupp M, Wetzel FT, Gupta P, Phillips FM. A prospective, randomized, double-blind study evaluating the efficacy of postoperative continuous local anesthetic infusion at the iliac crest bone graft site after spinal arthrodesis. Spine. 2005;30:2477-83. Continuous infusion of local anesthetic has been developed to decrease postoperative pain and is used in many surgical disciplines. This study tested its efficacy in patients undergoing spinal fusion with use of iliac crest bone grafts. Thirty-seven patients were randomized to placebo (saline solution infusion) or Marcaine (90 mL of 0.5%) with use of a continuous infusion technique. Significantly lower pain scores and less opioid consumption was present in the anesthetic group. No complications occurred in either group. The pump and anesthetics were cost-neutral. This was a well-done study showing the efficacy of an inexpensive (cost-neutral) method in decreasing postoperative pain. The use of this anesthetic technique should be considered in other musculoskeletal surgical areas. Steele EJ, Dawson AP, Hiller JE. School-based interventions for spinal pain: a systematic review. Spine. 2006;31:226-33. This was a systematic literature review of twelve papers. All twelve papers received a "weak quality rating"; therefore, no conclusions could be made regarding the effectiveness of a school-based spinal health intervention program. This paper strongly suggests there is no clear evidence that schools and health-promotion programs help with the treatment of spinal pain. There is simply not a clear answer in the current peer-review literature. Yukawa Y, Kato F, Ito K, Terashima T, Horie Y. A prospective randomized study of preemptive analgesia for postoperative pain in the patients undergoing posterior lumbar interbody fusion: continuous subcutaneous morphine, continuous epidural morphine, and diclofenac sodium. Spine. 2005;30:2357-61. The authors studied the use of preoperative and postoperative continuous subcutaneous morphine, continuous epidural morphine, and diclofenac sodium in a prospective randomized fashion. The diclofenac treatment group had the lowest initial visual analog scale pain scores immediately after surgery (p = 0.059) but required more supplemental analgesic medications in the first seventy-two hours after surgery (p = 0.013). The epidural group had more side effects, most commonly nausea and vomiting, than the other groups (p = 0.015). This study is very relevant to the practice of spine surgery as effective postoperative analgesia improves patient outcomes, reduces secondary complications by allowing for early mobilization, and shortens hospital stay. On the basis of the results of this study, it appears that the administration of continuous subcutaneous morphine might be a safe and useful approach for the treatment of postoperative pain after spinal surgery and warrants further study.
NOTE: The authors thank Drs. Jim Harrop, Alan Hilibrand, Steve Mardjetko, Dan Riew, and Harvinder Sandhu for peer reviewing the sections of this manuscript.
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