Surgeon Opinions on Use of Epidural Steroids in Treatment of Lumbar Disk Disease: Results of an Online Survey

“Standard of care” can vary along regional and specialty lines; it is common to discover that a local “standard” can be different somewhere else. Opinions may differ between pain management specialists, primary care physicians, and spine surgeons with regard to use of conservative treatment modalities. Opinion within a given group of practitioners, however, should converge. Local differences between hospitals may exist, but conferences, professional journals, and national boards for certification are mechanisms that should act to maintain homogeneity within a professional group. It could be expected that commonly utilized treatment approaches within a well defined group of sub-specialists should converge. One of the more common non-surgical options for herniated lumbar spinal discs is epidural steroid injections (ESIs). Patients may be referred to pain management centers for lumbar ESIs by their primary care physician or perhaps after consultation with a surgical specialist. We sought to assess the opinion of practicing spine surgeons with regard to timing and use of lumbar ESIs as a part of a conservative treatment approach to both lumbar disk herniations (HNP) and lumbar degenerative disk disease (DDD)

Surgical site infection and transfusion rates are higher in underweight total knee arthroplasty patients.

BACKGROUND: Underweight (UW) patients undergoing total hip arthroplasty have exhibited higher complication rates, including infection and transfusion. No study to our knowledge has evaluated UW total knee arthroplasty (TKA) patients. We, therefore, conducted a study to investigate if these patients are at increased risk for complications, including infection and transfusion. METHODS: A case-control study was conducted using a prospectively collected institutional database. Twenty-seven TKA patients were identified as UW (body mass index [BMI] \u3c 18.5 kg/m RESULTS: The average BMI was 17.1 kg/m CONCLUSIONS: Our study demonstrates that UW TKA patients have a higher likelihood of developing SSI and requiring blood transfusions. The specific reasons are unclear, but we conjecture that it may be related to decreased wound healing capabilities and low preoperative hemoglobin. Investigation of local tissue coverage and hematologic status may be beneficial in this patient population to prevent SSI. Based on the results of this study, a prospective evaluation of these factors should be undertaken

Risk factors for surgical site infection following total joint arthroplasty.

BACKGROUND: Currently, most hospitals in the United States are obliged to report infections that occur following total joint arthroplasty to the Centers for Disease Control and Prevention through the National Healthcare Safety Network surveillance. The objective of this study was to identify the risk factors of surgical site infections that were reported to the Centers for Disease Control and Prevention from a single institution. METHODS: For this study, 6111 primary and revision total joint arthroplasties performed from April 2010 to June 2012 were identified. Surgical site infection cases captured by infection surveillance staff on the basis of the Centers for Disease Control and Prevention definition were identified. Surgical site infection cases with index surgery performed at another institution were excluded. All cases were followed up for one year for development of surgical site infection. The model for predictors of surgical site infection was created by logistic regression and was validated by bootstrap resampling. RESULTS: Of all performed total joint arthroplasties, surgical site infection developed in eighty cases (1.31% [95% confidence interval, 1.02% to 1.59%]). The highest rate of surgical site infection was observed in revision total knee arthroplasty (4.57% [95% confidence interval, 2.31% to 6.83%]) followed by revision total hip arthroplasty (1.94% [95% confidence interval, 0.75% to 3.13%]). Among the variables examined, the predictive factors of surgical site infection were higher Charlson Comorbidity Index (odds ratio for a Charlson Comorbidity Index of ≥2, 2.29 [95% confidence interval, 1.32 to 3.94] and odds ratio for a Charlson Comorbidity Index of 1, 2.09 [95% confidence interval, 1.06 to 4.10]), male sex (odds ratio, 1.79 [95% confidence interval, 1.11 to 2.89]), and revision total knee arthroplasty (odds ratio, 3.13 [95% confidence interval, 1.17 to 8.34]), and a higher level of preoperative hemoglobin (odds ratio, 0.85 per point [95% confidence interval, 0.73 to 0.98 per point]) was protective against surgical site infection. The C-statistic of the model was 0.709 without correction and 0.678 after bootstrap correction, indicating that the model has fair predictive power. CONCLUSIONS: Low preoperative hemoglobin level is one of the risk factors for surgical site infection and preoperative correction of hemoglobin may reduce the likelihood of postoperative surgical site infection. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence

Complications of Decompressive Craniectomy

Introduction: Persistent elevation of intracranial pressure (ICP), if untreated, may lead to brain ischemia or lack of brain oxygen and even brain death.1-6,10 When standard treatments for elevated ICP are exhausted without any signs of improvement, decompressive craniectomy can be an effective alternative solution.7,19 Decompressive craniectomies (DC) have been used as a method of controlling intracranial pressure in patients with cerebral edema secondary to cerebral ischemia, subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI), among others. 8-10 Several studies over the years have demonstrated the efficacy of this procedure.7-9,11,35,36 However, consensus is still lacking in the utility of DC as an effective first tier treatment for intractable intracranial pressure due to the rudimentary neurological outcome assessments, and the many complications associated with this procedure.11,12,59 There are a limited number of studies that have looked at complications secondary to the procedure itself.13-18 The majority of these studies only investigated the impact of this procedure in patients with traumatic brain injury. The purpose of this study is to investigate the rates of various complications associated with the decompressive craniectomy procedure in patients that did not suffer from traumatic brain injury, and to determine whether the same associations between preoperative parameters and development of complications can be made

Variability of patient spine education by Internet search engine.

BACKGROUND: Patients are increasingly reliant upon the Internet as a primary source of medical information. The educational experience varies by search engine, search term, and changes daily. There are no tools for critical evaluation of spinal surgery websites. PURPOSE: To highlight the variability between common search engines for the same search terms. To detect bias, by prevalence of specific kinds of websites for certain spinal disorders. Demonstrate a simple scoring system of spinal disorder website for patient use, to maximize the quality of information exposed to the patient. STUDY DESIGN: Ten common search terms were used to query three of the most common search engines. The top fifty results of each query were tabulated. A negative binomial regression was performed to highlight the variation across each search engine. RESULTS: Google was more likely than Bing and Yahoo search engines to return hospital ads (P=0.002) and more likely to return scholarly sites of peer-reviewed lite (P=0.003). Educational web sites, surgical group sites, and online web communities had a significantly higher likelihood of returning on any search, regardless of search engine, or search string (P=0.007). Likewise, professional websites, including hospital run, industry sponsored, legal, and peer-reviewed web pages were less likely to be found on a search overall, regardless of engine and search string (P=0.078). CONCLUSION: The Internet is a rapidly growing body of medical information which can serve as a useful tool for patient education. High quality information is readily available, provided that the patient uses a consistent, focused metric for evaluating online spine surgery information, as there is a clear variability in the way search engines present information to the patient

Postoperative Urinary Retention (POUR): What Are The Risk Factors?

Introduction Total hip arthroplasty (THA) is a successful procedure alleviating pain in patients with debilitating arthritis. Postoperative urinary retention (POUR) is a common complication following surgery and is managed with intermittent or continued urinary catheterization. POUR has been estimated in retrospective literature to be on the order of 5% – 70% of surgical cases with early catheter removal or without a catheter. At our institution, and based on a Level 1 study here, urinary catheter is not used routinely in patients undergoing THA under regional anesthesia. The purpose of this study was to evaluate the incidence of POUR and risk factors leading to urinary retention in patients undergoing THA using regional anesthesia who did not receive urinary catheterization

Traumatic thoracic ASIA A examinations and potential for clinical trials

Study Design: Retrospective review of prospective database Objectives: To define the variability of neurologic examination and recovery after non-penetrating complete thoracic spinal cord injuries (ASIA A). Background Data: Neurologic examinations after SCI can be difficult and inconsistent. Unlike cervical SCI patients, alterations in thoracic (below T1) complete SCI (ASIA A – based on the ASIA Impairment Scale [AIS]) patients’ exams are based only on sensory testing, thus changes in the neurological level (NL) are determined only by sensory changes. Methods: A retrospective review of the placebo control patients in a multicenter prospective database utilized for the pharmacologic trial of Sygen. Patients were included if they had a complete thoracic SCI on initial evaluation, with completed ASIA examinations at follow-up weeks 4, 8, 16, 26 and 52. Specifically, pin prick (PP) and light touch (LT) were assessed and the absolute change was calculated as the number of spinal levels at a given observation time. Results 3165 patients were initially screened for the Sygen clinical trial, of which 57 were the control placebo patients used in this analysis. Alterations from the baseline exam (PP and LT) were fairly consistent and the median change/recovery in neurologic examination was one spinal level. Across all observations post-baseline, the average change for PP was 1.48 +/- 0.13 (mean +/- SE), and for LT, 1.40 +/-0.13. There were equal proportions of directional changes (none, improved, lost). Conclusions: Changes in a thoracic complete (ASIA A) SCI patient ASIA examination as measured through sensory modalities (PP/LT) are fairly uncommon. The overall examination had only 1-2 level variability across patients, indicating minimal change in the sensory exam over the follow-up period. Stability in the ASIA examination as measured through sensory modalities has thus been demonstrated over time, making it an excellent tool to monitor changes in neurologic function

Aspirin May Be Adequate for Venous Thromboembolic Event Prophylaxis after Revision Hip and Knee Arthroplasty

Introduction: The optimal prophylaxis for prevention of venous thromboembolic events (VTE) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) remains unknown.(1) Current studies focus on primary arthroplasty and there are little to no data on the ideal prophylaxis for VTE following revision arthroplasty.(2) Revision surgery, due to its complexity, longer operative time, higher risk of bleeding and infection diff­ers from primary arthroplasty.(3) The objective of this study was to evaluate whether aspirin, known to be e­ffective for prevention of VTE after primary arthroplasty, is also e­ffective against such events following revision THA and TKA

A Clinical Decision Support Tool to Predict the Risk of Failure in Patients with Femoroacetabular Impingement Undergoing Hip Preservation Surgery

In modern orthopaedics, risk prediction scores can help discriminate between ideal and poor candidates for a specifi­c therapeutic intervention. We consider these tools useful during the process of shared medical decision-making1. To our knowledge, such a strategy has never been explored in the ­field of hip preservation surgery. The aim of our study is to generate a clinical decision support tool to predict risk of failure after hip preservation surgery among patients with femoroacetabular impingement (FAI)

Thromboembolism After Intramedullary Nailing for Metastatic Bone Lesions.

BACKGROUND: The risk of venous thromboembolism (VTE) in patients undergoing intramedullary nailing for skeletal metastatic disease is currently undefined. The purpose of our study was to determine the risk of thromboembolic events, to define the risk factors for VTE, and to define the rate of wound complications in this population. METHODS: A retrospective review of surgical databases at three National Cancer Institute (NCI)-designated cancer centers identified 287 patients with a total of 336 impending or pathologic long-bone fractures that were stabilized with intramedullary nailing between February 2001 and April 2013. Statistical analysis was performed utilizing multivariable logistic regression and Fisher exact tests. RESULTS: The overall rate of VTE was twenty-four (7.1%) of the 336; thirteen (3.9%) were pulmonary embolism (PE), and eleven (3.3%), deep venous thrombosis (DVT). In two patients, adequate anticoagulation data were not available. We found no significant relationship between the type of anticoagulant used and VTE. There was a significant positive correlation found between lung-cancer histology and the development of VTE (p \u3c 0.001) or PE (p \u3c 0.001). The absence of radiation therapy approached significance (p = 0.06) with respect to decreased overall VTE risk. Wound complications were documented for 11 (3.3%) of the operations. CONCLUSIONS: There is a high rate of VTE among those with skeletal metastatic disease who undergo intramedullary nailing, even while receiving postoperative thromboembolic prophylaxis. Current anticoagulation protocols may be inadequate. Wound-complication risk with anticoagulant use in this population is low and should not be a deterrent to adequate anticoagulant use for this population