Publications by authors named "John D Koerner"

37 Publications

Correlation of Early Outcomes and Intradiscal Interleukin-6 Expression in Lumbar Fusion Patients.

Neurospine 2020 Mar 31;17(1):36-41. Epub 2020 Mar 31.

Thomas Jefferson University, Department of Orthopedic Surgery, Philadelphia, PA, USA.

Objective: To determine if there is correlation between intradiscal levels of interleukin-6 (IL-6) and early outcome measures in patients undergoing lumbar fusion for painful disc degeneration.

Methods: Intervertebral disc tissue was separated into annulus fibrosus/nucleus pulposus and cultured separately in vitro in serum-free medium (Opti-MEM). Conditioned media was collected after 48 hours. The concentration of IL-6 was quantified using enzyme-linked immunosorbent assay. Pearson correlation coefficients quantified relationships between IL-6 levels and pre- and postoperative visual analogue scale (VAS) back pain and Oswestry Disability Index (ODI), as well as change in VAS/ODI.

Results: Sixteen discs were harvested from 9 patients undergoing anterior lumbar interbody fusion (mean age, 47.4 years; range, 21-70 years). Mean preoperative and 6-month postoperative VAS were 8.1 and 3.7, respectively. Mean preoperative and postoperative ODI were 56.2 and 25.6, respectively. There were significant positive correlations between IL-6 expression and postoperative VAS (ρ = 0.38, p = 0.048) and ODI (ρ = 0.44, p = 0.02). No significant correlations were found between intradiscal IL-6 expression and preoperative VAS (ρ = -0.12, p = 0.54). Trends were seen associating IL-6 expression and change in VAS/ODI (ρ = -0.35 p = 0.067; ρ = -0.34, p = 0.08, respectively). A trend associated IL-6 and preoperative ODI (ρ = 0.36, p = 0.063).

Conclusion: The direct association between IL-6 expression and VAS/ODI suggests patients with elevated intradiscal cytokine expression may have worse early outcomes than those with lower expression of IL-6 after surgery for symptomatic disc degeneration.
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http://dx.doi.org/10.14245/ns.2040054.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7136096PMC
March 2020

Does Riluzole Influence Bone Formation?: An In Vitro Study of Human Mesenchymal Stromal Cells and Osteoblast.

Spine (Phila Pa 1976) 2019 Aug;44(16):1107-1117

Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA.

Study Design: A post-test design biological experiment.

Objective: The aim of this study was to evaluate the osteogenic effects of riluzole on human mesenchymal stromal cells and osteoblasts.

Summary Of Background Data: Riluzole may benefit patients with spinal cord injury (SCI) from a neurologic perspective, but little is known about riluzole's effect on bone formation, fracture healing, or osteogenesis.

Methods: Human mesenchymal stromal cells (hMSCs) and human osteoblasts (hOB) were obtained and isolated from healthy donors and cultured. The cells were treated with riluzole of different concentrations (50, 150, 450 ng/mL) for 1, 2, 3, and 4 weeks. Cytotoxicity was evaluated as was the induction of osteogenic differentiation of hMSCs. Differentiation was evaluated by measuring alkaline phosphatase (ALP) activity and with Alizarin red staining. Osteogenic gene expression of type I collagen (Col1), ALP, osteocalcin (Ocn), Runx2, Sox9, Runx2/Sox9 ratio were measured by qRT-PCR.

Results: No cytotoxicity or increased proliferation was observed in bone marrow derived hMSCs and primary hOBs cultured with riluzole over 7 days. ALP activity was slightly increased in hMSCs after treatment for 2 weeks with riluzole 150 ng/mL and slightly upregulated by 150% (150 ng/mL) and 90% (450 ng/mL) in hMSCs at 3 weeks. In hOBs, ALP activity almost doubled after 2 weeks of culture with riluzole 150 ng/mL (P < 0.05). More pronounced 2.6-fold upregulation was noticed after 3 weeks of culture with riluzole at both 150 ng/mL (P = 0.05) and 450 ng/mL (P = 0.05). No significant influence of riluzole on the mRNA expression of osteocalcin (OCN) was observed.

Conclusion: The effect of riluzole on bone formation is mixed; low-dose riluzole has no effect on the viability or function of either hMSCs or hOBs. The activity of ALP in both cell types is upregulated by high-dose riluzole, which may indicate that high-dose riluzole can increase osteogenic metabolism and subsequently accelerate bone healing process. However, at high concentrations, riluzole leads to a decrease in osteogenic gene expression, including Runx2 and type 1 collagen.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1097/BRS.0000000000003022DOI Listing
August 2019

The local cytokine and growth factor response to recombinant human bone morphogenetic protein-2 (rhBMP-2) after spinal fusion.

Spine J 2018 08 14;18(8):1424-1433. Epub 2018 Mar 14.

Rothman Institute, Thomas Jefferson University, 925 Chestnut St, Philadelphia, PA 19, USA.

Background Context: The systemic response regarding cytokine expression after the application of recombinant human bone morphogenetic protein-2 (rhBMP-2) in a rat spinal fusion model has recently been defined, but the local response has not been defined. Defining the local cytokine and growth factor response at the fusion site will help explain the roles of these molecules in the fusion process, as well as that of rhBMP-2. Our hypothesis is that the application of rhBMP-2 to the fusion site will alter the local levels of cytokines and growth factors throughout the fusion process, in a manner that is different from the systemic response, given the tissue-specific effects of rhBMP-2.

Purpose: The purpose of this study was to evaluate the local cytokine and growth factor response after the application of rhBMP-2 in a rat spinal fusion model.

Study Design/setting: This was a basic science animal model study.

Methods: This study was partially funded by a physician-sponsored grant from Medtronic. A total of 135 Wistar rats (age 8 weeks, weighing approximately 300-400 g) underwent L4-L5 posterolateral intertransverse fusion with demineralized bone graft (approximately 0.4-cm rat demineralized bone matrix [DBM] per side). In the first group, 10 µg of rhBMP-2 on an allograft collagen sponge (ACS) was added to the fusion site with approximately 0.4-cm rat DBM per side. In the second group, 100 µg of rhBMP-2 on an ACS was added to the fusion site with approximately 0.4-cm rat DBM per side, and the third experiment was the control group, which consisted of only an ACS plus 0.4-cm DBM per side. There were nine groups of five animals each per experiment. Each group was sacrificed at time points up to 4 weeks (1, 6, 24, and 48 hours, and 4, 7, 14, 21, and 28 days after surgery). At sacrifice, the DBM, transverse processes, and any new bone formed were harvested, immediately frozen in liquid nitrogen, and prepared for protein extraction. ELISA was performed to compare the levels of various cytokines (interleukin [IL]-1β, tumor necrosis factor alpha, IL-6, IL-1RA [IL-1 receptor antagonist], IL-4, and IL-10) and growth factors (vascular endothelial growth factor [VEGF], endothelia growth factor [EGF], insulin-like growth factor-1 [IGF-1], platelet derived growth factor [PDGF], transforming growth factor beta [TGF-β]) that are known to be involved in the fusion-fracture healing process. Fusion was evaluated on the rats sacrificed at 28 days by manual palpation and microcomputed tomography (microCT) by two independent observers.

Results: The expression of cytokines and growth factors varied throughout the fusion process at each time point. In the groups treated with rh-BMP-2, IL-6 and IL-1RA had higher expression in the early time points (1 and 6 hours). Tumor necrosis factor alpha demonstrated significantly lower expression in the groups treated with rhBMP-2 at Days 1, 2, and 4. At the early time points (1 and 6 hours), in the groups treated with rhBMP-2, all of the growth factors IGF-1, VEGF, platelet derived growth factor AB (PDGF-AB), TGF-β had equal or lower expression compared with controls. At 24 hours, there was a peak in IGF-1, VEGF, and PDGF-AB. These growth factors then declined, with IGF-1 and PDGF-AB having a second peak at Day 7. At 4 weeks, all of the rhBMP-2-treated animals fused based on manual palpation and microCT. The control group had four of five rats fused based on manual palpation and two of five rats based on microCT.

Conclusions: There is significant variability in the expression of cytokines throughout the fusion process after treatment with rhBMP-2. The inflammatory response appears to peak early (1 and 6 hours), followed by a significant decrease with rhBMP-2 treatment. However, the growth factor expression appears to be suppressed early (1 and 6 hours), followed by a peak at 24 hours, and a second peak at Day 7.
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http://dx.doi.org/10.1016/j.spinee.2018.03.006DOI Listing
August 2018

Outcome of a Resident Spine Surgical Skills Training Program.

Clin Spine Surg 2017 Oct;30(8):E1126-E1129

*Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA †Rothman Institute, Philadelphia, PA.

Study Design: Cadaver training lab.

Objective: To determine if a technical cadaver skills training lab for spinal surgery increases resident confidence, satisfaction in training, and perception of operating room safety.

Summary Of Background Data: Resident training is an important topic in the setting of work hour reform. The use of supplemental materials such as videos, sawbones, and simulators may become important to adequately train orthopedic residents. At present, there are no established curricula for training orthopedic surgery residents on anatomy and common procedures encountered during a spinal surgery rotation.

Methods: Residents were assembled into teams of a PGY-5 and PGY-2 and/or PGY-1 to perform dissection and procedures on 5 fresh-frozen spine cadavers. With attending and spine fellow supervision, residents performed anterior cervical, posterior cervical, and posterior thoracolumbar surgical exposure, decompression, and fusion procedures in the operating room using surgical tools and instrumentation. Residents were then queried about their confidence levels, satisfaction in training, and perception of safety using a Likert scale (0-10). Strong agreement (scores ≥8) and strong disagreement (scores ≤3) and correlations were evaluated.

Results: Seventeen residents completed the training program (7 PGY-1s, 2 PGY-2s, and 8 PGY-5s). After the training, the majority of residents strongly agreed that they had an increased confidence of their own abilities (59%). A significant majority (65%) of residents strongly agreed that they were satisfied with the benefits provided by the training program. Compared with other methods of education, residents strongly agreed that the training was more helpful than textbook chapters (94%), sawbones (94%), web-based training (94%), or a virtual-based (completely electronic) training (94%). After the training, residents strongly agreed that the training improved feelings of preparation (47%), safety (41%), and ability to prevent intraoperative errors (41%). The vast majority of residents strongly agreed "Before performing surgery on me, I would want a resident to perform this cadaveric training" (88%).

Conclusions: These results demonstrate that team-based, cadaveric training with adequate attending supervision, before onset of a spine surgical rotation, may lead to high resident confidence, satisfaction in training, and perception of patient safety.
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http://dx.doi.org/10.1097/BSD.0000000000000211DOI Listing
October 2017

Are Modic changes associated with intervertebral disc cytokine profiles?

Spine J 2017 01 4;17(1):129-134. Epub 2016 Aug 4.

Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, 925 Chestnut St, Philadelphia, PA, 19107, USA; The Thomas Jefferson University Department of Orthopaedic Surgery, 1025 Walnut St, Fifth Floor, Philadelphia, PA, 19107, USA.

Background Context: Degenerative changes including Modic changes (MCs) are commonly observed in patients with chronic low back pain. Although intervertebral disc (IVD) cytokine expression has been shown to be associated with low back pain, the cytokine profile for degenerative IVD with and without MC has not been compared.

Purpose: This study aimed to evaluate the potential association between IVD cytokine expression and MCs.

Study Design: A laboratory study was carried out.

Methods: The IVD tissue samples from 10 patients with type II MCs and10 patients without MCs who underwent an anterior lumbar interbody and fusion for significant low back pain were collected. The expression levels of 42 cytokines were determined using a RayBio Human Cytokine Antibody Array 3 (RayBiotech Inc, Norcross, GA, USA) and the results were verified with enzyme-linked immunosorbent assay (ELISA).

Results: The cytokine array demonstrated a statistically significant increase in the expression of granulocyte-macrophage colony-stimulating factor (GM-CSF) (p=.001) and epithelial-derived neutrophil-activating peptide 78 (ENA-78) (p=.04), and a trend toward an increase in interleukin-1β (IL-1β) (p=.12) and tumor necrosis factor-α (TNF-α) (p=.22) in IVDs associated with type II MCs. These results were validated with ELISA which demonstrated a 3.85-fold increase in the GM-CSF level between IVDs with type II MCs compared with those without MCs (p=.03). Similarly there was a significant increase in the level of both ENA-78 (3.68-fold, p=.02) and IL-1β (2.11-fold, p=.01) in IVDs with type II MCs. Lastly, there was a trend (p=.07) toward an increase in TNF-α in IVDs with type II MCs (4.4-fold).

Conclusion: Intervertebral discs with type II MCs demonstrate a significant increase in IL-1β, GM-CSF, and ENA-78, and there is a trend toward an increase in TNF-α. These results further strengthen the association between MCs and low back pain.
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http://dx.doi.org/10.1016/j.spinee.2016.08.006DOI Listing
January 2017

The Thoracolumbar AOSpine Injury Score.

Global Spine J 2016 Jun 29;6(4):329-34. Epub 2015 Sep 29.

Department of Orthopaedic Surgery, University Medical Center, Utrecht, The Netherlands.

Study Design Survey of 100 worldwide spine surgeons. Objective To develop a spine injury score for the AOSpine Thoracolumbar Spine Injury Classification System. Methods Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System. Using the results, as well as limited input from the AOSpine Trauma Knowledge Forum, the Thoracolumbar AOSpine Injury Score was developed. Results Beginning with 1 point for A1, groups A, B, and C were consecutively awarded an additional point (A1, 1 point; A2, 2 points; A3, 3 points); however, because of a significant increase in the severity between A3 and A4 and because the severity of A4 and B1 was similar, both A4 and B1 were awarded 5 points. An uneven stepwise increase in severity moving from N0 to N4, with a substantial increase in severity between N2 (nerve root injury with radicular symptoms) and N3 (incomplete spinal cord injury) injuries, was identified. Hence, each grade of neurologic injury was progressively given an additional point starting with 0 points for N0, and the substantial difference in severity between N2 and N3 injuries was recognized by elevating N3 to 4 points. Finally, 1 point was awarded to the M1 modifier (indeterminate posterolateral ligamentous complex injury). Conclusion The Thoracolumbar AOSpine Injury Score is an easy-to-use, data-driven metric that will allow for the development of a surgical algorithm to accompany the AOSpine Thoracolumbar Spine Injury Classification System.
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http://dx.doi.org/10.1055/s-0035-1563610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868575PMC
June 2016

The Effect of Substance P on an Intervertebral Disc Rat Organ Culture Model.

Spine (Phila Pa 1976) 2016 Dec;41(24):1851-1859

Rothman Institute, Philadelphia, PA.

Study Design: Laboratory study.

Objective: Evaluate the effect of substance P (SP) on an intervertebral disc rat organ culture model.

Summary Of Background Data: Monolayer cell experiments have demonstrated that exposure intervertebral disc tissue cells to SP leads to upregulation in inflammatory cytokine expression; however, this has not been evaluated in a more complex organ culture model.

Methods: Forty-eight intervertebral discs from eight rats were used in an organ culture model. Intervertebral discs were divided into three groups: control, SP-treated group, and a group treated with an SP antagonist followed by SP. Cytokine antibody array was used to quantify expression patterns, which were confirmed using ELISA and real-time polymerase chain reaction.

Results: The cytokine array demonstrated a 3.40 ±  0.59-fold increase in interleukin 6 (IL-6) expression in the SP group (P = 0.004), and the effect of SP was mitigated by the SP antagonist (P = 0.03). These results were verified as ELISA demonstrated a significant difference in the IL-6 level between the control group and SP group (0.73 vs. 5.80 ng/mL, P < 0.001), and there was a significant difference in the IL-6 level between the SP and the SP antagonist group (5.80 vs. 4.02 ng/mL, P = 0.01). Similarly, the real-time polymerase chain reaction demonstrated that the discs treated with SP had a 4.77-fold increase in IL-6 levels (P = 0.01) compared to controls, and a significantly greater increase in IL-6 levels between the intervertebral discs in the SP group and those in the SP antagonist group versus control (4.77 vs. 1.57, P = 0.02).

Conclusion: SP lead to the activation of an inflammatory pathway by increasing expression of IL-6 in an intervertebral disc organ culture model. These results provide evidence that SP may be an important factor in the link between intervertebral disc degeneration and low back pain.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1097/BRS.0000000000001676DOI Listing
December 2016

Zinc has insulin-mimetic properties which enhance spinal fusion in a rat model.

Spine J 2016 06 2;16(6):777-83. Epub 2016 Feb 2.

Department of Orthopaedics, Rutgers University, New Jersey Medical School, 90 Bergen St, Suite 7300, Newark, NJ 07101, USA.

Background Context: Previous studies have found that insulin or insulin-like growth factor treatment can stimulate fracture healing in diabetic and normal animal models, and increase fusion rates in a rat spinal fusion model. Insulin-mimetic agents, such as zinc, have demonstrated antidiabetic effects in animal and human studies, and these agents that mimic the effects of insulin could produce the same beneficial effects on bone regeneration and spinal fusion.

Purpose: The purpose of this study was to analyze the effects of locally applied zinc on spinal fusion in a rat model.

Study Design/setting: Institutional Animal Care and Use Committee-approved animal study using Sprague-Dawley rats was used as the study design.

Methods: Thirty Sprague-Dawley rats (450-500 g) underwent L4-L5 posterolateral lumbar fusion (PLF). After decortication and application of approximately 0.3 g of autograft per side, one of three pellets were added to each site: high-dose zinc calcium sulfate (ZnCaSO4), low-dose ZnCaSO4 (half of the high dose), or a control palmitic acid pellet (no Zn dose). Systemic blood glucose levels were measured 24 hours postoperatively. Rats were sacrificed after 8weeks and the PLFs analyzed qualitatively by manual palpation and radiograph review, and quantitatively by micro-computed tomography (CT) analysis of bone volume and trabecular thickness. Statistical analyses with p-values set at .05 were accomplished with analysis of variance, followed by posthoc tests for quantitative data, or Mann-Whitney rank tests for qualitative assessments.

Results: Compared with controls, the low-dose zinc group demonstrated a significantly higher manual palpation grade (p=.011), radiographic score (p=.045), and bone formation on micro-CT (172.9 mm(3) vs. 126.7 mm(3) for controls) (p<.01). The high-dose zinc also demonstrated a significantly higher radiographic score (p=.017) and bone formation on micro-CT (172.7 mm(3) vs. 126.7 mm(3)) (p<.01) versus controls, and was trending toward higher manual palpation scores (p=.058).

Conclusions: This study demonstrates the potential benefit of a locally applied insulin-mimetic agent, such as zinc, in a rat lumbar fusion model. Previous studies have demonstrated the benefits of local insulin application in the same model, and it appears that zinc has similar effects.
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http://dx.doi.org/10.1016/j.spinee.2016.01.190DOI Listing
June 2016

A Survey On Spine Surgeons' Opinions On The Release Of The Centers for Medicare and Medicaid Services Data.

Int J Spine Surg 2015 13;9:51. Epub 2015 Oct 13.

The Rothman Institute at Thomas Jefferson University, Philadelphia, PA.

Background: In April 2014 the Centers for Medicare and Medicaid Services (CMS) released a dataset for the public which included information on services provided by physicians and healthcare providers for Medicare beneficiaries in the 2012 calendar year. The objective of this study is to determine spine surgeons' opinions on the release of the CMS data, and determine how they feel this information may affect patient care.

Methods: A survey was sent to members of the Association for Collaborative Spine Research (ACSR) regarding their practice patterns and opinions on the release of the CMS data. Determinants included surgical subspecialty, practice setting, years in practice and region. The average response was collected for each question and compared across groups. Additionally, questions in which greater than 75% of respondents either agreed (agree or strongly agree) or disagreed (disagree or strongly disagree) were identified.

Results: Seventy-six surgeons completed the survey, and while the overall interobserver reliability between each question was only slight (κ = 0.11), more than 75% of respondents either agreed or strongly agreed with five statements and, more than 75% of respondents either disagreed or strongly disagreed with six statements. While 86% of surgeons are in favor of more transparency, 83% of respondents felt that without the proper context, the data released does not accurately portray spine surgery. Additionally, 96% of spine surgeons do not believe the CMS data helps patients decide which spine surgeon is best for them.

Conclusions: The small percentage of spine surgeons who responded to this survey are in favor of more transparency but do not feel the release of the CMS data either accurately represents spine surgeons or will help patients better identify the appropriate surgeon. In spite of these concerns, it is unlikely the release of the CMS data will significantly impact the accessibility of a spine surgeon to a Medicare beneficiary.
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http://dx.doi.org/10.14444/2051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4657607PMC
November 2015

Is there a regional difference in morphology interpretation of A3 and A4 fractures among different cultures?

J Neurosurg Spine 2016 Feb 9;24(2):332-339. Epub 2015 Oct 9.

The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

OBJECT The aim of this study was to determine if the ability of a surgeon to correctly classify A3 (burst fractures with a single endplate involved) and A4 (burst fractures with both endplates involved) fractures is affected by either the region or the experience of the surgeon. METHODS A survey was sent to 100 AOSpine members from all 6 AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East) who had no prior knowledge of the new AOSpine Thoracolumbar Spine Injury Classification System. Respondents were asked to classify 25 cases, including 6 thoracolumbar burst fractures (A3 or A4). This study focuses on the effect of region and experience on surgeons' ability to properly classify these 2 controversial fracture variants. RESULTS All 100 surveyed surgeons completed the survey, and no significant regional (p > 0.50) or experiential (p > 0.21) variability in the ability to correctly classify burst fractures was identified; however, surgeons from all regions and with all levels of experience were more likely to correctly classify A3 fractures than A4 fractures (p < 0.01). Further analysis demonstrated that no region predisposed surgeons to increasing their assessment of severity of burst fractures. CONCLUSIONS A3 and A4 fractures are the most difficult 2 fractures to correctly classify, but this is not affected by the region or experience of the surgeon; therefore, regional variations in the treatment of thoracolumbar burst fractures (A3 and A4) is not due to differing radiographic interpretation of the fractures.
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http://dx.doi.org/10.3171/2015.4.SPINE1584DOI Listing
February 2016

A Worldwide Analysis of the Reliability and Perceived Importance of an Injury to the Posterior Ligamentous Complex in AO Type A Fractures.

Global Spine J 2015 Oct 27;5(5):378-82. Epub 2015 Mar 27.

Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States.

Study Design Survey of spine surgeons. Objective To determine the reliability with which international spine surgeons identify a posterior ligamentous complex (PLC) injury in a patient with a compression-type vertebral body fracture (type A). Methods A survey was sent to all AOSpine members from the six AO regions of the world. The survey consisted of 10 cases of type A fractures (2 subtype A1, 2 subtype A2, 3 subtype A3, and 3 subtype A4 fractures) with appropriate imaging (plain radiographs, computed tomography, and/or magnetic resonance imaging), and the respondent was asked to identify fractures with a PLC disruption, as well as to indicate if the integrity of the PLC would affect their treatment recommendation. Results Five hundred twenty-nine spine surgeons from all six AO regions of the world completed the survey. The overall interobserver reliability in determining the integrity of the PLC was slight (kappa = 0.11). No substantial regional or experiential difference was identified in determining PLC integrity or its absence; however, a regional difference was identified (p < 0.001) in how PLC integrity influenced the treatment of type A fractures. Conclusion The results of this survey indicate that there is only slight international reliability in determining the integrity of the PLC in type A fractures. Although the biomechanical importance of the PLC is not in doubt, the inability to reliably determine the integrity of the PLC may limit the utility of the M1 modifier in the AOSpine Thoracolumbar Spine Injury Classification System.
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http://dx.doi.org/10.1055/s-0035-1549034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4577328PMC
October 2015

Can a Thoracolumbar Injury Severity Score Be Uniformly Applied from T1 to L5 or Are Modifications Necessary?

Global Spine J 2015 Aug 27;5(4):339-45. Epub 2015 Mar 27.

Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States.

Study Design Literature review. Objective The aim of this review is to highlight challenges in the development of a comprehensive surgical algorithm to accompany the AOSpine Thoracolumbar Spine Injury Classification System. Methods A narrative review of the relevant spine trauma literature was undertaken with input from the multidisciplinary AOSpine International Trauma Knowledge Forum. Results The transitional areas of the spine, in particular the cervicothoracic junction, pose unique challenges. The upper thoracic vertebrae have a transitional anatomy with elements similar to the subaxial cervical spine. When treating these fractures, the surgeon must be aware of the instability due to the junctional location of these fractures. Additionally, although the narrow spinal canal makes neurologic injuries common, the small pedicles and the inability to perform an anterior exposure make decompression surgery challenging. Similarly, low lumbar fractures and fractures at the lumbosacral junction cannot always be treated in the same manner as fractures in the more cephalad thoracolumbar spine. Although the unique biomechanical environment of the low lumbar spine makes a progressive kyphotic deformity less likely because of the substantial lordosis normally present in the low lumbar spine, even a fracture leading to a neutral alignment may dramatically alter the patient's sagittal balance. Conclusion Although the new AOSpine Thoracolumbar Spine Injury Classification System was designed to be a comprehensive thoracolumbar classification, fractures at the cervicothoracic junction and the lumbosacral junction have properties unique to these junctional locations. The specific characteristics of injuries in these regions may alter the most appropriate treatment, and so surgeons must use clinical judgment to determine the optimal treatment of these complex fractures.
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http://dx.doi.org/10.1055/s-0035-1549035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4516738PMC
August 2015

The surgical algorithm for the AOSpine thoracolumbar spine injury classification system.

Eur Spine J 2016 Apr 8;25(4):1087-94. Epub 2015 May 8.

University of British Columbia, Vancouver, BC, Canada.

Purpose: The goal of the current study is to establish a surgical algorithm to accompany the AOSpine thoracolumbar spine injury classification system.

Methods: A survey was sent to AOSpine members from the six AO regions of the world, and surgeons were asked if a patient should undergo an initial trial of conservative management or if surgical management was warranted. The survey consisted of controversial injury patterns. Using the results of the survey, a surgical algorithm was developed.

Results: The AOSpine Trauma Knowledge forum defined that the injuries in which less than 30% of surgeons would recommend surgical intervention should undergo a trial of non-operative care, and injuries in which 70% of surgeons would recommend surgery should undergo surgical intervention. Using these thresholds, it was determined that injuries with a thoracolumbar AOSpine injury score (TL AOSIS) of three or less should undergo a trial of conservative treatment, and injuries with a TL AOSIS of more than five should undergo surgical intervention. Operative or non-operative treatment is acceptable for injuries with a TL AOSIS of four or five.

Conclusion: The current algorithm uses a meaningful injury classification and worldwide surgeon input to determine the initial treatment recommendation for thoracolumbar injuries. This allows for a globally accepted surgical algorithm for the treatment of thoracolumbar trauma.
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http://dx.doi.org/10.1007/s00586-015-3982-2DOI Listing
April 2016

Is There an Optimal Proximal Locking Screw Length in Retrograde Intramedullary Femoral Nailing? Can We Stop Measuring for These Screws?

J Orthop Trauma 2015 Oct;29(10):e421-4

*Division of Orthopaedic Trauma, Harris Methodist Fort Worth Hospital, Fort Worth, TX; †Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, UMDNJ-New Jersey Medical School, Newark, NJ; ‡Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY; and §Department of Orthopedic Surgery, San Antonio Military Medical Center, San Antonio, TX.

Insertion of locking screws through the proximal thigh while locking retrograde femoral nails is arguably more difficult and traumatic to local tissues than locking at other intramedullary nail sites. The purpose of this study was to evaluate whether a "standard" screw length for proximal interlocking of retrograde nails is possible, therefore assessing whether the act of measuring for these screws can be omitted. This article retrospective evaluates screw position and estimated proximal locking screw length in patients undergoing retrograde nailing using a large radiographically measured computed tomography cohort, with validation through a smaller clinical cohort. According to these data, it seems reasonable to skip depth gauge measurement during anteroposterior interlocking of retrograde femoral nails and insert a standard length screw based on location relative to the lesser trochanter. This should decrease the amount of local trauma to the patient at the locking screw site while increasing operating room efficiency by avoiding what can often become a difficult step during the procedure.
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http://dx.doi.org/10.1097/BOT.0000000000000353DOI Listing
October 2015

Substance P Receptor Antagonist Suppresses Inflammatory Cytokine Expression in Human Disc Cells.

Spine (Phila Pa 1976) 2015 Aug;40(16):1261-9

*Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA †Department of Orthopaedic Surgery, Rothman Institute; and ‡Department of Orthopedics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.

Study Design: Laboratory study.

Objective: To evaluate whether blockade of the Substance P (SP) NK1R attenuates its proinflammatory effect on human intervertebral disc cells (IVD), and to evaluate the signaling pathways associated with SP.

Summary Of Background Data: SP and its receptors are expressed in human IVD cells, and cause upregulation of inflammatory mediators; however, the effects of blocking these receptors have not been studied in human IVD cells.

Methods: Human annulus fibrosus (AF) and nucleus pulposus (NP) cells were expanded in monolayer, and then suspended in alginate beads. The alginate beads were treated with culture medium first containing a high affinity NK1R antagonist (L-760735) at different concentrations, and then with medium containing both NK1R antagonist and SP at 2 concentrations. Ribonucleic acid was isolated and transcribed into cDNA. Quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) was performed to evaluate expression of interleukin (IL)-1β, IL-6, and IL-8. Western blot analysis was performed to examine levels of the phosphorylated p38 mitogen-activated protein kinase (MAPK), extracellular signal regulated kinase 1/2 (ERK1/2) and nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB p65). The cells were pretreated with specific inhibitors of p38 (SB203580), ERK1/2 (PD98059), and p65 (SM7368) and then stimulated with SP.

Results: We detected expression of NK1R, neurokinin receptor 2 (NK2R), and neurokinin receptor 3 (NK3R) in AF and NP cells. Treatment of disc cells with the NK1R antagonist was able to suppress expression of IL-1β, IL-6, and IL-8 in a dose-dependent manner. SP stimulation increased phosphorylation of p38-MAPK and ERK1/2, but not of NFκB p65. This indicates that p38-MAPK and ERK1/2 control SP-induced cytokine expression independently from NF-kB p65. Inhibition of p38 and ERK1/2 activation reduced SP-induced IL-6 production in human disc cells.

Conclusion: NK1R is responsible for the proinflammatory effect of SP on IVD cells and this effect can be blocked by preventing binding of SP to NK1R. This study shows for the first time that SP mediates signaling in disc cells through NK1R and that SP activates the proinflammatory p38-MAPK and ERK1/2 pathways.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000000954DOI Listing
August 2015

Establishing the injury severity of thoracolumbar trauma: confirmation of the hierarchical structure of the AOSpine Thoracolumbar Spine Injury Classification System.

Spine (Phila Pa 1976) 2015 Apr;40(8):E498-503

*Rothman Institute at Thomas Jefferson University, Philadelphia, PA †University Medical Center, Utrecht, the Netherlands ‡The University of British Columbia, Vancouver, British Columbia, Canada §Catholic University, Curitiba, Brazil ¶University of Maryland School of Medicine, Baltimore, MD ‖University of Washington/Harborview Medical Center, Seattle WA **University of Toronto, Ontario, Canada ††Schön Klinik Nürnberg Fürth, Center for Spinal Surgery, Fürth, Germany; and ‡‡Berufsgenossenschaftliche Unfallklinik Frankfurt, Center for Spinal Surgery and Neurotraumatology, Frankfurt/Main, Germany.

Study Design: Survey of spine surgeons.

Objective: To develop a validated regional and global injury severity scoring system for thoracolumbar trauma.

Summary Of Background Data: The AOSpine Thoracolumbar Spine Injury Classification System was recently published and combines elements of both the Magerl system and the Thoracolumbar Injury Classification System; however, the injury severity of each fracture has yet to be established.

Methods: A survey was sent to 100 AOSpine members from all 6 AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East). Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System including the morphology, neurological grade, and patient specific modifiers. A grade of zero was considered to be not severe at all, and a grade of 100 was the most severe injury possible.

Results: Seventy-four AOSpine surgeons from all 6 AO regions of the world numerically graded the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System to establish the injury severity score. The reported fracture severity increased significantly (P < 0.0001) as the subtypes of fracture type A and type B increased, and a significant difference (P < 0.0001) in severity was established for burst fractures with involvement of 2 versus 1 endplates. Finally, no regional or experiential difference in severity or classification was identified.

Conclusion: Development of a globally applicable injury severity scoring system for thoracolumbar trauma is possible. This study demonstrates no regional or experiential difference in perceived severity or thoracolumbar spine trauma. The AOSpine Thoracolumbar Spine Injury Classification System provides a logical approach to assessing these injuries and enables rational strategies for treatment.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000000824DOI Listing
April 2015

Degenerative Lumbar Scoliosis.

JBJS Rev 2015 Apr;3(4)

1Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 2Department of Orthopaedic Surgery, Baylor College of Medicine, 7200 Cambridge Street, Floor 10A, Houston, TX 77030 3University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 3021, Kansas City, KS 66160.

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http://dx.doi.org/10.2106/JBJS.RVW.N.00061DOI Listing
April 2015

Revision surgery for failed cervical spine reconstruction: review article.

HSS J 2015 Feb 25;11(1):2-8. Epub 2014 Jul 25.

Rothman Institute, Thomas Jefferson University and Hospital, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107 USA.

Background: As the number of cervical spine procedures performed continues to increase, the need for revision surgery is also likely to increase. Surgeons need to understand the etiology of post-surgical changes, as well as have a treatment algorithm when evaluating these complex patients.

Questions/purposes: This study aims to review the rates and etiology of revision cervical spine surgery as well as describe our treatment algorithm.

Methods: We used a narrative and literature review. We performed a MEDLINE (PubMed) search for "cervical" and "spine" and "revision" which returned 353 articles from 1993 through January 22, 2014. Abstracts were analyzed for relevance and 32 articles were reviewed.

Results: The rates of revision surgery on the cervical spine vary by the type and extent of procedure performed. Patient evaluation should include a detailed history and review of the indication for the index procedure, as well as lab work to rule out infection. Imaging studies including flexion/extension radiographs and computed tomography are obtained to evaluate potential pseudarthrosis. Magnetic resonance imaging is helpful to evaluate the disc, neural elements, soft tissue, and to differentiate scar from infection. Sagittal alignment should be corrected if necessary.

Conclusions: Recurrent or new symptoms after cervical spine reconstruction can be effectively treated with revision surgery after identifying the etiology, and completing the appropriate workup.
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http://dx.doi.org/10.1007/s11420-014-9394-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342401PMC
February 2015

Anterior lumbar spine surgery: a systematic review and meta-analysis of associated complications.

Spine J 2015 May 26;15(5):1118-32. Epub 2015 Feb 26.

Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.

Background Context: The anterior approach to the lumbar spine is increasingly used to accomplish various surgical procedures. However, the incidence and risk factors for complications associated with anterior lumbar spine surgery (ALS) have not been fully elucidated.

Purpose: To identify and document types of complications and complication rates associated with ALS, determine risk factors for these events, and evaluate the effect of measures used to decrease complication rates.

Study Design: Systematic review and meta-analysis.

Methods: A systematic review of the English-language literature was conducted for articles published between January 1992 and December 2013. A MEDLINE search was conducted to identify articles reporting complications associated with ALS. For each complication, the data were combined using a generalized linear mixed model with a binomial probability distribution and a random effect based on the study. Predictors used were the type of procedure (open, minimally invasive, or laparoscopic), the approach used (transperitoneal vs. retroperitoneal), use of recombinant bone morphogenetic protein-2, use of preoperative computed tomography angiography (CTA), and the utilization of an access surgeon. Open surgery was used as a reference category.

Results: Seventy-six articles met final inclusion criteria and reported complication rates in 11,410 patients who underwent arthrodesis and/or arthroplasty via laparoscopic, mini-open, and open techniques. The overall complication rate was 14.1%, with intraoperative and postoperative complication rates of 9.1% and 5.2%, respectively. Only 3% of patients required reoperation or revision procedures. The most common complications reported were venous injury (3.2%), retrograde ejaculation (2.7%), neurologic injury (2%), prosthesis related (2%), postoperative ileus (1.4%), superficial infection (1%), and others (1.3%). Laparoscopic and transperitoneal procedures were associated with higher complication rates, whereas lower complication rates were observed in patients receiving mini-open techniques. Our analysis indicated that the use of recombinant bone morphogenetic protein-2 was associated with increased rates of retrograde ejaculation; however, there may be limitations in interpreting these data. Data regarding the use of preoperative CTA and an access surgeon were limited and demonstrated mixed benefit.

Conclusions: Overall complication rates with ALS are relatively low, with the most common complications occurring at a rate of 1% to 3%. Complication rates are related to surgical technique, approach, and implant characteristics. Further randomized controlled trials are needed to validate the use of preventative measures including CTA and the use of an access surgeon.
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http://dx.doi.org/10.1016/j.spinee.2015.02.040DOI Listing
May 2015

AOSpine subaxial cervical spine injury classification system.

Eur Spine J 2016 07 26;25(7):2173-84. Epub 2015 Feb 26.

Catholic University of Parana, Curitiba, Brazil.

Purpose: This project describes a morphology-based subaxial cervical spine traumatic injury classification system. Using the same approach as the thoracolumbar system, the goal was to develop a comprehensive yet simple classification system with high intra- and interobserver reliability to be used for clinical and research purposes.

Methods: A subaxial cervical spine injury classification system was developed using a consensus process among clinical experts. All investigators were required to successfully grade 10 cases to demonstrate comprehension of the system before grading 30 additional cases on two occasions, 1 month apart. Kappa coefficients (κ) were calculated for intraobserver and interobserver reliability.

Results: The classification system is based on three injury morphology types similar to the TL system: compression injuries (A), tension band injuries (B), and translational injuries (C), with additional descriptions for facet injuries, as well as patient-specific modifiers and neurologic status. Intraobserver and interobserver reliability was substantial for all injury subtypes (κ = 0.75 and 0.64, respectively).

Conclusions: The AOSpine subaxial cervical spine injury classification system demonstrated substantial reliability in this initial assessment, and could be a valuable tool for communication, patient care and for research purposes.
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http://dx.doi.org/10.1007/s00586-015-3831-3DOI Listing
July 2016

Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naïve spinal surgeons.

Eur Spine J 2016 Apr 20;25(4):1082-6. Epub 2015 Jan 20.

School of Medicine, University of Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands.

Purpose: The aims of this study were (1) to demonstrate the AOSpine thoracolumbar spine injury classification system can be reliably applied by an international group of surgeons and (2) to delineate those injury types which are difficult for spine surgeons to classify reliably.

Methods: A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ).

Results: The overall Kappa coefficient for all cases was 0.56, which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility.

Conclusion: In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.
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http://dx.doi.org/10.1007/s00586-015-3765-9DOI Listing
April 2016

Variation in the management of thoracolumbar trauma and postoperative infection.

J Spinal Disord Tech 2015 May;28(4):E212-8

*The Rothman Institute, Thomas Jefferson University †Department of Orthopedic Surgery §Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA ‡Assistance Publique-Hôpitaux de Paris, Paris, France #Pontificia Universidade Catolica do Paraná, Curitiba, Brazil.

Study Design: Multinational survey of spine trauma surgeons.

Objectives: To survey spine trauma surgeons, examine the variety of management practices for thoracolumbar fractures, and investigate the need for future areas of study.

Background: Attempts to develop a universal thoracolumbar classification system represent the first step in standardizing treatment of thoracolumbar injuries, but there is little consensus regarding diagnosis and management of these injuries.

Methods: A survey questionnaire regarding a fictional neurologically intact patient with a burst fracture was administered to 46 spine surgeons. The questionnaire consisted of 2 domains: management of thoracolumbar fractures and management of postoperative infection. Survey results were compiled and evaluated and consensus arbitrarily assumed when the majority of surgeons agreed on a single question answer.

Results: Although majority consensus was reached on most questions, the interobserver reliability was poor. Consensus was achieved that magnetic resonance imaging should be performed during initial imaging. The majority would also operate regardless of magnetic resonance imaging findings, and would not operate at night. The favored technique was a posterior approach with decompression. Percutaneous fusion was considered a viable option by the majority of surgeons. No consensus was reached regarding instrumentation levels or construct length. The majority would use posterolateral bone grafting, and would not remove instrumentation nor perform an anterior reconstruction. Consensus was reached that postoperative bracing is unnecessary. Regarding management of infection, consensus was reached to use intraoperative vancomycin powder but not culture the nares before surgery. The majority used a set time period for antibiotic treatment when a drain was required, and would not apply supplementary bone graft at the time of final debridement and closure.

Conclusions: There is lack of consensus regarding the appropriate management of thoracolumbar fractures. In the future, multicenter prospective studies are necessary to establish guidelines for the management of thoracolumbar fractures.
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http://dx.doi.org/10.1097/BSD.0000000000000224DOI Listing
May 2015

Differential gene expression in anterior and posterior annulus fibrosus.

Spine (Phila Pa 1976) 2014 Nov;39(23):1917-23

*Department of Orthopaedics, Thomas Jefferson University, Philadelphia, PA †Rothman Institute, Philadelphia, PA; and ‡Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA.

Study Design: Laboratory study.

Objective: To evaluate the differential gene expression of cytokines and growth factors in anterior versus posterior annulus fibrosus (AF) intervertebral disc (IVD) specimens.

Summary Of Background Data: Histological analysis has demonstrated regional differences in vascular and neural ingrowth in the IVD, and similar differences may exist for cytokine and growth factor expression in patients with degenerative disc disease (DDD). Regional expression of these cytokines may also be related to the pain experienced in DDD.

Methods: IVD tissue was obtained from patients undergoing anterior lumbar interbody fusion surgery for back pain with radiological evidence of disc degeneration. For a control group, the discs of patients undergoing anterior lumbar discectomy for degenerative scoliosis were obtained as well. The tissue was carefully removed and separated into anterior and posterior AF. After tissue processing, an antibody array was completed to determine expression levels of 42 cytokines and growth factors.

Results: Nine discs from 7 patients with DDD and 5 discs from 2 patients with scoliosis were analyzed. In the DDD group, there were 10 cytokines and growth factors with significantly increased expression in the posterior AF versus the anterior AF ([interleukin] IL-4, IL-5, IL-6, M-CSF, MDC, tumor necrosis factor β, EGF, IGF-1, angiogenin, leptin). In the scoliosis group, only angiogenin and PDGF-BB demonstrated increased expression in the posterior AF. No cytokines or growth factors had increased expression in the anterior AF compared with posterior AF.

Conclusion: The posterior AF expresses increased levels of cytokines and growth factors compared with the anterior AF in patients with DDD. This differential expression may be important for targeting treatment of painful IVDs.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1097/BRS.0000000000000590DOI Listing
November 2014

Blood loss during posterior spinal fusion for adolescent idiopathic scoliosis.

Spine (Phila Pa 1976) 2014 Aug;39(18):1479-87

*Thomas Jefferson University/Rothman Institute, Philadelphia, PA †Rutgers University-New Jersey Medical School, Newark, NJ; and ‡Medstar Georgetown University Hospital, Washington, DC.

Study Design: Retrospective uncontrolled case series.

Objective: The purpose of this study was to determine the association, if any, between intraoperative blood loss and need for transfusion with the use of periapical (Ponte) osteotomies, as well as other patient and surgical variables among patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumentation and fusion.

Summary Of Background Data: Blood loss during posterior spinal fusion for AIS can be substantial. Numerous techniques are used to minimize intraoperative blood loss and the need for allogeneic transfusion. However, it is unclear which patient and surgeon variables affect blood loss most significantly.

Methods: A review was conducted on consecutive patients with AIS who had undergone posterior spinal fusion from July 1997 to February 2013 by a single primary surgeon at 1 institution. The relationship of estimated blood loss, normalized blood loss (normalized blood loss = estimated blood loss/number of levels fused/patient's weight in kilograms), autologous blood retrieved, and allogeneic transfusion received with various patient- and procedure-related variables were analyzed.

Results: Estimated blood loss, normalized blood loss, and autologous blood retrieved were higher in patients who underwent periapical Ponte osteotomies (n = 38) (P < 0.0001, P < 0.001, P < 0.01, respectively). The mean major curve correction was 64% in patients without osteotomies, and 65% in patients with osteotomies (P = 0.81). All patients who underwent osteotomies (38/38) received allogeneic transfusion versus 26% (19/73) of those without osteotomies (P < 0.001). The likelihood of transfusion correlated with increasing number of osteotomies and a lower preoperative hemoglobin level (odds ratio, 3.34; P = 0.003; and odds ratio, 0.51; P = 0.02, respectively).

Conclusion: In patients with AIS undergoing posterior spinal fusion with instrumentation, performing periapical osteotomies increased all measures of intraoperative blood loss and need for transfusion without substantially improving major curve correction. As expected, a lower preoperative hemoglobin level was observed in patients who received a blood transfusion after posterior instrumentation and fusion.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000000439DOI Listing
August 2014

Which Variables Are Associated With Patient-reported Outcomes After Discectomy? Review of SPORT Disc Herniation Studies.

Clin Orthop Relat Res 2015 Jun;473(6):2000-6

Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA.

Background: The Spine Patient Outcomes Research Trial (SPORT) evaluated the effects of surgery versus nonoperative treatment for lumbar intervertebral disc herniation (IDH), among other pathologies. Multiple subgroup analyses have been completed since the initial publications, which have further defined which patient factors lead to better or worse patient-reported outcomes; however, the degree to which these factors influence patient-reported outcomes has not been explored.

Questions/purposes: We reviewed the subgroup analyses of the SPORT IDH studies to answer the following questions: (1) What factors predicted improvement in patient-reported outcomes after operative or nonoperative treatment of lumbar IDH? (2) What factors predicted worse patient-reported outcomes compared to baseline after operative or nonoperative treatment of lumbar IDH? And (3) what factors influenced patient-reported outcomes of surgery in patients with lumbar IDH?

Methods: We conducted a MEDLINE(®) search to identify the subgroup analyses of the SPORT IDH data that were responsive to our study questions. Eleven articles were identified that met our search criteria.

Results: The patient factors associated with larger improvements in Oswestry Disability Index at 4 years with either surgical or nonoperative treatment included a higher baseline Oswestry Disability Index, BMI of less than 30, not being depressed, being insured, having no litigation pending, not having workers compensation, and having symptoms for less than 6 weeks, though there were others. Factors leading to improvement with surgical treatment were mostly related to anatomic characteristics of the disc herniation such as posterolateral and sequestered herniations. There were no patient or clinical factors identified that were associated with worse patient-reported outcomes compared to baseline after either operative or nonoperative treatment. At 2-year followup, the treatment effects were greater for those patients with upper-level herniations, patients not receiving workers compensation, and nondiabetic patients. In a 4-year multivariate analysis, being married, without joint problems, and having worse symptoms at baseline resulted in greater treatment effect with surgery.

Conclusions: While most patients with IDH will likely see improvement with either surgical or nonoperative treatment, there are patient-related factors that can help predict which subgroups will demonstrate a greater improvement with surgery, such as not having joint problems, being married, having worsening symptoms at baseline, and not having diabetes. These results can help providers and patients when discussing treatment options.

Level Of Evidence: Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1007/s11999-014-3671-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4419016PMC
June 2015

Intramedullary nailing of diaphyseal femur fractures secondary to gunshot wounds: predictors of postoperative malrotation.

J Orthop Trauma 2014 Dec;28(12):711-4

*Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, NYU Hospital for Joint Diseases, New York, NY; †Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Jefferson Medical Center, Rothman Institute, Philadelphia, PA; and ‡Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Hospital of the University of Pennsylvania, Philadelphia, PA.

Objectives: The purpose of this study was to determine significant factors that may impact the postoperative differences in femoral version (DFV) and differences in femoral length (DFL) between the fixed and uninjured sides after intramedullary nailing (IMN) secondary to gunshot wounds.

Design: Retrospective data registry study.

Setting: Academic level I trauma center.

Patients: Over a 10-year period, 417 patients underwent IMN of a diaphyseal femur fracture (OTA/AO 32A-C). Of these, 57 patients sustained fractures caused by gunshots and had a postoperative computed tomographic scanogram.

Main Outcome Measures: DFV and DFL. The effect of the following variables on DFV and DFL were determined through univariate and stepwise multivariate regression analyses: age, sex, body mass index, trauma fellowship-trained versus nontrauma surgeon, daytime versus nighttime surgery, antegrade versus retrograde nail insertion, use of traction, type of operating table, and AO and Winquist classifications.

Results: The mean postoperative DFV for all patients was 8.62 degrees (±6.67 degrees). Postoperative DFV greater than 15 degrees was found in 12.3% of all patients. After IMN, no significant differences in DFV were found with increasing complexity of AO/OTA or Winquist fracture classification. None of the aforementioned independent variables were significantly predictive of postoperative DFV in univariate or multivariate analyses. The mean postoperative DFL for all patients was 5.25 mm (±4.36 mm). In a multivariate model, classification as Winquist type 3 or 4 was weakly (adjusted R = 0.075) but significantly predictive of less DFL than categorization as type 1 or 2 (P = 0.027).

Conclusions: Although gunshot-associated femur fractures may present surgical challenges for treatment through IMN, acceptable femoral rotation and length are obtainable regardless of the fracture complexity or a variety of demographic and surgically-related variables.

Level Of Evidence: Prognostic level II.
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December 2014

Clinical and radiographic degenerative spondylolisthesis (CARDS) classification.

Spine J 2015 Aug 3;15(8):1804-11. Epub 2014 Apr 3.

Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 1015 Walnut St, Philadelphia, PA 19107, USA.

Background Context: Lumbar degenerative spondylolisthesis (DS) is a common, acquired condition leading to disabling back and/or leg pain. Although surgery is common used to treat patients with severe symptoms, there are no universally accepted treatment guidelines. Wide variation in vertebral translation, disc collapse, sagittal alignment, and vertebral mobility suggests this is a heterogeneous disease. A classification scheme would be useful to differentiate homogenous subgroups that may benefit from different treatment strategies.

Purpose: To develop and test the reliability of a simple, clinically useful classification scheme for lumbar DS.

Study Design: Retrospective case series.

Patient Sample: One hundred twenty-six patients.

Outcome Measures: Proposed radiographic classification system.

Methods: A classification system is proposed that considers disc space height, sagittal alignment and translation, and the absence or presence of unilateral or bilateral leg pain. Test cases were graded by six observers to establish interobserver reliability and regraded in a different order 1 month later to establish intraobserver reliability using Kappa analysis. To establish the relative prevalence of each subtype, a series of 100 consecutive patients presenting with L4-L5 DS were classified.

Results: Four radiographic subtypes were identified: Type A: advanced Disc space collapse without kyphosis; Type B: disc partially preserved with translation of 5 mm or less; Type C: disc partially preserved with translation of more than 5 mm; and Type D: kyphotic alignment. The leg pain modifier 0 denotes no leg pain, 1 denotes unilateral leg pain, and 2 represents bilateral leg pain. The Kappa value describing interobserver reliability was 0.82, representing near-perfect agreement. Intraobserver reliability analysis demonstrated Kappa=0.83, representing near-perfect agreement. Grading of the consecutive series of 100 patients revealed the following distribution: 16% Type A, 37% Type B, 33% Type C, and 14% Type D.

Conclusions: A new radiographic and clinical classification scheme for lumbar DS with high inter- and intraobserver reliabilites is proposed. Use of this classification scheme should facilitate communication to enhance the quality of outcomes research on DS.
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http://dx.doi.org/10.1016/j.spinee.2014.03.045DOI Listing
August 2015

In response.

Spine (Phila Pa 1976) 2014 Apr;39(7):631

Department of Orthopaedic Surgery, The Rothman Institute Philadelphia, PA The Rothman Institute, Thomas Jefferson University Philadelphia, PA Pennsylvania Spine Institute, Harrisburg, PA Pennsylvania Spine Institute, Harrisburg, PA Trident Regional Medical Center, Charleston, SC Trident Regional Medical Center, Charleston, SC.

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http://dx.doi.org/10.1097/BRS.0000000000000268DOI Listing
April 2014