Publications by authors named "Joseph S Butler"

93 Publications

A Systematic Review of Risk Factors Associated With Distal Junctional Failure in Adult Spinal Deformity Surgery.

Clin Spine Surg 2021 Jul 7. Epub 2021 Jul 7.

School of Medicine, Royal College of Surgeons in Ireland School of Medicine, Trinity College Dublin National Spinal Injuries Unit, Department of Trauma and Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland Division of Orthopedics, Walter Reed National Military Medical Center, Washington, DC Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, CA Rothman Institute, Thomas Jefferson University, Philadelphia, PA Mayo Clinic, Department of Orthopedics, Rochester, MN School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.

Background: The surgical management of adult spinal deformity (ASD) is a major surgical undertaking associated with considerable perioperative risk and a substantial complication profile. Although the natural history and risk factors associated with proximal junctional kyphosis (PJK) and proximal junctional failure are widely reported, distal junctional failure (DJF) is less well understood.

Study Design: A systematic review was carried out.

Objectives: The primary objective is to identify the risk factors associated with DJF. The secondary objective is to delineate the incidence rate and causative factors associated with DJF.

Methods: A systematic review of articles in Medline/PubMed and The Cochrane Library databases was performed according to preferred reporting items for systematic reviews and meta-analyses guidelines. Data was collated to determine the prevalence of DJF and overall revision rates, and identify potential risk factors for development of DJF.

Results: Twelve studies were included for systematic review. There were 81/2261 (3.6%) cases of DJF. Overall, DJF represented 27.3% of all revision surgeries. Anterior-posterior surgery had a reduced incidence of postoperative DJF [5.0% vs. 8.7%; P=0.08; relative risk (RR)=1.73], as did patients below 60 years of age at the time of surgery (2.9% vs. 3.9%; P=0.09; RR=1.34). There was a higher incidence of DJF among those patients who received interbody fusion (9.9% vs. 5.1%; P=0.06; RR=1.93) compared with those who did not. However, none of these findings reached statistical significance. There were significantly more rates of DJF for fusions ending on L5 compared with constructs fused to the sacrum (11.7% vs. 3.6%; P=0.02; RR=3.28).

Conclusions: Cohorts 60 years and above of age at the time of surgery and patients managed with posterior-only fusion or interbody fusion have increased incidences of DJF. Fusion to L5 instead of the sacrum significantly influences DJF rates. However, the quality of available evidence is low and further high-quality studies are required to more robustly analyze the clinical, radiographic, and surgical risk factors associated with the development of DJF after ASD surgery.
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http://dx.doi.org/10.1097/BSD.0000000000001224DOI Listing
July 2021

The impact of the SARS-CoV-2 pandemic on referral characteristics in a national tertiary spinal injuries unit.

Ir J Med Sci 2021 Jun 11. Epub 2021 Jun 11.

National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.

Background: The SARS-CoV-2 pandemic has had profound implications on healthcare institutions.

Aims: This study aims to assess and compare referral patterns during COVID-19 to corresponding dates for the preceding 3 years (2017-2019), in order to preemptively coordinate the logistics of the surgical unit for similar future experiences.

Methods: Retrospective review for our institution, a national tertiary referral centre for spine pathology. Two distinct time-points were chosen to represent the varied levels of social restriction during the current pandemic: (i) study period 1 (SP1) from 11 November 2020 to 08 June 2020 represents a national lockdown, and (ii) study period 2 (SP2) from 09 June 2020 to 09 September 2020 indicates an easing of restrictions. Both periods were compared to corresponding dates (CP1: 11 March-08 June and CP2 09 June-09 September) for the preceding 3 years (2017-2019). Data collected included age, gender, and mechanism of injury (MOI) for descriptive analyses. MOIs were categorised into disc disease, cyclist, road-traffic-accident (RTA), falls < 2 m, falls > 2 m, malignancy, sporting injuries, and miscellaneous.

Results: All MOI categories witnessed a reduction in referral numbers during SP1: disc disease (-29%), cyclist (-5%), RTAs (-66%), falls < 2 m (-39%), falls > 2 m (-17%), malignancy (-33%), sporting injuries (-100%), and miscellaneous (-58%). Four of 8 categories (RTAs, falls < 2 m, malignancy, miscellaneous) showed a trend towards return of pre-lockdown values during SP2. Two categories (disc disease, falls > 2 m) showed a further reduction (-34%, -27%) during SP2. One category (sporting injuries) portrayed a complete return to normal values during SP2 while a notable increase in cyclist-related referrals was witnessed (+ 63%) when compared with corresponding dates of previous years.

Conclusion: Spinal injury continues to occur across almost all categories, albeit at considerably reduced numbers. RTAs and falls remained the most common MOI. Awareness needs to be drawn to the reduction of malignancy-related referrals to dissuade people with such symptoms from avoiding presentation to hospital over periods of social restrictions.
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http://dx.doi.org/10.1007/s11845-021-02678-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193012PMC
June 2021

Radiographic Measures of Spinal Alignment Are Not Predictive of the Development of C5 Palsy Following Anterior Cervical Discectomy and Fusion Surgery.

Int J Spine Surg 2021 Apr 1;15(2):213-218. Epub 2021 Apr 1.

Rothman Orthopaedic Institute, Philadelphia, Pennsylvania.

Background: Postoperative C5 palsy is a common complication following cervical decompression, occurring more frequently after posterior-based procedures. It has been theorized that this is the result of C5 nerve stretch resulting from spinal cord drift with these procedures. As such, it is thought to be less common after anterior cervical decompression and fusion (ACDF). However, no consensus has been reached on its true etiology. The purpose of this study is to assess the rate of C5 palsy following ACDF and to determine whether any radiographic or demographic parameters were predictive of its development.

Methods: Two hundred and twenty-six patients who received ACDF between September 2015 and September 2016 were reviewed, and 122 were included in the final analysis. Patient demographic, surgical, and radiographic data were analyzed, including preoperative and postoperative radiographic and motor examination results. The Mann-Whitney test was used to compare continuous variables between independent groups, and Fisher's exact test was used to compare categorical variables between groups.

Results: Seven patients developed a C5 palsy in the postoperative period, an incidence rate of 5.7%. Among the radiographic parameters evaluated, there were no statistically significant differences between the C5 palsy and nonpalsy groups. Additionally, there were no statistically significant differences in age, patient sex, or numbers of vertebral levels fused between groups.

Conclusions: Ultimately, we did not identify any statistically significant demographic or radiographic predictive factors for the development of C5 palsy following ACDF surgery.

Level Of Evidence: 3.
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http://dx.doi.org/10.14444/8029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8059402PMC
April 2021

A meta-analysis of the diagnostic accuracy of hounsfield units on computed topography relative to dual-energy X-ray absorptiometry for the diagnosis of osteoporosis in the spine surgery population.

Spine J 2021 Mar 13. Epub 2021 Mar 13.

National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, DN, Ireland; School of Medicine and Medical Science, University College Dublin, DN, Ireland.

Background: The preoperative identification of osteoporosis in the spine surgery population is of crucial importance. Limitations associated with dual-energy x-ray absorptiometry, such as access and reliability, have prompted the search for alternative methods to diagnose osteoporosis. The Hounsfield Unit(HU), a readily available measure on computed tomography, has garnered considerable attention in recent years as a potential diagnostic tool for reduced bone mineral density. However, the optimal threshold settings for diagnosing osteoporosis have yet to be determined.

Methods: We selected studies that included comparison of the HU(index test) with dual-energy x-ray absorptiometry evaluation(reference test). Data quality was assessed using the standardised QUADAS-2 criteria. Studies were characterised into 3 categories, based on the threshold of the index test used with the goal of obtaining a high sensitivity, high specificity or balanced sensitivity-specificity test.

Results: 9 studies were eligible for meta-analysis. In the high specificity group, the pooled sensitivity was 0.652 (95% CI 0.526 - 0.760), specificity 0.795 (95% CI 0.711 - 0.859) and diagnostic odds ratio was 6.652 (95% CI 4.367 - 10.133). In the high sensitivity group, the overall pooled sensitivity was 0.912 (95% CI 0.718 - 0.977), specificity was 0.67 (0.57 - 0.75) and diagnostic odds ratio was 19.424 (5.446 - 69.275). In the balanced sensitivity-specificity group, the overall pooled sensitivity was 0.625 (95% CI 0.504 - 0.732), specificity was 0.914 (0.823 - 0.960) and diagnostic odds ratio was 14.880 (7.521 - 29.440). Considerable heterogeneity existed throughout the analysis.

Conclusion: In conclusion, the HU is a clinically useful tool to aide in the diagnosis of osteoporosis. However, the heterogeneity seen in this study warrants caution in the interpretation of results. We have demonstrated the impact of differing HU threshold values on the diagnostic ability of this test. We would propose a threshold of 135 HU to diagnose OP. Future work would investigate the optimal HU cut-off to differentiate normal from low bone mineral density.
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http://dx.doi.org/10.1016/j.spinee.2021.03.008DOI Listing
March 2021

Impact of Sarcopenia on Degenerative Lumbar Spondylosis.

Clin Spine Surg 2021 Mar;34(2):43-50

The Mater Hospital, Dublin, Ireland.

Sarcopenia is characterized by progressive age-related and systematic loss of skeletal muscle mass, strength, and function. It was classified as an independent disease in 2016; thus, there is a sparsity of research on the association of sarcopenia with lower back pain and spinal diseases. Its prevalence is around 10% worldwide and it has been shown to be detrimental to quality of life in the elderly. Sarcopenia can be clinically identified by assessing muscle mass and physical performance measurements to show reduced strength (eg, grip strength chair rise and knee extensions) or function (eg, walking speed or distance). Radiographic imaging techniques such as computed tomography, ultrasound, or magnetic resonance imaging help diagnose sarcopenia in the lumbar spine by measuring either the cross-sectional area or the fatty infiltrate of the lumbar musculature. The presence of sarcopenia in patients preoperatively may lead to worse postoperative outcomes. Research in the treatment options for sarcopenia presurgery is still in its infancy but exercise (both aerobic and resistance exercise have been found to slow down the rate of decline in muscle mass and strength with aging) and nutrition have been utilized to varying success and show great promise in the future.
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http://dx.doi.org/10.1097/BSD.0000000000001047DOI Listing
March 2021

What Is the Superior Technique for Long Construct Spinopelvic Fixation in Adult Spinal Deformity Surgery: Iliac Screws or S2-Alar-Iliac Screws.

Clin Spine Surg 2020 Dec 7. Epub 2020 Dec 7.

National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital.

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http://dx.doi.org/10.1097/BSD.0000000000001121DOI Listing
December 2020

Regenerative Medicine Modalities for the Treatment of Degenerative Disk Disease.

Clin Spine Surg 2020 Dec 1. Epub 2020 Dec 1.

National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.

Degenerative disk disease is a pathologic state associated with axial skeletal pain, radiculopathy, and myelopathy, and will inevitably increase in prevalence in parallel with an aging population. The objective of regenerative medicine is to convert the inflammatory, catabolic microenvironment of degenerative disease into an anti-inflammatory, anabolic environment. This comprehensive review discusses and outlines both in vitro and in vivo efficacy of regenerative treatment modalities for degenerative disk disease, such as; mesenchymal stem cells, gene therapy, tissue engineering, and biologic treatments. To date, clinical applications have been limited secondary to a lack of standardized high quality clinical data. Additional research should focus on determining the optimal cellular makeup and concentration for each of these interventions. Nevertheless, modern medicine provides a new avenue of confronting disease, with methods surpassing traditional methods of removing the pathology in question, as regenerative medicine provides the opportunity to recover from the diseased state.
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http://dx.doi.org/10.1097/BSD.0000000000001114DOI Listing
December 2020

Methods to Mitigate Industry Influence in Industry Sponsored Research.

Clin Spine Surg 2021 May;34(4):143-145

National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.

Medical and surgical research has always had a long-standing relationship with industry-based funding from sources, such as drug and device companies. Concerns exist surrounding the association between funding sources, outcome from studies and publication bias. Studies demonstrating increased odds ratios associated with positive results in industry sponsored studies across medicine have stimulated Cochrane reviews, literature reviews and other articles to examine this relationship further. In spine surgery in particular, studies with positive results have an odds ratio of 3.3 of being published. This article discusses the biases associated with industry sponsorship, possible ways to reduce such biases and ways to improve transparency in research relationships. This article explores the types of bias that can be encountered at different stages of research including previous trials in spine surgery. The means of improving transparency including the Physician Payment Sunshine Act of 2010 and International Committee of Medical Journal Editors (ICJME) accreditation are discussed. We recognize that physicians undertaking industry sponsored research should be protected and not be liable to perverse incentives. We conclude that mitigating bias in industry sponsored research is a multistep process and needs a multifaceted approach. The main beneficiary of research should be patients and as such a collective effort from medical professionals, health care institutions, journals and industry should approach research, and publications with that in mind.
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http://dx.doi.org/10.1097/BSD.0000000000001098DOI Listing
May 2021

What Is the Optimal Surgical Treatment for Low-Grade Isthmic Spondylolisthesis? ALIF or TLIF?

Clin Spine Surg 2020 12;33(10):389-392

Spine Service, Department of Trauma & Orthopaedic Surgery, Tallaght University Hospital.

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http://dx.doi.org/10.1097/BSD.0000000000000926DOI Listing
December 2020

Does Conjugation With Structural Carriers Augment the Fusion Properties of Demineralized Bone Matrix?

Clin Spine Surg 2020 Jul 3. Epub 2020 Jul 3.

*Royal College of Surgeons in Ireland, St. Stephen's Green †School of Medicine, Trinity College Dublin ‡National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital §UCD School of Medicine & Medical Science, University College Dublin, Dublin, Ireland.

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http://dx.doi.org/10.1097/BSD.0000000000001043DOI Listing
July 2020

Two-stage anterior and posterior fusion versus one-stage posterior fusion in patients with Scheuermann's kyphosis.

Bone Joint J 2020 Oct;102-B(10):1368-1374

Spinal Deformity Unit, Royal National Orthopaedic Hospital, Stanmore, UK.

Aims: Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann's kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion.

Methods: A retrospective review of patients treated surgically for Scheuermann's kyphosis between 2006 and 2014 was performed. A total of 62 patients were identified, with 31 in each group. Parameters were compared to evaluate postoperative outcomes using chi-squared tests, independent-samples -tests, and z-tests of proportions analyses where applicable.

Results: There were six postoperative infections in the two-stage anteroposterior group compared with three in the one-stage posterior-only group. A total of four patients in the anteroposterior group required revision surgery, compared with six in the posterior-only group. There was a significantly higher incidence of junctional failure associated with the one-stage posterior-only approach (12.9% vs 0%, p = 0.036). Proximal junction kyphosis (anteroposterior fusion (74.2%) vs posterior-only fusion (77.4%); p = 0.382) and distal junctional kyphosis (anteroposterior fusion (25.8%) vs posterior-only fusion (19.3%), p = 0.271) are common postoperative complications following both surgical approaches.

Conclusion: A two-stage anteroposterior fusion was associated with a significantly greater correction of the kyphosis compared with a one-stage posterior-only fusion, with a reduced incidence of junctional failure (0 vs 3). There was a notably greater incidence of infection with two-stage anteroposterior fusion; however, all were medically managed. More patients in the posterior-only group required revision surgery. Cite this article: 2020;102-B(10):1368-1374.
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http://dx.doi.org/10.1302/0301-620X.102B10.BJJ-2020-0273.R3DOI Listing
October 2020

The Incidence, Risk Factors, and Complications Associated With Surgical Delay in Multilevel Fusion for Adult Spinal Deformity.

Global Spine J 2020 Sep 25:2192568220954395. Epub 2020 Sep 25.

Uniformed Services University-8395Walter Reed National Military Medical Center, Bethesda, MD, USA.

Study Design: Retrospective database review.

Objectives: The incidence and risk factors for surgical delay of multilevel spine fusion for adult spinal deformity (ASD), and the complications corresponding therewith, remain unknown. The objectives of this study are to assess the incidence and risk factors for unexpected delay of elective multilevel spinal fusions on the date of surgery as well as the postoperative complications associated with these delays.

Methods: We conducted a retrospective review of the ACS-NSQIP database on patients undergoing elective spinal instrumentation of greater than 7 levels for ASD between the years 2005 and 2015. Preoperative risk factors for delay and postoperative complications were compared between the cohorts of patients with and without surgical delays.

Results: Multivariate analysis of 1570 (15.6%) patients identified advanced age, male sex, American Society of Anesthesiologists (ASA) Class 4, and history of smoking as independent risk factors for delay. Patients experiencing surgical delay demonstrated longer operative times, increased intraoperative bleeding, longer hospitalizations, and significantly higher rates of postoperative complications. Patients experiencing delay demonstrated an almost 7-fold increase in mortality rate (3.4% vs 0.5%, < .001).

Conclusions: Delays in elective surgical care for spinal deformity are negatively related to patient outcomes. Advanced age, male sex, increased ASA class, and a history of smoking cigarettes place patients at risk for surgical delay of multilevel spinal fusion. Patients experiencing surgical delay are at higher risk for postoperative complications, including a 7-fold increase in mortality. These findings suggest that ASD surgery should be postponed in patients experiencing a delay, until modifiable risk factors can be medically optimized, and perhaps postponed indefinitely in those with nonmodifiable risk factors.
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http://dx.doi.org/10.1177/2192568220954395DOI Listing
September 2020

A Comparison of Revision Rates and Patient-Reported Outcomes for a 2-Level Posterolateral Fusion Augmented With Single Versus 2-Level Transforaminal Lumbar Interbody Fusion.

Global Spine J 2020 Dec 20;10(8):958-963. Epub 2019 Nov 20.

387400The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Study Design: Retrospective, single institution, multisurgeon case control series.

Objective: To determine whether there are differences in reoperation rates or outcomes for patients undergoing 2-level posterolateral fusion (PLF) augmented by a transforaminal lumbar interbody fusion (TLIF) at only one of the levels or at both.

Methods: A total of 416 patients were identified who underwent 2-level PLF with a TLIF at either one of those levels (n = 183) or at both (n = 233) with greater than 1-year follow-up. Demographic, surgical, radiographic, and clinical data was reviewed for each patient. These included age, sex, race, body mass index, smoking status, Charleston Comorbidity Index, operative time, estimated blood loss, length of stay, and patient-reported outcome measures.

Results: Each cohort underwent 24 reoperations. Although the number of overall reoperations was not significantly different ( > .05), among the reoperation types, there were significantly more reoperations for adjacent segment disease in the 2-level group compared to the 1-level group (19 vs 12, = .04). There was no difference in reoperation for pseudarthrosis between the groups ( > .05). Although both groups experienced significant improvements in Oswestry Disability Index ( < .001) and Short Form-12 health questionnaire ( < .001), there were no differences between improvements for 1- versus 2-level cohorts.

Conclusions: For patients undergoing 2-level PLF in the setting of a TLIF, using a TLIF at one versus both levels does not seem to influence reoperation rates or outcomes. However, reoperation rates for adjacent segment disease are increased in the setting of a 2-level PLF augmented by a 2-level TLIF.
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http://dx.doi.org/10.1177/2192568219889360DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645084PMC
December 2020

Advantages and Design of PROMIS Questionnaires.

Clin Spine Surg 2020 12;33(10):408-410

Spine Service, Department of Trauma & Orthopaedic Surgery, Tallaght University Hospital.

The Patient-Reported Outcomes Measurement Information System (PROMIS) is a National Institute of Health initiative to improve the measurement of clinically important symptoms and outcomes. Patient-Reported Outcomes capture health outcomes that are relevant to the daily functioning of the patient and include the monitoring of physical, mental, and social health. PROMIS offers a standardized tool to measure Patient-Reported Outcomes for use in both the clinical and research setting. It is a flexible and dynamic tool for both patient and clinician, and its use is continuing to grow internationally. This article discusses the rationale and design of this tool, as well as its advantages to both research and clinical practice.
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http://dx.doi.org/10.1097/BSD.0000000000001056DOI Listing
December 2020

What Is Finite Element Analysis?

Clin Spine Surg 2020 10;33(8):323-324

Department of Orthopaedic Surgery, Royal College of Surgeons in Ireland, Cappagh National Orthopaedic Hospital.

Finite element analysis is a computational technique to predict how different materials will react when a range of forces are applied. In the field of orthopedics, this technique has predominantly been used for implant design and testing. As the technology improves, increasing clinical applications are being developed, offering promise in the areas of surgical planning and the opportunity to tailor implants to individual patient characteristics. This article introduces the various preclinical mechanical tests available, as well as providing a brief overview of the finite element analysis technology.
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http://dx.doi.org/10.1097/BSD.0000000000001050DOI Listing
October 2020

Surgical Management of Thoracolumbar Burst Fractures: Surgical Decision-making Using the AOSpine Thoracolumbar Injury Classification Score and Thoracolumbar Injury Classification and Severity Score.

Clin Spine Surg 2021 02;34(1):4-13

Rothman Institute, Philadelphia, PA.

The management of thoracolumbar burst fractures is controversial with no universally accepted treatment algorithm. Several classification and scoring systems have been developed to assist in surgical decision-making. The most widely accepted are the Thoracolumbar Injury Classification and Severity Score (TLICS) and AOSpine Thoracolumbar Injury Classification Score (TL AOSIS) with both systems designed to provide a simple objective scoring criteria to guide the surgical or nonsurgical management of complex injury patterns. When used in the evaluation and treatment of thoracolumbar burst fractures, both of these systems result in safe and consistent patient care. However, there are important differences between the 2 systems, specifically in the evaluation of the complete burst fractures (AOSIS A4) and patients with transient neurological deficits (AOSIS N1). In these circumstances, the AOSpine system may more accurately capture and characterize injury severity, providing the most refined guidance for optimal treatment. With respect to surgical approach, these systems provide a framework for decision-making based on patient neurology and the status of the posterior tension band. Here we propose an operative treatment algorithm based on these fracture characteristics as well as the level of injury.
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http://dx.doi.org/10.1097/BSD.0000000000001038DOI Listing
February 2021

Discography or SPECT/CT: What is the Best Diagnostic Tool for the Surgical Assessment of Degenerative Disk Disease?

Clin Spine Surg 2020 Jul 8. Epub 2020 Jul 8.

School of Medicine & Medical Science, University College Dublin.

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http://dx.doi.org/10.1097/BSD.0000000000001042DOI Listing
July 2020

Are Carbon-fiber Implants More Efficacious Than Traditional Metallic Implants for Spine Tumor Surgery?

Clin Spine Surg 2020 May 15. Epub 2020 May 15.

National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital.

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http://dx.doi.org/10.1097/BSD.0000000000001007DOI Listing
May 2020

Timing of surgical fixation in traumatic spinal fractures.

Bone Joint J 2020 May;102-B(5):627-631

National Spinal Injuries Unit, Department of Trauma and Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland, UCD School of Medicine & Medical Science, Dublin, Ireland.

Aims: The timing of surgical fixation in spinal fractures is a contentious topic. Existing literature suggests that early stabilization leads to reduced morbidity, improved neurological outcomes, and shorter hospital stay. However, the quality of evidence is low and equivocal with regard to the safety of early fixation in the severely injured patient. This paper compares complication profiles between spinal fractures treated with early fixation and those treated with late fixation.

Methods: All patients transferred to a national tertiary spinal referral centre for primary surgical fixation of unstable spinal injuries without preoperative neurological deficit between 1 July 2016 and 20 October 2017 were eligible for inclusion. Data were collected retrospectively. Patients were divided into early and late cohorts based on timing from initial trauma to first spinal operation. Early fixation was defined as within 72 hours, and late fixation beyond 72 hours.

Results: In total, 86 patients underwent spinal surgery in this period. Age ranged from 16 to 88 years. Mean Injury Severity Score (ISS) was higher in the early stabilization cohort (p = 0.020). Age was the sole significant independent variable in predicting morbidity on multiple regression analysis (p < 0.003). There was no significant difference in complication rates based on timing of surgical stabilization (p = 0.398) or ISS (p = 0.482).

Conclusion: Our results suggest that these patients are suitable for early appropriate care with spinal precautions and delayed definitive surgical stabilization. Earlier surgery conferred no morbidity benefit and had no impact on length of stay. Cite this article: 2020;102-B(5):627-631.
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http://dx.doi.org/10.1302/0301-620X.102B5.BJJ-2019-1716.R1DOI Listing
May 2020

Surgeon proficiency in robot-assisted spine surgery.

Bone Joint J 2020 May;102-B(5):568-572

National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.

Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal. There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced. Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described. The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery. Cite this article: 2020;102-B(5):568-572.
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http://dx.doi.org/10.1302/0301-620X.102B5.BJJ-2019-1392.R2DOI Listing
May 2020

Do Equivalence Trials Display Superiority Over the Traditional Comparative Study Methods in Orthopedic Surgery?

Clin Spine Surg 2020 06;33(5):201-204

National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital.

Superiority and equivalence trials are 2 commonly encountered methods of designing randomized controlled trials. Traditionally, the goal of a randomized controlled trial is to show superiority. However, in more recent times, there has been a tendency to show equivalence in clinical randomized trials. These differing conclusions at first glance seem to be drawn on the basis of the results of the respective trials. However, to accurately reach these conclusions, there are stark contrasts in the methodologies of these different study types. This article provides a brief overview of superiority and equivalence trials, highlights the differences between the 2, and their relevance to orthopedic surgery.
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http://dx.doi.org/10.1097/BSD.0000000000000978DOI Listing
June 2020

Current Strategies for Reconstruction of Soft Tissue Defects of the Spine.

Clin Spine Surg 2020 02;33(1):9-19

Department of Plastic & Reconstructive Surgery, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.

Spinal surgery has been revolutionized by advances in instrumentation, bone graft substitutes, and perioperative care. Extensive dissection, creation of large areas of dead space, and the use of instrumentation in compromised patients, however, predisposes to high rates of wound complications. Postoperative wound complications in patients undergoing complex spinal surgery can have devastating sequelae, including hardware exposure, meningitis, and unplanned reoperation. Recognition of high-risk patients and prediction of wound closure difficulties, combined with preemptive reconstructive surgical strategies may prevent complications. The purpose of this review is to discuss the principles of spine wound management and provide a synopsis of the soft tissue reconstructive strategies utilized in spinal surgery. We review the senior author's preferred reconstructive algorithm for the management of these complex wounds, in addition to outcomes data relating to the timing of reconstructive surgery.
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http://dx.doi.org/10.1097/BSD.0000000000000936DOI Listing
February 2020

Is the Adoption of ERAS Protocols into Spinal Surgery Inevitable?

Clin Spine Surg 2020 06;33(5):175-178

School of Medicine, Trinity College Dublin.

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http://dx.doi.org/10.1097/BSD.0000000000000900DOI Listing
June 2020

Management of Herniated Lumbar Disk Disease and Cauda Equina Syndrome in Pregnancy.

Clin Spine Surg 2019 12;32(10):412-416

National Spinal Injuries Units, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital.

Lower back pain is a commonly reported symptom during pregnancy. However, herniated lumbar disk disease is an uncommon cause for such pain. Cauda equina syndrome (CES) during pregnancy is a rare clinical scenario. This review highlights the epidemiology, diagnostic and treatment strategies, and challenges encountered when managing herniated lumbar disk disease and CES in pregnancy. Magnetic resonance imaging is the diagnostic modality of choice. Nonoperative treatment strategies are successful in the vast majority of cases in patients with a herniated disk in the absence of CES. CES and progressive neurological deficits remain absolute indications for surgical intervention regardless of gestational age. For such patients or those with debilitating symptoms refractory to nonoperative treatment strategies, surgery has been demonstrated to be safe in the pregnant patient population. However, surgery should be performed with obstetric and midwifery support should complications occur to the fetus.
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http://dx.doi.org/10.1097/BSD.0000000000000886DOI Listing
December 2019

360-Degree Complex Primary Reconstruction Using Porous Tantalum Cages for Adult Degenerative Spinal Deformity.

Global Spine J 2019 Sep 21;9(6):613-618. Epub 2018 Nov 21.

Royal National Orthopaedic Hospital, Stanmore, UK.

Study Design: Retrospective cohort study.

Objective: To assess both implant performance and the amount of correction that can be achieved using multilevel anterior lumbar interbody fusion (ALIF).

Methods: Retrospective cohort study (n = 178) performed over a 4-year period. Surgical variables examined included blood loss, operative time, perioperative complications, and secondary/revision procedures. Follow-up radiographic assessment was performed to record implant-related problems. Radiographic parameters were examined pre- and postoperatively. Health-related quality of life (HRQOL) outcome measures were collected preoperatively and at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Descriptive and comparative statistical analysis, using paired-sample test and repeated-measures analysis of variance (rANOVA), was performed.

Results: Lumbar lordosis increased from 42° ± 17° preoperatively to 55° ± 11° postoperatively ( < .001). The visual analog scale back pain mean score improved from 8.3 ± 1.5 preoperatively to 2.6 ± 2.4 at 2 years ( < .001). The mean Oswestry Disability Index improved from 69.5 ± 21.5 preoperatively to 19.9 ± 15.2 at 2 years ( < .001). The EQ-5D mean score improved from 0.2 ± 0.2 preoperatively to 0.8 ± 0.1 at 2 years ( = .02). There were no neurological, vascular, or visceral approach-related injuries reported. No rod breakages and no symptomatic nonunions occurred. There was one revision procedure performed for fracture.

Conclusions: The use of porous tantalum cages as part of a 360-degree fusion to treat adult degenerative spinal deformity has been demonstrated to be a safe and effective strategy, leading to good clinical, functional, and radiographic outcomes in the short term.
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http://dx.doi.org/10.1177/2192568218814531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6693065PMC
September 2019

Image-guidance, Robotics, and the Future of Spine Surgery.

Clin Spine Surg 2020 06;33(5):179-184

Department of Trauma and Orthopaedic Surgery, National Spinal Injuries Units, Mater Misericordiae University Hospital.

Spine surgery has seen considerable advancements over the last 2 decades, particularly in the fields of image-guidance and robotics. These technologies offer the potential to overcome the various technical challenges in spinal surgery, such as physical and mental fatigue, hand tremor, difficulties with manual dexterity, and surgical precision. This review provides an overview of the image-guidance and robotics systems currently available. It will also provide an insight into the emerging technologies in development in the field of spine surgery. Image-guided and robotic-assisted surgical systems have been demonstrated to be safe, accurate, and time-efficient. Future advancements in the field include "augmented reality" systems, which build on these navigation platforms, but are yet to come to market. These developing technologies have considerable potential to improve the field of spine surgery. Further research is required in this area to determine superiority of these developing technologies over conventional techniques before widespread use should be adapted.
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June 2020

A systematic review of the presentation of scan-negative suspected cauda equina syndrome.

Surgeon 2020 Feb 11;18(1):49-52. Epub 2019 Jun 11.

Spine Service, Department of Trauma & Orthopaedic Surgery, Tallaght University Hospital, Dublin, Ireland; National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.

Background: A significant proportion of patients presenting with suspected cauda equina syndrome (CES) do not have associated radiological evidence to support the diagnosis, often termed 'scan-negative'. Due to the limited number of studies regarding the matter, there is no clear understanding for this presentation. As a result, no treatment protocol exists for the scan-negative group. The purpose of this review is to assess the potential contributing factors leading to the presentation of suspected CES with normal imaging.

Methods: A systematic review was conducted on PubMed and Cochrane databases. Bibliographies of key articles and Google Scholar were searched for additional results. The search strategy provided 204 results. Of those, 8 had no identifiable causation for suspected CES and were included for systematic review.

Results: 6 of 8 studies investigated for a difference in clinical presentation between cohorts that may indicate a normal scan. Studies were either inconclusive and contradictory. Two studies suggest a functional somatic disorder as reasoning for negative MRI, with positive provisional findings.

Conclusion: A psychogenic hypothesis is plausible and warrants further investigation. The need for additional studies is essential to scheming a potential treatment protocol for the scan-negative population, which currently does not exist.
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http://dx.doi.org/10.1016/j.surge.2019.04.003DOI Listing
February 2020

Timing of surgical fixation in traumatic spinal fractures: A systematic review.

Surgeon 2020 Feb 4;18(1):37-43. Epub 2019 May 4.

Spine Service, Department of Trauma & Orthopaedic Surgery, Tallaght University Hospital, Dublin, Ireland; National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.

Background: The optimal timing of fracture fixation following spinal injury is controversial. Many spinal fractures occur as part of polytrauma requiring a complex management strategy. Whilst the decision to stabilize unstable spinal column injuries is without debate, the duration between injury and definitive fixation can impact on the incidence of post-operative complications. This study was designed to systemically summarize and compare the complication profile of early vs late stabilization of spinal injuries, in an attempt to unveil an appropriate treatment protocol for traumatic spinal fractures.

Methods: A comprehensive search strategy was performed on the PubMed, Cochrane, and Google Scholar databases using key words. The search strategy provided 1120 results. Forty-six articles were reviewed for full-text. Reference lists were analysed for potential additional texts.

Results: Sixteen articles met the inclusion criteria and were included for systematic review. Studies were controversial and the overall result was inconclusive. Several studies favour early stabilisation to reduce post-surgical complication rates, especially in cases of patients with high Injury Severity Scale (ISS) scores. However, this is challenged by a small number of studies reporting a higher mortality rate in the early-stabilisation cohort.

Conclusion: Due to limited studies and a small overall cohort, the authors would cautiously recommend the early surgical fixation of unstable spine fractures in the stable trauma patient. For severely injured patients, the discordance among literature warrants the need for further investigation.
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February 2020
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