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A retrospective cohort analysis of the effects of renin-angiotensin system inhibitors on spinal fusion in ACDF patients. Spine J 2019; 19:1354-1361. [PMID: 31059820 DOI: 10.1016/j.spinee.2019.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Recently, preclinical and clinical studies suggest an association between renin-angiotensin system (RAS) blockers and bone healing, particularly in the context of osteoporotic bone fractures. PURPOSE To determine the correlation between the use of RAS inhibitors and fusion outcomes and neurologic status in anterior cervical discectomy and fusion (ACDF) surgery. STUDY DESIGN Retrospective observational study. PATIENT SAMPLE Patients who underwent ACDF for degenerative disorders. OUTCOME MEASURES Spinal fusion status and neurologic function (modified Japanese Orthopedic Association [mJOA] and Nurick grading scales). METHODS A retrospective chart review was performed, including 200 patients who underwent ACDF for degenerative disorders with 1-year minimum follow-up. Demographic data, comorbidities, antihypertensive medication, neurologic examination, and fusion status were collected. Spinal fusion was assessed via plain cervical x-ray, resorting to dynamic radiographs and/or computer tomography (CT) in cases of uncertainty. Preoperative mJOA and Nurick scores and recovery rates were calculated to determine neurologic status. RESULTS Of the 200 patients (42.5% females, 57.5% males, median age of 53.7 years), 82 hypertensive patients were identified. Seventy-seven (93.9%) were taking antihypertensive medication as follows: 36.4% angiotensin-II receptor blockers (ARBs), 35.1% angiotensin-converting enzyme inhibitors (ACEIs), and the remaining patients were taking other medication. In the analysis of fusion rates, patients treated with ARBs exhibited a higher fusion rate, while those treated with ACEIs displayed a lower fusion rate compared to untreated nonhypertensive patients (p = .04 and .02, respectively). The difference in fusion rates between ARBs and ACEIs was also significant, with the former displaying higher rates (p < .001). Smoking exhibited a negative correlation with spinal fusion (p < .001). In the multivariate analysis, ARBs remained an independent factor for successful fusion (p = .02), while smoking remained a risk factor for failed fusion (p = .002). In the neurologic examination, ACEIs, hypertension status, and older age correlated with lower modified Japanese Orthopedic Association (mJOA) recovery rates (p = .001, <.001, and <.001, respectively) in the univariate analysis. CONCLUSIONS In ACDF patients, we observed that ARBs were associated with higher fusion rates. Conversely, ACEIs and smoking were related to failed fusion. Prospective case-control studies are needed to confirm these RAS inhibitors effects on spinal fusion.
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Chin KR, Pencle FJR, Quijada KA, Mustafa MS, Mustafa LS, Seale JA. Decreasing radiation dose with FluoroLESS Standalone Anterior Cervical Fusion. JOURNAL OF SPINE SURGERY 2019; 4:696-701. [PMID: 30714000 DOI: 10.21037/jss.2018.06.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Radiation dose continues to be a concern especially in the field of spine surgery, where anterior and posterior instrumentation is frequently utilized to treat multiple pathologies. The authors aim to demonstrate the feasibility of decreasing the radiation dose in standalone anterior cervical discectomy and fusion (ACDF). Methods Standalone ACDF (S-ACDF) with 48 consecutive patients (Group 1) with a comparison control group with ACDF with an anterior cervical plate (ACP) of 49 patients (Group 2). Fluoroscopy was performed for positioning, identification of level, placement of the implant, each screw, final AP and lateral images for the first 20 patients in Group 1. Screw placement could then be performed confidently based on cosine rule of cosine (Ѳ) = adj/hyp. Results Forty-eight patients in Group 1 (S-ACDF) and 49 patients in Group 2 (ACDF-ACP). Statistical significance not demonstrated for age, BMI or gender, P=0.691, 0.947 and 0.286 respectively. Mean radiation dose in group 1 of 17.9±6.6 mAs and 0.8±0.3 mSv was significantly less compared to group 2 which was 29.8±5.4 and 1.3±0.2 mSv, P<0.001. The average radiation dose for single-level fusion in Group 1 was 12.5±3.5 mAs and 0.5±0.1 mSv this is compared to Group 2 of 27.8±3.9 mAs and 1.2±0.2 mSv, P=0.001. The average radiation dose for two level fusion in Group 1 was 22.2±5.1 mAs and 0.9±0.2 mSv this is compared to Group 2 of 33.9±6.0 and 1.4±0.3 mSv, P=0.001. Conclusions In the outpatient setting, S-ACDF has shown a statistically significant intergroup difference in overall radiation dose, as well as single and two-level fusions, (P<0.001). We conclude that S-ACDF can decrease overall radiation exposure to patients.
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Affiliation(s)
- Kingsley R Chin
- Department of Orthopedics, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Florida, FL, USA.,Faculty of Sports Science, University of Technology, Kingston, Jamaica, WI, USA.,Department of Research, Less Exposure Surgery (LES) Society, Malden, MA, USA
| | - Fabio J R Pencle
- Faculty of Sports Science, University of Technology, Kingston, Jamaica, WI, USA.,Department of Research, Less Exposure Surgery (LES) Society, Malden, MA, USA
| | - Kathleen A Quijada
- Department of Research, Less Exposure Surgery (LES) Society, Malden, MA, USA
| | - Moawiah S Mustafa
- Department of Orthopedics, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Luai S Mustafa
- Department of Orthopedics, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Jason A Seale
- Department of Orthopedics, Less Exposure Surgery Specialists Institute (LESS Institute), Hollywood, FL, USA
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Kani KK, Chew FS. Anterior cervical discectomy and fusion: review and update for radiologists. Skeletal Radiol 2018; 47:7-17. [PMID: 29058045 DOI: 10.1007/s00256-017-2798-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 10/06/2017] [Accepted: 10/11/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The goals of this article are to describe the various types of interbody grafts and anterior cervical plating systems, techniques for optimizing evaluation of cervical spine metallic implants on CT and MR imaging, expected appearance and complications of ACDF on postoperative imaging and imaging assessment of fusion. Optimization for optimizing metal induced artifacts. CONCLUSION Currently, ACDF is the most commonly performed surgical procedure for degenerative cervical spine disease. Interbody fusion is performed with bone grafts or interbody spacers, and may be supplemented with anterior cervical plating. Compressive pathologies at the vertebral body level may be addressed by simultaneous corpectomy. Postoperatively, imaging plays an integral role in routine screening of asymptomatic individuals, fusion assessment and evaluation of complications.
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Affiliation(s)
- Kimia Khalatbari Kani
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Felix S Chew
- Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
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Snyder LA. Improving Intraoperative Fluoroscopic Visualization in Cervical Spine Surgery. World Neurosurg 2016; 92:533-534. [PMID: 27338212 DOI: 10.1016/j.wneu.2016.06.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 06/13/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Laura A Snyder
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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De Vloo P, Schrooten B, Daenekindt T, Deckers J, Peuskens D, Engelborghs K, Weyns F, Wuyts J. Intermittent Feet Dorsiflexion as a Simple Trick to Improve Cervical Fluoroscopic Visualization. World Neurosurg 2016; 92:548-551.e1. [PMID: 27241093 DOI: 10.1016/j.wneu.2016.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/16/2016] [Accepted: 05/18/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Anterior cervical surgery is routinely performed using fluoroscopy. Visualizing the lower cervical levels can be challenging, particularly in obese, muscular, and broad-shouldered patients. We found that grabbing both feet of the patient at the level of the metatarsals and cranially pushing the feet, creating dorsiflexion at the ankle joints, seems to increase the number of fluoroscopically visualized cervical levels. We aimed to measure the average change in fluoroscopically visualized levels when performing this maneuver. METHODS In 10 consecutive patients undergoing an anterior cervical discectomy and fusion procedure, we counted the number of fluoroscopically visualized cervical levels. Visible cervical levels in lateral fluoroscopic cervical images that were taken with and without the execution of the aforementioned maneuver were counted by 2 blinded observers. RESULTS Performing this maneuver added on average almost 1 vertebral body height to the fluoroscopic image. The additional number of fluoroscopically visible cervical levels was significantly higher in patients <50 years old but was not affected by sex or body mass index. CONCLUSIONS We propose a simple, convenient, and effective technique to increase the number of visualized cervical levels on lateral cervical fluoroscopy. This maneuver may have some advantages compared with other commonly used techniques.
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Affiliation(s)
- Philippe De Vloo
- Department of Neurosurgery, Ziekenhuis Oost-Limburg, Genk, Belgium; Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
| | | | | | - Jens Deckers
- Department of Neurosurgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Diedrik Peuskens
- Department of Neurosurgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Koen Engelborghs
- Department of Neurosurgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Frank Weyns
- Department of Neurosurgery, Ziekenhuis Oost-Limburg, Genk, Belgium; Department of Morphology, Faculty of Medicine, University of Hasselt, Hasselt, Belgium
| | - Jan Wuyts
- Department of Neurosurgery, Ziekenhuis Oost-Limburg, Genk, Belgium
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Derakhshan A, Lubelski D, Steinmetz MP, Benzel EC, Mroz TE. Utility of Computed Tomography following Anterior Cervical Diskectomy and Fusion. Global Spine J 2015; 5:411-6. [PMID: 26430596 PMCID: PMC4577315 DOI: 10.1055/s-0035-1554773] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 03/16/2015] [Indexed: 11/22/2022] Open
Abstract
Study Design Retrospective case series. Objective To assess the utility of postoperative computed tomography (CT) following anterior cervical diskectomy and fusion (ACDF) and to determine the clinical circumstances most likely to lead to an abnormal CT scan. Methods Patients who underwent ACDF at a tertiary center over a span of 5 years were investigated. Only patients who had a minimum of 6 months' postoperative follow-up and a CT within 2 years after the surgery were included in the study group. All the postoperative notes were reviewed to determine indications for the CT, abnormalities identified, and whether the scan led to an alteration in the treatment course. Results The charts of 690 patients who underwent ACDF were reviewed. Of the 690 patients, 45 (7%) had postoperative CTs. These patients accounted for 53 postoperative CT scans, 45 (85%) of which were taken for patients who expressed persistent postoperative symptoms and/or had abnormal imaging. There were no indications for 8 (15%) of the CTs. Patients who had a CT for persistent symptoms and/or abnormal preliminary imaging were significantly more likely to have an abnormal CT (p = 0.03) and/or an alteration in treatment course (p = 0.04) compared with those with no symptomatic or radiologic indication for CT. Conclusions CT is associated with minimal utility regarding the alteration of treatment course when employed in asymptomatic patients. Postoperative CT should be ordered solely for symptomatic patients or those with other abnormal preliminary imaging. Judicious use of postoperative CT will limit the radiation exposure and cost.
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Affiliation(s)
- Adeeb Derakhshan
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Daniel Lubelski
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Michael P. Steinmetz
- Department of Neurosciences and Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, United States
| | - Edward C. Benzel
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Thomas E. Mroz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States,Address for correspondence Thomas E. Mroz, MD Departments of Orthopaedic and Neurological SurgeryCenter for Spine Health, The Cleveland Clinic, 9500 Euclid Avenue, S-40, Cleveland, OH 44195United States
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Bohl DD, Lese AB, Patterson JT, Grauer JN, Dodds SD. Routine imaging after operatively repaired distal radius and scaphoid fractures: a survey of hand surgeons. J Wrist Surg 2014; 3:239-244. [PMID: 25364636 PMCID: PMC4208955 DOI: 10.1055/s-0034-1394131] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background There is currently no standard of care for imaging after hand and upper-extremity procedures, and current imaging practices have not been characterized. Questions/Purposes To characterize current imaging practices and to compare those practices to the best available evidence. Patients and Methods A survey was distributed to attending-level surgeons at a regional hand and upper-extremity surgery conference in the United States in 2013. 40 out of 75 surgeons completed the survey (53%). Results All results are presented for distal radius and scaphoid fractures, respectively. There was a high degree of variability between respondents in the number of radiographic series routinely ordered during follow-up of asymptomatic patients, with the number of series ranging from 1-6 and 1-6. On average, respondents did not order an excessive number of follow-up radiographs for asymptomatic patients, with means (± standard deviations) of 2.6 ± 1.0 and 3.3 ± 1.2 radiographic series. Radiographic series were taken at only 74% and 81% of postoperative visits with asymptomatic patients. Only 10% and 8% of respondents felt it was acceptable medical practice to save costs by ordering postoperative radiographs only when patients are symptomatic. Conclusions Among a sample of 40 fellowship-trained hand surgeons, these findings demonstrate a high degree of variability in number of radiographs obtained after operative repair of distal radius and scaphoid fractures. On average, respondents were relatively efficient with respect to total number of postoperative radiographs ordered. Level of Evidence Diagnostic study, level IV.
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Affiliation(s)
- Daniel D. Bohl
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Andrea B. Lese
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Joseph T. Patterson
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Seth D. Dodds
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
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Gruskay JA, Webb ML, Grauer JN. Methods of evaluating lumbar and cervical fusion. Spine J 2014; 14:531-9. [PMID: 24183750 DOI: 10.1016/j.spinee.2013.07.459] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 06/12/2013] [Accepted: 07/21/2013] [Indexed: 02/09/2023]
Abstract
Introduced in 1911, spinal fusion is now widely used to stabilize the cervical, thoracic, and lumbar spine. Despite advancements in surgical techniques, including the use of instrumentation and optimizing bone graft options, pseudarthrosis remains one of the most significant causes of clinical failure following attempted fusion. Diagnosis of this common complication is based on a focused clinical assessment and imaging studies. Pseudarthrosis classically presents with the onset of or return of axial or radicular symptoms during the first postoperative year. However, this diagnosis is complicated because other diagnoses can mimic these symptoms (such as infection or adjacent segment degeneration) and because many cases of pseudarthrosis are asymptomatic. Computed tomography and assessment of motion on flexion/extension radiographs are the two preferred imaging modalities for establishing the diagnosis of pseudarthrosis. The purpose of this article was to review the current status of imaging and clinical practices for assessing fusion following spinal arthrodesis.
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Affiliation(s)
- Jordan A Gruskay
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA
| | - Matthew L Webb
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA.
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