1
|
Fogel H, Yeritsyan D, Momenzadeh K, Kheir N, Yeung CM, Abbasian M, Lozano EM, Nazarian RM, Nazarian A. The Effect of Cannabinoids on Single-level Lumbar Arthrodesis Outcomes in a Rat Model. Spine J 2024:S1529-9430(24)00217-1. [PMID: 38704096 DOI: 10.1016/j.spinee.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND CONTEXT The opioid epidemic is a public health crisis affecting spine care and pain management. Medical marijuana is a potential non-opioid analgesic yet to be studied in the surgical setting since its effects on bone healing are not fully understood. Studies have demonstrated analgesic and potentially osteoinductive properties of cannabinoids with endocannabinoid receptor expression in bone tissue. PURPOSE We hypothesize that tetrahydrocannabinol (THC) and cannabidiol (CBD) will not decrease bone healing in spinal fusion. STUDY DESIGN Seventy-eight adult Sprague-Dawley rats were used for this study. Utilizing allogenic bone grafts (6 donor rats), posterolateral inter-transverse lumbar fusion at the L4-L5 level was performed. The animals were equally divided into four treatment groups, each receiving 0.1ml intraperitoneal injections weekly as follows: placebo (saline), 5mg/kg THC, 5mg/kg CBD, and a combination of 5mg/kg THC and 5mg/kg CBD (Combo). METHODS Callus tissue was harvested 2- and 8-weeks post-surgery for qPCR assessment to quantify changes in the expression of osteogenic genes. Manual palpation was done to assess the strength of the L4-L5 arthrodesis on all rats. μCT image-based callus analysis and histology were performed. One-way ANOVA followed by post hoc comparisons was performed. RESULTS μCT demonstrated no significant differences. Treatment groups had slightly increased bone volume and density compared to control. qPCR at two weeks indicated downregulated RANKL/OPG ratios skewing towards osteogenesis in the CBD group, with the THC and CBD+THC groups demonstrating a downward trend (P>0.05). ALPL, BMP4, and SOST were significantly higher in the CBD group, with CTNNB1 and RUNX2 also showing an upregulating trend. The CBD group showed elevation in Col1A1 and MMP13. Data at eight weeks showed ALPL, RUNX2, BMP4, and SOST were downregulated for all treatment groups. In the CBD+THC group, RANK, RANKL, and OPG were downregulated. OPG downregulation reached significance for the THC and CBD+THC group compared to saline. Interestingly, the RANKL/OPG ratio showed upregulation in the CBD and CBD+THC groups. RANKL showed upregulation in the CBD group. At 2 and 8 weeks, the CBD treatment group showed superior histological progression, increasing between time points. CONCLUSION This study demonstrates that CBD and THC have no adverse effect on bone healing and the rate of spinal fusion in rats. Osteogenic factors were upregulated in the CBD-treated groups at two weeks, which indicates a potential for bone regeneration. In this group, compared to control, the RANKL/OPG ratio at the early healing phase demonstrates the inhibition of osteoclast differentiation, enhancing bone formation. Interestingly, it shows promoted osteoclast differentiation at the later healing phase, enhancing bone remodeling. This aligns with the physiological expectation of a lower ratio in the early phases and a higher ratio in the later remodeling phases. CLINICAL SIGNIFICANCE CBD and THC showed no inhibitory effects on bone healing in a spinal fusion model. Moreover, histologic and gene expression analysis demonstrated that CBD may, in fact, enhance bone healing. Further research is needed to confirm the safe usage of THC and CBD in the post-operative setting following spinal fusions.
Collapse
Affiliation(s)
- Harold Fogel
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Diana Yeritsyan
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kaveh Momenzadeh
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Nadim Kheir
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Mohammadreza Abbasian
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Edith Martinez Lozano
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rosalynn M Nazarian
- The Pathology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ara Nazarian
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Yerevan State Medical University, Yerevan, Armenia.
| |
Collapse
|
2
|
Gupta A, Cha T, Schwab J, Fogel H, Tobert D, Bono CM, Hershman S. Response to Assessing impacts of gender on adverse postoperative outcomes in patients undergoing osteoporotic vertebral compression fracture surgery. Osteoporos Int 2022; 33:947-948. [PMID: 35061051 DOI: 10.1007/s00198-021-06243-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Anmol Gupta
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Mount Sinai Hospital, 1 Gustave L Levy Place, New York, NY, 10029, USA
| | - Thomas Cha
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Joseph Schwab
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Harold Fogel
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Daniel Tobert
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Christopher M Bono
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Stuart Hershman
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| |
Collapse
|
3
|
Xiong GX, Tobert D, Fogel H, Cha T, Schwab J, Shin J, Bono C, Hershman S. Open epidural blood patch to augment durotomy repair in lumbar spine surgery: surgical technique and cohort study. Spine J 2021; 21:2010-2018. [PMID: 34144204 DOI: 10.1016/j.spinee.2021.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/18/2021] [Accepted: 06/11/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Incidental durotomy during elective spine surgery is relatively common. While usually benign and self-limited, it can be associated with morbidity, increased cost, and medicolegal ramifications. Dural repair typically involves performing a primary closure using a suture or dural staple; repairs are then frequently augmented with a sealant, patch, or fat/fascial graft. Although primary repair of an incidental durotomy is standard practice, the ideal secondary sealant or augment choice remains unclear. A wide variety of commercially available dural sealant options exist, and while none have demonstrated consistent superiority, all are associated with single-use costs in the hundreds to thousands of dollars and have concerns regarding swelling, local inflammation, or short-lived dural adherence. PURPOSE The goal of this study is to compare the results of dural repair augmentation using an open intraoperative epidural blood patch to a hydrogel technique. STUDY DESIGN/SETTING Retrospective comparative cohort study at an academic referral center PATIENT SAMPLE: Adult patients undergoing lumbar spine surgery from March 2017 to January 2021 who sustained an incidental durotomy. Patients undergoing surgery for infection were excluded. OUTCOME MEASURES The primary outcome was failure of the repair as determined by a return to the operating room for re-exploration of a persistent cerebrospinal fluid (CSF) leak within 30 days of the index procedure. A secondary outcome was the incidence of a postoperative positional headache, and if present, the method used to obtain resolution. The primary predictor was use of a suture and hydrogel technique ("hydrogel" group), or the use of an epidural blood patch ("EBP" group). METHODS The method for applying an open epidural blood patch is presented in detail and involves primarily repairing the durotomy followed by allowing whole blood to pool and clot in the operative field until the durotomy is completely covered. This was compared with a group of patients undergoing secondary augmentation with commercially available hydrogel. In both groups, mechanical resistance to CSF leakage was confirmed with direct visualization and a Valsalva maneuver, respectively. Patients were instructed to remain flat until the morning after surgery. Chart review was used for data abstraction on preoperative, demographic, perioperative, and postoperative clinical factors. To compare between the hydrogel and EBP group, Wilcoxon rank-sum testing was used to test for non-parametric comparisons of means, and chi-square testing between binomial data. RESULTS Of 732 patients during the study period, forty-eight patients met study criteria. Twenty-five patients were in the hydrogel group and 23 in the EBP group. Mean age was 69.3 years (standard error 1.3 years). Patients were predominantly female (n = 31, 64.6%) with a mean BMI of 29.5 (SE 0.8), with no significant baseline differences between the hydrogel and EBP groups. Two patients in the hydrogel group (8.0%) and two in the EBP group (8.7%) had mild positional headaches postoperatively that resolved without intervention within 24 hours. One (4.3%) patient in the EBP group had positional headaches following an initial headache-free period; this patient was returned to the operating room and no evidence of a persistent CSF leak was found despite meticulous exploration. CONCLUSIONS An open, intraoperatively placed epidural blood patch may be an efficacious and cost-effective way to manage an incidental durotomy. This method merits further study as an allergy-free, no swell, cost-neutral method of dural repair augmentation.
Collapse
Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Boston, MA
| | | | | | - Thomas Cha
- Massachusetts General Hospital, Boston, MA
| | | | - John Shin
- Massachusetts General Hospital, Boston, MA
| | | | | |
Collapse
|
4
|
Gupta A, Cha T, Schwab J, Fogel H, Tobert D, Qureshi S, Hecht A, Bono CM, Hershman S. Age Is Just a Number: Patient Age Does Not Affect Outcome Following Surgery for Osteoporotic Vertebral Compression Fractures. Global Spine J 2021; 11:1083-1088. [PMID: 32762371 PMCID: PMC8351062 DOI: 10.1177/2192568220941451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE Multiple studies have shown that osteoporotic patients are at an increased risk for medical and surgical complications, making optimal management of these patients challenging. The purpose of this study was to determine the relationship between patient age and the likelihood of surgical complications, mortality, and 30-day readmission rates following surgery for osteoporotic vertebral compression fractures (OVCFs). METHODS A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database from 2007 to 2014 identified 1979 patients who met inclusion criteria. A multivariate logistic regression analysis was conducted to calculate odds ratios (OR), with corresponding P values and 95% confidence intervals, of the relationship between age (treated as a continuous variable) and perioperative mortality, surgical complications, and 30-day readmission rates. RESULTS Younger patients were statistically more likely to endure a minor (OR = 0.98; P = .002) or major complication (OR = 0.97; P = .009). The older a patient was, on the other hand, the higher the likelihood that patient would be readmitted within 30 days of surgery (OR =1.02; P = .004). Mortality within the 30-day perioperative period was not statistically correlated with age. CONCLUSIONS The impact of age on adverse outcomes following surgery for OVCF is mixed. While younger patients are more likely to endure complications, older patients are more likely to be readmitted within 30 days following surgery. Patient age showed no correlation with mortality rates. In the setting of surgical treatment for an OVCF, a patient's age can help determine the risk of complications and the rate of readmission following intervention.
Collapse
Affiliation(s)
- Anmol Gupta
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY, USA,Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas Cha
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph Schwab
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Harold Fogel
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel Tobert
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Sheeraz Qureshi
- Weill Cornell Medical College, Hospital for Special Surgery, New York, NY, USA
| | - Andrew Hecht
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY, USA
| | | | - Stuart Hershman
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA,Stuart Hershman, Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
5
|
Gupta A, Cha T, Schwab J, Fogel H, Tobert D, Razi AE, Paulino C, Bono CM, Hershman S. Quantifying the Impact of Comorbidities on Outcomes Following Surgery for Osteoporotic Vertebral Compression Fractures. Journal of Clinical Interventional Radiology ISVIR 2021. [DOI: 10.1055/s-0041-1729466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Abstract
Introduction Studies have shown that osteoporotic patients are more likely to have medical or surgical complications postoperatively. In this study, we determine the predictive value of various comorbidities on the likelihood of postoperative complications, mortality, and 30-day readmission following cement augmentation for osteoporotic vertebral compression fractures (OVCFs).
Materials and Methods A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database from 2007 to 2014 identified 1979 patients who met inclusion criteria. A multivariate logistic regression analysis was utilized to determine the relationship between various comorbidities and perioperative mortality, postoperative complications, and 30-day readmission rates.
Results A history of cerebrovascular accident (CVA), coagulopathy, diminished preoperative functional status, and/or an American Society of Anesthesiologists (ASA) class > 2 were statistical predictors of postoperative complications. CVA generated the highest odds ratio among these comorbidities (OR = 5.36, p = 0.02 for minor complications; OR = 4.60 p = 0.05 for major complications). Among the 15 comorbidities considered, steroid use (OR =1.81; p = 0.03) and an ASA class > 2 (OR = 14.65; p = 0.01) were the only ones that were correlated with mortality; an ASA class > 2 had a particularly strong effect on the likelihood of mortality (OR = 14.65). Chronic obstructive pulmonary disorder (COPD), obesity, significant weight loss, and an ASA class > 2 were correlated with 30-day readmissions. Congestive heart failure (CHF), diabetes, dialysis, hypertension, or smoking was not correlated with adverse postoperative outcomes.
Conclusion Of the 15 comorbidities considered in this study, four were statistically associated with increased rates of postoperative complications, two were associated with increased mortality, and four were associated with increased rates of readmission at 30 days. The presence of CHF, diabetes mellitus (DM), hypertension, ascites, renal failure, or smoking were not associated with the adverse outcomes studied.
Level of Evidence III.
Collapse
Affiliation(s)
- Anmol Gupta
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Thomas Cha
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Joseph Schwab
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Harold Fogel
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Daniel Tobert
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Afshin E. Razi
- Department of Orthopaedics, Maimonides Bone and Joint Center, Maimonides Medical Center, Brooklyn, New York, United States
| | - Carl Paulino
- Department of Orthopaedic Surgery, SUNY Downstate Health Sciences University, NYP Brooklyn Methodist Hospital, Brooklyn, New York, United States
| | - Christopher M. Bono
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Stuart Hershman
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| |
Collapse
|
6
|
Gupta A, Cha T, Schwab J, Fogel H, Tobert D, Cho S, Hecht A, Bono CM, Hershman S. Males Have Higher Rates of Peri-operative Mortality Following Surgery for Osteoporotic Vertebral Compression Fracture. Osteoporos Int 2021; 32:699-704. [PMID: 32929524 DOI: 10.1007/s00198-020-05630-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/01/2020] [Indexed: 11/29/2022]
Abstract
UNLABELLED In this study, we evaluated the association between sex and the incidence of postoperative mortality in the peri-operative period following surgical intervention for OVCF. We found no statistical association between surgical complications and patient sex. However, males exhibited higher rates of mortality and 30-day readmissions relative to females. INTRODUCTION Osteoporotic vertebral compression fractures (OVCF) contribute substantially to the financial burden of the US healthcare system. As the size of the elderly population grows, the number of fractures attributed to osteoporosis is expected to increase. Studies have shown that osteoporotic patients are at an increased risk for medical and surgical complications. The purpose of this study was to evaluate the association between sex and the incidence of postoperative mortality in the peri-operative period following surgical intervention for OVCF. METHODS A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database from 2007 to 2014 identified 1979 patients. Patients were grouped as male or female. Mortality within 30 days of surgery due to any cause, incidence of surgical complications, and 30-day readmission rates following surgery were tabulated. A multivariate logistic regression analysis was conducted to calculate odds ratios (OR) with corresponding p values and 95% confidence intervals. RESULTS In total, 1979 patients met inclusion and exclusion criteria. Mortality within the 30 days following surgery for OVCF was statistically greater in men than in women (OR = 1.58; p = 0.050). The 30-day readmission rate was also statistically higher in men (OR = 1.41; p = 0.017). Neither minor (OR = 0.90; p = 0.560) nor major (OR = 1.14; p = 0.569) complications were statistically correlated with sex. On average, men underwent surgery for OVCF at a younger age than women. CONCLUSIONS Male patients undergoing surgery for OVCF have higher rates of peri-operative mortality and 30-day readmissions following surgery. Sex was not found to be associated with postoperative complications. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- A Gupta
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Mount Sinai Hospital, 425 West 59th St., New York, NY, 10019, USA
| | - T Cha
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
| | - J Schwab
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
| | - H Fogel
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
| | - D Tobert
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
| | - S Cho
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Mount Sinai Hospital, 425 West 59th St., New York, NY, 10019, USA
| | - A Hecht
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Mount Sinai Hospital, East 98th St., New York, NY, 10029, USA
| | - C M Bono
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
| | - S Hershman
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA.
| |
Collapse
|
7
|
Gupta A, Cha T, Schwab J, Fogel H, Tobert DG, Razi AE, Paulino C, Hecht AC, Bono CM, Hershman S. Osteoporosis is under recognized and undertreated in adult spinal deformity patients. J Spine Surg 2021; 7:1-7. [PMID: 33834122 DOI: 10.21037/jss-20-668] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Adult spinal deformity (ASD) patients may have osteoporosis, predisposing them to an increased risk for surgical complications. Prior studies have demonstrated that treating osteoporosis improves surgical outcomes. In this study we determine the prevalence of osteoporosis in ASD patients undergoing long spinal fusions and the rate at which osteoporosis is treated. Methods ASD patients who frequented either of two major academic medical centers from 2010 through 2019 were studied. All study participants were at least 40 years of age and endured a spinal fusion of at least seven vertebral levels. Medical records were explored for a diagnosis of osteoporosis via ICD-10 code and, if present, whether pharmacological treatment was prescribed. T-tests and chi-squared analyses were used to determine statistical significance. Results Three hundred ninety-nine patients matched the study's inclusion criteria. Among this group, 131 patients (32.8%) had been diagnosed with osteoporosis prior to surgery. With a mean age of 66.4 years, osteoporotic patients were on average three years older than non-osteoporotic (P=0.002) and more likely to be female (74.8% vs. 61.9%; P=0.01). At the time of surgery, 34.4% of osteoporotic patients were receiving pharmacological treatment. Although not statistically significant, women were more likely to receive medical treatment than men (P=0.07). Conclusions The prevalence of osteoporosis in ASD patients undergoing a long spinal fusion is substantially higher than that of the general population. Surgeons should have a low threshold for bone density testing in ASD patients. With only about one-third of osteoporotic patients treated, there is a classic "missed opportunity" in this population.
Collapse
Affiliation(s)
- Anmol Gupta
- Department of Orthopaedics, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Cha
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph Schwab
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harold Fogel
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel G Tobert
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Afshin E Razi
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Maimonides Bone and Joint Center, Maimonides Medical Center, Brooklyn, NY, USA
| | - Carl Paulino
- Department of Orthopaedic Surgery, Fe Health Sciences University, New York-Presbyterian (NYP) Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Andrew C Hecht
- Department of Orthopaedics, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher M Bono
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stuart Hershman
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
8
|
Xiong G, Fogel H, Tobert D, Cha T, Schwab J, Bono C, Hershman S. Vancomycin-impregnated calcium sulfate beads compared with vancomycin powder in adult spinal deformity patients undergoing thoracolumbar fusion. North American Spine Society Journal (NASSJ) 2021; 5:100048. [PMID: 35141614 PMCID: PMC8819864 DOI: 10.1016/j.xnsj.2020.100048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/16/2020] [Accepted: 12/23/2020] [Indexed: 10/26/2022]
|
9
|
Gupta A, Cha T, Schwab J, Fogel H, Tobert D, Razi AE, Hecht A, Bono CM, Hershman S. Osteoporosis increases the likelihood of revision surgery following a long spinal fusion for adult spinal deformity. Spine J 2021; 21:134-140. [PMID: 32791242 DOI: 10.1016/j.spinee.2020.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/10/2020] [Accepted: 08/05/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Adult spinal deformity (ASD) can be a debilitating condition that requires surgical intervention. ASD patients often present with osteoporosis, predisposing them to increased rates of instrumentation failure and postoperative fractures, frequent reasons for revision surgery. We hypothesized that the rate and timing of revision surgery are different in osteoporotic and nonosteoporotic patients undergoing long fusions for ASD. To our knowledge, the timing of revision surgeries, in particular, have not previously been explored. PURPOSE To determine the rate and timing of revision surgery in osteoporotic and nonosteoporotic patients following a long fusion for ASD. STUDY DESIGN Retrospective comparative study. PATIENT SAMPLE ASD patients who underwent a long spinal fusion surgery at two large academic medical centers from 2010 to 2019. OUTCOME MEASURES Occurrence of revision surgery. METHODS Inclusion criteria were patient age of least 40 years and spinal fusion spanning at least seven levels for ASD. Patient records were reviewed for a diagnosis of osteoporosis as per ICD codes and revision surgery within 2 years of the index procedure. Revision surgery was defined as an unplanned procedure related to the index surgery for the treatment of a spine-related complication. Chi-squared tests comparing demographic data, revision rates, and multiple revisions were conducted. The incidence and prevalence of revision surgeries as a function of time and osteoporotic status were evaluated for significant differences via the Mann-Whitney U and Mantel-Haenszel log rank tests. Finally, a logistic regression analysis was utilized to determine the predictive value of osteoporosis, age, and gender on the likelihood for complications. RESULTS Three hundred ninety-nine patients matched the study criteria. In the osteoporotic group, 40.5% of patients underwent a revision surgery compared to 28.0% in the nonosteoporotic group (p=.01). The occurrence of multiple revision surgeries following the index procedure was similar in both groups: 8.4% in osteoporotic patients and 8.6% in nonosteoporotic patients. Age and gender were not statistically correlated with the incidence of revision surgery. CONCLUSIONS ASD patients with osteoporosis have an increased risk of undergoing revision for a surgery-related complication within 2 years of the index procedure. These complications included failure of hardware, pseudoarthrosis, proximal junction failure, and infection, among other issues that required surgical intervention. As others have also highlighted the importance of poor bone density on construct failure, our data further underscore the importance of preoperative osteoporosis surveillance. Though intuitive, further study is needed to demonstrate that improving patients' bone density can decrease the incidence of related complications and the need or revision surgery.
Collapse
Affiliation(s)
- Anmol Gupta
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Thomas Cha
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Joseph Schwab
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Harold Fogel
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Daniel Tobert
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Afshin E Razi
- Department of Orthopaedics, Maimonides Bone and Joint Center, Maimonides Medical Center, 6010 Bay Pkwy, Brooklyn, NY 11204, USA
| | - Andrew Hecht
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, 5 East 98th St, New York, NY 10029, USA
| | - Christopher M Bono
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Stuart Hershman
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA.
| |
Collapse
|
10
|
Fogel H, Golz A, Burleson A, Muriuki M, Havey R, Carandang G, Patwardhan A, Tonino P. A Biomechanical Analysis of Tibial Fixation Methods in Hamstring-Graft Anterior Cruciate Ligament Reconstruction. Iowa Orthop J 2019; 39:141-147. [PMID: 31413687 PMCID: PMC6604523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND There are conflicting results on the biomechanical properties of tibial fixation devices in anterior cruciate ligament reconstruction. The objective of this study is to compare the initial biomechanical properties of tibial fixation in hamstring-graft ACL reconstruction with interference screw, suspension button, and Tape Locking ScrewTM devices. We hypothesized there are no differences in the initial biomechanical properties of these three tibial fixation techniques. METHODS Twenty-one fresh-frozen porcine tibiae were equally divided into three groups of seven tibiae to evaluate the fixation of human hamstring tendon grafts with interference screw, suspension button, or Tape Locking Screw fixation. Using a servohydraulic materials testing system, each graft was subjected to 500 cycles of loading followed by a monotonic failure test. RESULTS Interference screw fixation demonstrated significantly lower cyclic displacement (1.28 ± 0.73 mm) than the other groups fixated with either a suspension button device (2.54 ± 0.27 mm, p = 0.003) or a Tape Locking Screw (2.32 ± 0.42 mm, p = .009), and a significantly greater cyclic stiffness (212.19 ± 40.30 N/mm) than the Tape Locking Screw (137.64 ± 26.17 N/mm, p = 0.002). The interference screw also demonstrated significantly higher pullout stiffness (166.83 ± 23.22 N/mm) than the suspension button (112.78 ± 24.14 N/mm, P = 0.002) and Tape Locking Screw (109.11 ± 12.91 N/mm, P = 0.0002). CONCLUSIONS Tibial fixation with an interference screw demonstrated superior biomechanical properties for cyclic testing compared to the suspension button and Tape Locking Screw. Load to failure did not differ between groups, and there were no significant biomechanical differences between the suspension button and Tape Locking Screw fixation devices. CLINICAL RELEVANCE Despite the initial biomechanical differences, all three fixation devices exhibited mean loads to failure and cyclic displacements below clinically relevant thresholds of failure. These data suggest all three fixation methods are viable options for achieving a functional ACL reconstruction.Level of Evidence: V.
Collapse
Affiliation(s)
- H Fogel
- Massachusetts General Hospital, Harvard Medical School, Department of Orthopaedic Surgery, Boston, MA USA
| | - A Golz
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL USA
| | - A Burleson
- Beacon Orthopaedics and Sports Medicine, Sharonville, OH USA
| | - M Muriuki
- United States Department of Veterans Affairs, Musculoskeletal Biomechanics Laboratory, Edward Hines Jr. VA Hospital, Hines, IL USA
| | - R Havey
- United States Department of Veterans Affairs, Musculoskeletal Biomechanics Laboratory, Edward Hines Jr. VA Hospital, Hines, IL USA
| | - G Carandang
- United States Department of Veterans Affairs, Musculoskeletal Biomechanics Laboratory, Edward Hines Jr. VA Hospital, Hines, IL USA
| | - A Patwardhan
- United States Department of Veterans Affairs, Musculoskeletal Biomechanics Laboratory, Edward Hines Jr. VA Hospital, Hines, IL USA
| | - P Tonino
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL USA
| |
Collapse
|
11
|
Fogel H, Ehri LC. Teaching Elementary Students Who Speak Black English Vernacular to Write in Standard English: Effects of Dialect Transformation Practice. Contemp Educ Psychol 2000; 25:212-235. [PMID: 10753547 DOI: 10.1006/ceps.1999.1002] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although nonstandard dialects of English are legitimate forms of spoken language used by many Americans, students in U.S. schools must acquire writing competence using Standard English (SE). Participants in this study were 3rd- and 4th-grade African-American students who exhibited Black English Vernacular (BEV) features in their written work. Six syntactic features differing in BEV and SE were targeted. Students received one of three treatments to increase their use of the SE features in their writing: (1) exposure to SE features in stories; (2) story exposure plus explanation of SE rules; and (3) story exposure, SE rule instruction, and guided practice transforming sentences from BEV to SE features. The third treatment proved most effective in enabling students to translate BEV sentences into SE forms and to employ the targeted SE features in their free writing. Results indicate that having students practice translating nonstandard sentences that typify their own writing and providing corrective feedback are effective for teaching them to use SE forms in their writing. Findings are interpreted to support a social-cognitive view of self-regulated learning. Copyright 2000 Academic Press.
Collapse
|
12
|
Abstract
OBJECTIVE Whether glucagonlike peptide-I-(7-37) (GLP-I-[7-37]), a naturally occurring intestinal peptide, is insulinotropic in nondiabetic and non-insulin-dependent (type II) diabetic subjects. RESEARCH DESIGN AND METHODS GLP-I-(7-37) or saline placebo was infused (1-5 ng.kg-1.min-1 for 30 min) in 4 nondiabetic and 11 type II diabetic subjects in the fasting and prandial state. Glucose, insulin, and GLP-I-(7-37) levels were measured. RESULTS GLP-I-(7-37) infusion resulted in a 3- to 10-fold increase in peak insulin levels and in insulin area under the curve in nondiabetic and diabetic subjects. In diabetic subjects, infusion concurrent with a standard meal eliminated the postprandial glucose excursion for 60 min after the meal. Insulin-releasing potency of GLP-I-(7-37) was attenuated at decreased glucose levels. CONCLUSIONS GLP-I-(7-37) has potent insulinotropic effects in nondiabetic and diabetic subjects. Whether GLP-I-(7-37) is useful as a therapeutic medication in type II diabetes requires further investigation.
Collapse
Affiliation(s)
- D M Nathan
- Diabetes Unit, Massachusetts General Hospital, Boston 02114
| | | | | | | | | |
Collapse
|
13
|
Nathan DM, Fogel H, Norman D, Russell PS, Tolkoff-Rubin N, Delmonico FL, Auchincloss H, Camuso J, Cosimi AB. Long-term metabolic and quality of life results with pancreatic/renal transplantation in insulin-dependent diabetes mellitus. Transplantation 1991; 52:85-91. [PMID: 1858159 DOI: 10.1097/00007890-199107000-00018] [Citation(s) in RCA: 90] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Evaluation of whole-organ pancreas transplantation in the therapy of IDDM has been difficult because of generally poor graft survival and significant complications in past experience. We report a technically successful simultaneous pancreas/kidney transplant program with patient and graft survival of 85% over 3 years of follow-up (mean 21 months) in 33 subjects with IDDM. Glucose metabolism was normalized without need for exogenous insulin immediately posttransplant in all but one recipient and remained normal in 85% of recipients. The outcome in pancreas/kidney recipients was compared with that in 18 insulin-dependent diabetic recipients of kidney transplant only performed in the same period. Quality of life was assessed with one general and one diabetes-specific questionnaire. General quality of life issues improved significantly in both pancreas/kidney and kidney recipients, but diabetes specific quality of life improved only in the pancreas/kidney recipients. Pancreas/kidney recipients required twice as long a period of hospitalization for the transplant and two times as many readmissions for a variety of complications. Only a minority of hospital admissions was strictly attributable to the pancreas graft. Of the five deaths in the pancreas/kidney recipients, two were attributable to the pancreas transplant. Pancreas transplantation in IDDM can now be accomplished with a high degree of success, resulting in normalized glucose metabolism and with overall mortality similar to kidney transplantation alone. Successful pancreas transplantation improves quality of life with respect to diabetes but this benefit is accomplished at a cost of increased hospital admissions and complications related to the transplanted pancreas. The effects of pancreas transplantation on the long-term complications of insulin-dependent diabetes remain unknown.
Collapse
Affiliation(s)
- D M Nathan
- Diabetes, Unit, Massachusetts General Hospital, Boston
| | | | | | | | | | | | | | | | | |
Collapse
|