A Review of Vitamin D in Spinal Surgery: Deficiency Screening, Treatment, and Outcomes

In this review, we discuss the demonstrated value of vitamin D in bone maintenance, fracture resistance, spinal health, and spine surgery outcomes. Despite this, the effect of vitamin D levels in spine surgery has not been well described. Through this review of literature, several conclusions were drawn. First, despite the fact that a high number of spine surgery patients are vitamin D deficient, screening is not commonly performed. Second, adequate vitamin D levels will not be achieved in a majority of these patients without supplementation. Last, inadequate vitamin D levels may increase the risk of pseudarthrosis. Given these findings, we suggest that many patients undergoing spinal surgery could be treated with vitamin D supplementation prior to surgery without the need for confirmatory testing for vitamin D deficiency. This is a more cost-effective method than screening all patients. However, future randomized trials and cost-effectiveness analyses are needed to determine the ultimate effects of vitamin D supplementation on clinical morbidity and surgical outcomes.

Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Isthmic Versus Degenerative Spondylolisthesis

Background

Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is a common surgical procedure for treatment of degenerative spondylolisthesis (DS) but remains controversial for treatment of isthmic spondylolisthesis (IS). Few studies have compared IS and DS outcomes after MIS TLIF. Therefore, the objective of the current study was to compare outcomes of patients with IS and DS after MIS TLIF.

Methods

A retrospective cohort analysis was performed on a prospectively maintained database of patients who underwent a primary, 1-level MIS TLIF for grade I or II IS or DS. Grade I and II DS and grade I IS patients were treated with MIS TLIF via a unilateral tubular approach, whereas the grade II IS patients were treated via a bilateral tubular approach. Differences in patient demographics and preoperative characteristics were assessed using independent sample t tests and χ² tests. The type of spondylolisthesis and its effect on postoperative outcomes was analyzed using Poisson regression with robust error variance (binary outcomes) or linear regression (continuous outcomes) adjusted for preoperative characteristics. Subgroup analysis comparing grade I IS versus DS and grade II IS versus DS was performed.

Results

A total of 223 patients were included (IS: 62 [27.8%]; DS: 161 [72.2%]). IS patients were younger (P < .001), had a lower comorbidity burden (P < .001), and a greater incidence of grade II spondylolisthesis (P < .001) at L5-S1 (P < .001) than the DS cohort. Patients with IS experienced longer operative times (P < .001) and lower, but not statistically significant, arthrodesis rates compared to the DS cohort. No differences were observed in the remaining preoperative patient characteristics, perioperative or postoperative outcomes.

Conclusions

Despite being younger and having a lower comorbidity burden than the DS cohort, similar outcomes were observed after MIS TLIF for IS patients.

Level of Evidence

3.

Clinical Relevance

These results suggest MIS TLIF is an appropriate treatment option for IS patients despite the increased instability inherent with IS.

Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Grade I Versus Grade II Isthmic Spondylolisthesis

Background

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is often used to treat low-grade isthmic spondylolisthesis (IS). No studies have compared surgical outcomes for grade I and II IS following MIS-TLIF. Therefore, the objective of the current study was to compare outcomes between patients with grade I and II IS following MIS-TLIF.

Methods

A retrospective cohort analysis was performed on a prospectively maintained database of patients who underwent a primary 1-level MIS-TLIF for treatment of IS between 2007 and 2015. Grade I patients underwent a unilateral tubular approach with a single interbody cage and bilateral pedicle screw instrumentation. Grade II patients underwent a bilateral tubular approach with bilateral interbody cage and pedicle screw placement. Baseline patient demographics and characteristics were compared using Student t test and χ² analysis. Differences in peri- and postoperative outcomes were assessed using Poisson regression with robust error variance or linear regression adjusted for perioperative variables.

Results

A total of 58 patients with IS underwent MIS-TLIF; 21 (36.2%) were grade I and 37 (63.8%) were grade II. The grade I cohort was younger (42.2 versus 50.6 years, P = .029); no other differences in preoperative variables were observed. No significant differences in operative time, estimated blood loss, length of hospital stay, postoperative visual analogue scale scores, or complication and revision rates were demonstrated between cohorts. Arthrodesis rate was lower in the grade I cohort, though not statistically significant.

Conclusions

Despite the grade I cohort being younger with less-severe diagnoses, the grade II cohort experienced similar outcomes. This finding may be due to the grade II cohort receiving bilateral cages, potentially providing a better fusion environment.

Clinical Relevance

These results suggest that MIS-TLIF provides sufficient stabilization and fusion for treatment of grade II IS despite increased vertebral body displacement. In addition, MIS-TLIF with bilateral approach and interbody cage placement should be examined for treatment of high-grade IS cases.

Assessing Online Patient Education Readability for Spine Surgery Procedures

BACKGROUND CONTEXT

Increased patient reliance on Internet-based health information has amplified the need for comprehensible online patient education articles. As suggested by the American Medical Association and National Institute of Health, spine fusion articles should be written for a 4th-6th-grade reading level to increase patient comprehension, which may improve postoperative outcomes.

PURPOSE

The purpose of this study is to determine the readability of online health care education information relating to anterior cervical discectomy and fusion (ACDF) and lumbar fusion procedures.

STUDY DESIGN

Online health-education resource qualitative analysis.

METHODS

Three search engines were utilized to access patient education articles for common cervical and lumbar spine procedures. Relevant articles were analyzed for readability using Readability Studio Professional Edition software (Oleander Software Ltd). Articles were stratified by organization type as follows: General Medical Websites (GMW), Healthcare Network/Academic Institutions (HNAI), and Private Practices (PP). Thirteen common readability tests were performed with the mean readability of each compared between subgroups using analysis of variance.

RESULTS

ACDF and lumbar fusion articles were determined to have a mean readability of 10.7±1.5 and 11.3±1.6, respectively. GMW, HNAI, and PP subgroups had a mean readability of 10.9±2.9, 10.7±2.8, and 10.7±2.5 for ACDF and 10.9±3.0, 10.8±2.9, and 11.6±2.7 for lumbar fusion articles. Of 310 total articles, only 6 (3 ACDF and 3 lumbar fusion) were written for comprehension below a 7th-grade reading level.

CONCLUSIONS

Current online literature from medical websites containing information regarding ACDF and lumbar fusion procedures are written at a grade level higher than the suggested guidelines. Therefore, current patient education articles should be revised to accommodate the average reading level in the United States and may result in improved patient comprehension and postoperative outcomes.

Implementation of a "real world" School-Based Asthma Therapy program targeting urban children with poorly controlled asthma

OBJECTIVE

Describe implementation and clinical impact of a "real world" School-Based Asthma Therapy (SBAT) Program serving an urban, largely Medicaid population in a large midwestern city in the United States.

METHODS

A retrospective, descriptive evaluation of SBAT was conducted. Students were referred by school nurses or providers, enrolled throughout the year, and could reenroll in subsequent years. A total of 286 students participated in the 2015-2016 school year. Kruskal-Wallis nonparametric testing compared Asthma Control Test™ (ACT) scores from enrollment (anytime between 2013 and 2015) to 2015-2016 for 198 students; and pre- and postenrollment asthma-related emergency department (ED), inpatient, and critical care (pediatric intensive care unit or PICU) utilization rates (events/student/year) for 98 students enrolled for a full year.

RESULTS

SBAT participation grew from 17 to 131 schools and from 38 to 268 students between 2013-2014 and 2015-2016. Mean ACT scores increased from 16.2 (SD = 4.89) to 21.37 (SD = 3.41) (K-W χ² = 35.45, p = 0.008). Healthcare utilization rates from 1-year preenrollment to 1-year postenrollment decreased for ED (0.91-0.44; K-W χ² = 18.61, p = 0.0002) and Inpatient (0.38-0.10; K-W χ² = 7.68, p = 0.02). Reduction in PICU (0.27-0.02) was not statistically significant.

CONCLUSIONS

SBAT, modeled after programs shown in controlled trials to improve asthma health markers ( 1-3 ), was successfully implemented in economically challenged, urban schools. Rapid growth and patient reenrollment reflect program acceptance by schools, providers, and caregivers. Improved ACT scores and healthcare utilization supported program efficacy. SBAT could be one solution to improved asthma control in underserved school-aged pediatric patients.

Lateral lumbar interbody fusion: a systematic review of complication rates

BACKGROUND CONTEXT

Lateral lumbar interbody fusion (LLIF) is a frequently used technique for the treatment of lumbar pathology. Despite its overall success, LLIF has been associated with a unique set of complications. However, there has been inconsistent evidence regarding the complication rate of this approach.

PURPOSE

To perform a systematic review analyzing the rates of medical and surgical complications associated with LLIF.

STUDY DESIGN

Systematic review.

PATIENT SAMPLE

6,819 patients who underwent LLIF reported in clinical studies through June 2016.

OUTCOME MEASURES

Frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and spine (MSK) categories.

METHODS

This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies that identified rates of any complication following LLIF procedures were obtained from PubMed, MEDLINE, and EMBASE databases. Articles were excluded if they did not report complications, presented mixed complication data from other procedures, or were characterized as single case reports, reviews, or case series containing less than 10 patients. The primary outcome was frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and MSK categories. All rates of complications were based on the sample sizes of studies that mentioned the respective complications. The authors report no conflicts of interest directly or indirectly related to this work, and have not received any funds in support of this work.

RESULTS

A total of 2,232 articles were identified. Following screening of title, abstract, and full-text availability, 63 articles were included in the review. A total of 6,819 patients had 11,325 levels fused. The rate of complications for the categories included were as follows: wound (1.38%; 95% confidence interval [CI]=1.00%-1.85%), cardiac (1.86%; CI=1.33%-2.52%), vascular (0.81%; CI=0.44%-1.36%), pulmonary (1.47; CI=0.95%-2.16%), gastrointestinal (1.38%; CI=1.00%-1.87%), urologic (0.93%; CI=0.55%-1.47%), transient neurologic (36.07%; CI=34.74%-37.41%), persistent neurologic (3.98%; CI=3.42%-4.60%), and MSK or spine (9.22%; CI=8.28%-10.23%).

CONCLUSIONS

The current study is the first to comprehensively analyze the complication profile for LLIFs. The most significant reported complications were transient neurologic in nature. However, persistent neurologic complications occurred at a much lower rate, bringing into question the significance of transient symptoms beyond the immediate postoperative period. Through this analysis of complication profiles, surgeons can better understand the risks to and expectations for patients following LLIF procedures.

Patient knowledge regarding radiation exposure from spinal imaging

BACKGROUND CONTEXT

Spine surgeons employ a high volume of imaging in the diagnosis and evaluation of spinal pathology. However, little is known regarding patients' knowledge of the radiation exposure associated with these imaging techniques.

PURPOSE

To characterize spine patients' knowledge regarding radiation exposure from various imaging modalities.

STUDY DESIGN/SETTING

A cross-sectional survey study.

PATIENT SAMPLE

One hundred patients at their first clinic visit with a single spine surgeon at an urban institution.

OUTCOME MEASURES

The primary outcome was patient estimate of radiation dose for various common spinal imaging modalities as compared with true dose.

METHODS

An electronic survey was administered to all new patients before their first appointment with a single spinal surgeon. The survey asked patients to estimate how many chest x-rays (CXRs) worth of radiation were equivalent to various common spinal imaging modalities. Patient estimates were compared to true effective radiation doses determined from the literature. The survey also asked patients whether they would consider avoiding types of imaging modalities out of concern for excessive radiation exposure.

RESULTS

Patients accurately approximated the radiation associated with two views of the cervical spine, with a median estimate of 3.5 CXRs, compared with an actual value of 4.7 CXRs. However, patients underestimated the dose for computed tomography (CT) scans of the cervical spine (2.0 CXRs vs. 145.3 CXRs), two views of the lumbar spine (3.0 CXRs vs. 123.3 CXRs), and CT scans of the lumbar spine (2.0 CXRs vs. 638.3 CXRs). The majority of patients believed that there is at least some radiation exposure associated with magnetic resonance imaging (MRI). The percent of patients who would consider forgoing imaging recommend by their surgeon out of concern for radiation exposure was 14% for x-rays, 13% for CT scans, and 9% for MRI.

CONCLUSION

These results demonstrate a lack of patient understanding regarding radiation exposure associated with common spinal imaging techniques. These data suggest that patients might benefit from increased counseling and/or educational materials regarding radiation exposure before undergoing diagnostic imaging of the cervical or lumbar spine.

Preoperative mental health status may not be predictive of improvements in patient-reported outcomes following an anterior cervical discectomy and fusion

OBJECTIVE

Prior studies have correlated preoperative depression and poor mental health status with inferior patient-reported outcomes following lumbar spinal procedures. However, literature regarding the effect of mental health on outcomes following cervical spinal surgery is limited. As such, the purpose of this study is to test for the association of preoperative SF-12 Mental Component Summary (MCS) scores with improvements in Neck Disability Index (NDI), SF-12 Physical Component Summary (PCS), and neck and arm pain following anterior cervical discectomy and fusion (ACDF).

METHODS

A prospectively maintained surgical database of patients who underwent a primary 1- or 2-level ACDF during 2014–2015 was reviewed. Patients were excluded if they did not have complete patient-reported outcome data for the preoperative or 6-week, 12-week, or 6-month postoperative visits. At baseline, preoperative SF-12 MCS score was assessed for association with preoperative NDI, neck visual analog scale (VAS) score, arm VAS score, and SF-12 PCS score. The preoperative MCS score was then tested for association with changes in NDI, neck VAS, arm VAS, and SF-12 PCS scores from the preoperative visit to postoperative visits. These tests were conducted using multivariate regression controlling for baseline characteristics as well as for the preoperative score for the patient-reported outcome being assessed.

RESULTS

A total of 52 patients were included in the analysis. At baseline, a higher preoperative MCS score was negatively associated with a lower preoperative NDI (coefficient: −0.74, p < 0.001) and preoperative arm VAS score (−0.06, p = 0.026), but not preoperative neck VAS score (−0.03, p = 0.325) or SF-12 PCS score (0.04, p = 0.664). Additionally, there was no association between preoperative MCS score and improvement in NDI, neck VAS, arm VAS, or SF-12 PCS score at any of the postoperative time points (6 weeks, 12 weeks, and 6 months, p > 0.05 for each). The percentage of patients achieving a minimum clinically important difference at 6 months did not differ between the bottom and top MCS score halves (p > 0.05 for each).

CONCLUSIONS

The results of this study suggest that better preoperative mental health status is associated with lower perceived preoperative disability but is not associated with severity of preoperative neck or arm pain. In contrast to other studies, the present study was unable to demonstrate that preoperative mental health is predictive of improvement in patient-reported outcomes at any postoperative time point following an ACDF.