5 Findings on XLIF for Scoliosis Surgery

In a recent study published in the journal Spine, researchers set out to examine extreme lateral interbody fusion as a treatment for adult degenerative scoliosis.

The prospective, multicenter, single-arm study was conducted through evaluation of clinical and radiographical results of 107 patients undergoing the XLIF procedure. On average, there were three levels treated per patient.

The study found:

•    85 percent of patients were satisfied with the procedure and would choose it again.


•    The complication rate for XLIF was found to be overall lower than that of traditional surgical approaches to degenerative scoliosis.


•     All clinical outcome measures showed significant improvement at 24 months.


•    Overall Cobb angle was corrected from 20.9 degrees to 15.2 degrees.


•    The greatest Cobb angle correction was observed in patients supplemented with bilateral pedicle screws.

The study provides supporting evidence that the XLIF procedure leads to good clinical and radiographical outcomes, without the high complication rate often associated with traditional surgical treatment of degenerative scoliosis.

The researchers included Frank Phillips, MD, Robert Isaacs, MD, William Blake Rodgers, MD, Kaveh Khajavi, MD, Antoine Tohmeh, MD, Vedat Deviren, MD, Mark Peterson, MD, Jonathan Hyde, MD, and Mark Kurd, MD.



Source : Becker's Spine Review , 30th September 2013

Study finds braces twice as effective in preventing corrective surgery for scoliosis

In the first large-scale test of whether wearing a brace helps to prevent an already-curved childhood spine from twisting further, bracing was nearly twice as effective as a watch-and-wait approach at preventing kids from needing corrective surgery.

But the study also found that too many children with scoliosis are being given a brace when they don't need one. Data from the new research may help doctors identify which children need to wear the brace and when it is better to just keep tabs on the child.

The study "really answers the question that parents raise - 'If you're going to prescribe a brace for my child, does it work?'" said Dr. Stuart Weinstein, lead author of the study, which was published online by the New England Journal Medicine and reported Thursday at the Scoliosis Research Society's annual meeting in Lyon, France. "The answer is that braces have a very high success rate," he told Reuters Health.

"We also found that the longer the child wore the brace, the more likely you were to achieve success," he said. "Children who wore it more than 13 hours a day had a 90 percent to 93 percent chance of success for avoiding having the curve progressing to a surgical threshold."

The results were so pronounced, the test of 242 youngsters in the U.S. and Canada was halted early.


"It certainly reinforces our present approach to bracing in these at-risk adolescents," Dr. Allan Beebe, an orthopedic specialist at Nationwide Children's Hospital in Columbus, Ohio, who was not connected with the research, told Reuters Health in an email. "This study appears to be better science" than the previous research on bracing.


About 2 to 3 percent of children have some degree of spine curvature, but only 0.3 to 0.5 percent have progressively worsening curves that make them candidates for treatment aimed at avoiding the need for surgery.


Once the spinal curve gets beyond 50 degrees, there's a high risk it will continue worsening into adulthood unless corrected surgically. So treating the problem early is preferable, and less expensive.


Weinstein and his colleagues point out in their report that there were more than 3,600 spinal surgeries to correct adolescent scoliosis in the U.S. in 2009. At a total cost of $514 million, the procedure "ranked second only to appendicitis" for children 10 to 17 years old.


"Bracing has been the standard method of trying to protect patients from needing surgery ever since a brace was developed in the 1940s, said Weinstein, of the University of Iowa. "But it was never really proven if it was effective. There was never a randomized trial where some children were braced and some weren't. The data were inconsistent."


The original plan for the study was to randomly assign some children to a brace and to simply watch others to see whether the curve of the spine became too severe. In either case, progression of the curve to 50 degrees or more indicated that the assigned treatment had not worked.


But many parents had strong feelings about how they wanted their child treated and declined to allow a treatment to be randomly selected for them. So the research team let those parents choose a treatment; 70 percent chose a brace.


"The interesting fact was that when you looked at both the randomized children and those who chose their preference, bracing produced an overwhelming 72 percent success rate when it came to preventing the need for surgery," Weinstein said. The success rate in the observation group was 48 percent.


The success rate among children randomly assigned to bracing was even higher, at 78 percent.


A temperature sensor logged the amount of time the child wore the brace.


"The study provided pretty overwhelming evidence that braces are effective," Weinstein said.


But it was also clear from the results that many bracing treatments are unnecessary.


Nearly half of the participants in the watch-and-wait group during the trial did not have curve progression to the point of needing surgery. The same was true for 41 percent of kids in the bracing group who actually spent very little time wearing their braces.


"We're unnecessarily bracing two patients to get the one patient who actually needs it. We are still overtreating patients," Weinstein said.


A further analysis of the data might prevent some of that unnecessary treatment, he said.


"We will probably, in the next year or so, be analyzing all the factors so we can hone down better who the ideal candidate for bracing is," Weinstein said.



Source : Medcitynews , 23rd September 2013

10 Pivotal Cost-Effectiveness Studies on Spine Surgery to Know

Here are 10 studies published and presented in the past five years on cost-effectiveness of spine surgery.

Spinal Deformity: Dr. Richard Hostin. Published in May 2013, this article in Spine Deformity: The Official Journal of the Scoliosis Research Society includes several co-authors and the International Spine Study Group. The authors aimed to calculate the cost of improvement in health-related quality of life by examining consecutive patients with adult spinal deformity in a single center over a five year period: 2005 to 2010. They collected costs from hospital data on total costs incurred during the episode of care and found that cost-effectiveness ranged from an average of $5,658 per 1-point improvement in the SRS Self-image to an average cost of $25,918 per 1-point improvement in the SF-36 Physical Component Score. There were 164 patients examined in the study with an average of 3.2 years follow-up. Authors concluded surgical treatment for adult spinal deformity could be more cost effective for select proposes like pain reduction and less cost-effective for other purposes, such as improved functional activity.

Intervertebral disc herniation: SPORT. Jon D. Lurie, MD, Gunnar B. Andersson, MD, Sigurd Berven, MD, James Weinstein, DO, were co-authors on this article. As part of the Spine Patient Outcomes Research Trial, these surgeons and research partners examined the cost-effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over a two-year period. The researchers examined 775 patients who underwent surgery and 416 who underwent nonoperative treatment for intervertebral disc herniation and found the average difference in QALYs over the two-years after treatment was 0.21 in favor of surgery. Surgery was more costly than nonoperative care — $14,137 more expensive for adult surgery and $34,355 for Medicare populations. The estimated economic value of surgery varied considerably, according to the study authors, but overall found surgery moderately cost-effective.

Spinal stenosis: SPORT. Published in a 2011 Issue of Spine and reported in Medscape, this article examined cost-effectiveness of spinal stenosis and two other disorders as part of the Spine Patient Outcome Research Trial. The patients were followed for two years and researchers calculated cost per quality-adjusted life year gained in 2004 US dollars, comparing that number to nonoperative care using a societal perspective with costs and QALYs discounted at 3 percent per year. Surgery was performed initially or over a four-year period for 414 of the 634 patients for spinal stenosis. QALY gained for spinal stenosis patients was 0.22 and costs per QALY gained decreased for spinal stenosis from $77,600 at two years to $59,400 at four years. The study authors include Jon D. Lurie, MD, Gunnar B. Andersson, MD, Sigurd Berven, MD, James Weinstein, DO, Harry Herkowitz, MD, Todd Albert, MD, Keith Bridwell, MD, and other non-physician authors.

Degenerative spondylolisthesis: SPORT. Published in a 2011 Issue of Spine and reported in Medscape, this article examined cost-effectiveness of surgical treatment for degenerative spondylolisthesis and two other disorders as part of the Spine Patient Outcome Research Trial. The patients were followed for two years and researchers calculated cost per quality-adjusted life year gained in 2004 US dollars, comparing that number to nonoperative care using a societal perspective, with costs and QALYs discounted at 3 percent per year. Surgery was performed initially or over a four-year period for 391 of the 601 patients for degenerative spondylolisthesis. QALY gained for degenerative spondylolisthesis patients was 0.34 and costs per QALY gained decreased for degenerative spondylolisthesis from $115,600 at two years to $64,300 at four years. The study authors include Jon D. Lurie, MD, Gunnar B. Andersson, MD, Sigurd Berven, MD, James Weinstein, DO, Harry Herkowitz, MD, Todd Albert, MD, Keith Bridwell, MD, and other non-physician authors.

Outpatient cervical disc arthroplasty: Dr. Richard Wohns. Richard Wohns, MD, founder of NeoSpine in the Puget Sound Area, Wash., published an article describing the cost-effectiveness of outpatient cervical disc arthroplasty in Surgical Neurology International in 2010. The article reviewed 26 patients who underwent outpatient cervical disc arthroplasty and found 100 percent of patients improved after the surgery and no postoperative complications. The cost of outpatient single-level cervical disc arthroplasty was 62 percent less than outpatient single-level cervical anterior discectomy with fusion using allograft and plate. The arthroplasty procedure cost 84 percent less than inpatient single-level cervical disc arthroplasty.

Posterior spinal fusion compared to hip and knee arthroplasty: Sonoran Spine Research and Education Foundation. In 2012, researchers and surgeons at the Sonoran Spine Research and Education Foundation in Mesa, Ariz., published an article online examining the cost-effectiveness and outcomes for spinal fusion and joint replacement patients. The study used a Markov model of 1,000 patients for the three cohorts: spinal fusion, knee replacement and hip replacement. The cost of revision surgery was neglected. Researchers found the total hip arthroplasty group had a cost of $27,450.93 per change in QALY and the total knee arthroplasty group had a cost of $59,165.40 per change in QALY. The posterior spinal fusion group reported a cost of $34,110.03 per change in QALY. The cost of the index procedure was more expensive for the spinal surgery, but when adjusting for the improvements in quality of life, the spine surgery had similar costs to the total hip and knee arthroplasty.

Image-guided spine surgery: Dr. Robert G. Watkins IV. Robert G. Watkins IV, MD, teamed with Robert G. Watkins III, MD, and Akash Gupta, MD, to examine the cost-effectiveness of image-guided spine surgery in this study. The surgeons examined 100 patients undergoing thoracolumbar pedicle screw instrumentation using image guidance and compared them to a retrospective group of 100 patients who underwent screw placement prior to the use of image guidance. Revision reduced from 3 percent to 0 percent when the image guidance was used, and the cost-savings for the placement of pedicle screws as $71,286 per 100 cases. The time required to place screws with image guidance was 20 minutes for two screws, 29 minutes for four screws, 38 minutes for six screws and 50 minutes for eight screws. The researchers calculated cost-savings for the time spent placing pedicle screws with image guidance by subtracting the time required with the current non-guidance techniques from the averages with guidance and multiplying that number by $93 per minute. The article was published in The Open Orthopaedic Journal in 2010.

Spinal fusion surgery: The Ohio State University. Surgeons from the department of orthopedics at The Ohio State University published this 2012 article in the Journal of Bone and Joint Surgery examining the most cost-effective graft option for spinal fusion to treat L4-L5 degenerative spondylolisthesis. They used a Markov decision model to identify the cost and effectiveness of spinal fusion surgery and revision surgery associated with each graft option. The incremental cost-effectiveness ratio for each graft option when compared with living with chronic back pain was $21,308 per QALY for iliac crest bone graft; $16,595 per QALY for rhBMP-2; $21,204 per QALY for local bone alone; $21,287 per QALY for demineralized bone matrix with local bone; and $28,153 per QALY for corticocancellous allograft chips.

Artificial disc replacement: Dr. Richard Delamarter. Richard Delamarter, MD, co-director of the Cedars-Sinai Spine Center, reported a 2011 study in which he found that artificial disc replacement for patients with degenerative disc disease had a more positive economic impact than spinal fusions. The study examined 209 patients with damaged cervical spine discs who underwent either cervical disc replacement or spinal fusion. Four years after the surgery, the fusion patients were four times more likely to need additional surgery and half of those operations were necessary because of new disc complications occurring at levels adjacent to the fusion. Another study focused on patients suffering from three-level lower back disc disease, comparing the cost of care between disc replacement and fusion. The total hospital costs for the disc replacement patients were, on average, 49 percent lower than fusion patients.

Transforaminal lumbar interbody fusion: Dr. Matthew J. McGirt, MD. Dr. McGirt partnered with Alexandra Paul, MD, Brandon Davis, MD, Oran Aaronson, MD, Clint Devon, MD, and Joseph Cheng, MD, and non-physician researchers to conduct this study into the cost-effectiveness of transforaminal lumbar interbody fusion. The study was presented at the American Association of Neurological Surgeons annual meeting in April 2011, which discussed the economic benefits for patients with leg and back pain associated with grade 1 degenerative spondylolisthesis to receive TLIF. Researchers followed patients for two years to see where the postoperative economic impact lay:

•    Patients reported less disability and improved quality of life according to questionnaires they were given.


•    The mean two-year direct medical cost was $25,251.


•    The mean surgical cost was $21,311±2,086, and the mean outpatient resource cost was $3,940±2,720.


•    The average total two-year cost of TLIF was $36,835±11,800.


•    The average reported annual income prior to surgery was $50,000. Patients missed an average of 60 work days, representing a two-year societal cost of $11,584.


•    At two years after surgery, the total cost per Quality Adjusted Life Years gained of TLIF was $42,854, well below the accepted $50,000 cost-effective threshold.



Source : Becker's Spine Review , 4th October 2013

Back bracing for scoliosis needs work, studies show : NEW YORK

Bracing for scoliosis has been so controversial that until now, one recognized medical group advised against it. But braces have been used for years to prevent spine surgery for the problem, and now a report in the prestigious New England Journal of Medicine racks up scientific evidence that braces do indeed need work.

You can see the scoliosis, curvature of the spine, as 12-year-old Shannon White bends forward. It started when she was very young.

"I was going to my doctor and she noticed that my shoulders weren't even, and I was about 5 or 6 at that time," said Shannon.

She went to a pediatric orthopedist.

"He started bracing me and hope that as I grew, it would decrease the curvature," said Shannon.

The new report backs up the idea of wearing a brace like this for 13 to 18 hours a day.

The report compared kids Shannon's age to see if bracing versus no bracing prevented progression of spine curvature. The results favored bracing so much that the study was stopped so all the kids could use the braces.

It's very flexible as well. Shannon has been wearing it for the hours that she sleeps, and for several hours after school.

"At sleep overs it's a little uncomfortable on the ground or in a sleeping bag," said Shannon.

But she told me she's now used to it, and she's able to take it off for sports, including gymnastics. She's had it two years. She'll wear it another year until her spine and the rest of her bones stop growing. She's had no progression of the curvature in the years she's worn the brace.

"That was our number one goal, to prevent the need for surgery on her back, and the brace has accomplished that," said Shannon's mom, Valerie White.

Scoliosis has a big genetic factor, Shannon's father had the problem. Because of that, she had a one in five chance of getting it too. In the pipeline is some DNA research that may help doctors figure out which patients will go on to progression of spine curvature, and which kids won't.

Dr. David Konigsberg THE VALLEY HOSPITAL



Source : ABC Local , 4th October 2013

Study supports use of back braces to treat scoliosis

Adolescents with scoliosis – curvature of the spine – may be able to benefit from treatment with a back brace and avoid surgery, according to a study published in the Sept. 19 online edition of the New England Journal of Medicine.

More likely to occur in girls than in boys, adolescent idiopathic scoliosis (AIS) is a curvature of the spine with no clear underlying cause. Doctors have recommended bracing as a treatment for more than 50 years, but until now, studies of its effectiveness have produced mixed results.



A new study from the National Institutes of Health (NIH), however, should help to clear up any doubts about the efficacy of bracing.



According to an NIH news release, researchers set out to compare the risk of curve progression in adolescents who had AIS and wore a brace with those who did not wear one. The study team, led by Stuart Weinstein, MD, a professor of orthopedic surgery at the University of Iowa, recruited patients who – based on their age, skeletal immaturity and curve severity – were at high risk for continued worsening of their spinal curves.



Study investigators analyzed data on 242 patients at 25 sites across the U.S. and Canada between March 2007 and February 2011. The children in the study were aged 10 to 15, still growing, and had spinal curvatures of 20 to 40 degrees.



In the study group, 116 patients were randomly assigned to observation or bracing for at least 18 hours a day. Because some parents did not want to wait and see how their child’s curve progressed, a group of 126 patients were allowed to choose for themselves if they wanted bracing or observation.



Bracing was considered a failure if a child’s spinal curvature progressed to 50 degrees or more, when surgery, which entails putting screws and rods in the spine to straighten it, is often suggested. Bracing was deemed a success if the child reached skeletal maturity without this degree of curve progression.



Study results showed that in the combined randomized and preference groups, 72 percent of the patients who wore braces reduced the risk of curve progression and the need for surgery. Wearing a brace more than an average of 13 hours a day was associated with success rates of 90 to 93 percent. Results showed that the more hours the brace was worn, the higher the success rate.



In addition, the researchers found that 48 percent of patients in the observation group, and 41 percent of the patients in the bracing group who wore a brace infrequently also had positive outcomes.



“There are a lot of doctors like me who treat scoliosis as the primary focus of their practice who had doubts about whether bracing was effective. Now the jury is in,” Weinstein told the New York Times.



For one doctor, the study helps prescribe bracing for image-conscious teens.



“When you have a teenager who is anxious about wearing a brace to school or what their friends will say, it gave us a bit of heartache to try to convince them if we weren’t certain ourselves,” said Dr. Paul Sponseller, the director of orthopedic surgery at Johns Hopkins Children Center, in the New York Times article.



“In light of this new evidence, we can say we really do have a basis for putting them through bracing,” added Sponseller, who was not involved in the study.

Source : Examiner.com , 19th September 2013

Minimal access spinal technology has revolutionized the world : Chandigarh

Physical independence is of significant importance to human beings. Impaired mobility due to pain, disabilities, injuries or infections can affect an individual physically, psychologically and emotionally. Spinal deformity or trauma is such a condition that can be life changing if not taken care of, with patients shying away from their social lives.

 

However now with the changing face of vertebral surgeries, there is hope for spinal patients to live a life free of pain and stigma and embrace the company of others. One such cutting edge technique, minimal access spinal technology (MAST) has revolutionized the traditional spinal surgery norms. With minimal scarring and quick recovery, MAST is one of the most widely used spinal surgery procedures in the world.

"Most of the patients I have treated with spine problems used to shy away from the company of other people because they were afraid of being stared at and ridiculed, and this was detrimental for their self esteem and confidence," said Dr. Amit Kapoor,Orthospine, Ivy Hospital,Mohali. "Those patients who opted for MAST surgery experienced a total transformation since their spinal issues were resolved and there were no ugly scars that would prompt them to cover up their backs," he added.

Compared to the traditional spinal surgery, MAST stands out with its benefits, the doctor explained. "Scars affect an individual greatly, especially when it comes to wearing clothes. With minimal access spinal surgery or keyhole spinal surgery there is less or no scar formation. This is a boon for patients as they can now wear summer clothes without feeling awkward. Earlier with traditional spinal surgeries the recovery period was much longer and was an ongoing process associated with back pain," he said.

According to Dr. Amit Kapoor the most beneficial aspect of MAST is the quick recovery time that allows the patient to go home the very next day, and they can resume their normal routine within a week.

"Patients now feel confident, empowered and independent after the surgery, unlike with traditional spinal surgeries," he said, going on to explain that, " Spinal surgery is required in case of various injuries, infections and deformities. Awareness about the medical condition with prompt action can help the patient greatly."


Source : T.O.I , 19th July 2013

City doctors perform spine straightening surgery : Vishakha Patnam

In a complex four-and-a-half hour surgery, a severe spinal deformity of a 14-year-old girl from Anakapalle was completely corrected by doctors in the city recently. Neeraja, a ninth standard student of a local government school, had developed a small hump on the right side of her back a couple of years ago that kept getting progressively worse.

She was diagnosed with a severe case of scoliosis, in which the spine gets bent to one side, twisting the back into an abnormal shape. While scoliosis usually affects adolescent girls, one out of 10,000 cases of the ailment are severe, where there is a large curve of the spine. Though moderate curvature can be prevented from progressing by wearing braces, in severe cases the curvature progresses rapidly and needs to be operated upon early. Large curves also cause respiratory problems later in life apart from causing fatigue and mental stress due to social stigma, say doctors.

The curvature of the spine was corrected by inserting 23 titanium pedicle screws into the vertebrae that were connected to rods, which in turn were de-rotated to unbend the spine, explained Dr B Leela Prasad, who along with Dr M Muralimohan and Dr J Naresh Babu operated on Neeraja on June 30 and kept her under observation for almost a week.

"Bone grafts were also placed to prevent worsening of the deformity in the future. After the surgery she was kept under observation and made to sit up and walk from the second day. Follow-up showed that her spine got back its shape and she can go back to school after a month," said Dr Leela Prasad.

"I had assumed it was due to the weight of the school bag carried by her. But the size of the hump kept on increasing and she developed an obvious deformity. Neeraja was depressed and confined herself indoors to avoid being made fun of. Local doctors diagnosed it as scoliosis but said this was major surgery that could leave her paralysed for life and advised us to approach doctors in any of the metro cities," said her mother Subhadra.

"We then consulted Dr Leela Prasad, who after examining the patient and reviewing the x-rays suggested surgical correction of the deformity. We were scared that the surgery would cripple her permanently and feared for her life. But Neeraja was brave enough and was determined to get her deformity rectified," said her father Satyanarayana.

Source : TOI , 9th July 2013