Does Recombinant Human Bone Morphogenic Protein 2 Affect Perioperative Blood Loss after Lumbar and Thoracic Spinal Fusion?

Brett Freedman,Bayard Carlson,William Robinson,Mohamad Bydon,Michael Yaszemski,Paul Huddleston,Brett Freedman 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.5

Study Design: Retrospective cohort design. Purpose: This study aimed to determine whether recombinant human bone morphogenic protein 2 (rhBMP-2) reduces total perioperative blood loss during lumbar and thoracic fusion. Overview of Literature: Previous studies on rhBMP-2 versus iliac crest bone grafting in thoracic and lumbar fusions have yielded mixed results regarding reductions in blood loss and have largely neglected the postoperative period when analyzing total blood loss. Additionally, these studies have been limited by heterogeneity and sample size. Methods: We analyzed the blood loss patterns of 617 consecutive adult patients undergoing lumbar and/or thoracic fusions requiring subfascial drain placement at a single institution from January 2009 to December 2016. Patients were divided into BMP and non-BMP cohorts, and a propensity score analysis was conducted to account for the differences between cohorts. Results: At a per-level fused basis, the BMP group exhibited a significant reduction in the intraoperative (66.1 mL per-level fused basis; 95% confidence interval [CI], 127.9 to 4.25 mL; p =0.036) and total perioperative blood loss (100.7 mL per-level fused basis; 95% CI, 200.9 to 0.5 mL; p =0.049). However, no significant differences were observed in an analysis when not controlling for the number of levels or when examining the postoperative drain output. Conclusion: RhBMP-2 appears to reduce both intraoperative and total blood loss during lumbar and thoracic fusions on a per-level fused basis. This total reduction in blood loss was achieved via intraoperative effects because RhBMP-2 had no significant effect on the postoperative drain output.

A Comparison of Computed Tomography Measures for Diagnosing Cervical Spinal Stenosis Associated with Myelopathy: A Case-Control Study

Brett Arthur Freedman,C Edward Hoffler II,Brian M Cameron,John M Rhee,Maneesh Bawa,David G Malone,Melissa Bent,Tim S Yoon 대한척추외과학회 2015 Asian Spine Journal Vol.9 No.1

Study Design: Retrospective comparative study. Purpose: To assess differences in computed tomography (CT) imaging parameters between patients with cervical myelopathy and controls. Overview of Literature: There is a lack of information regarding the best predictor of symptomatic stenosis based on osseous canal dimensions. We postulate that smaller osseous canal dimensions increase the risk of symptomatic central stenosis. Methods: CT images and medical records of patients with cervical myelopathy (19 patients, 8 males; average age, 64.4±13.4 years) and controls (18 patients, 14 males; average age, 60.4±11.0 years) were collected. A new measure called the laminar roof pitch angle (=angle between the lamina) was conducted along with linear measures, ratios and surrogates of canal perimeter and area at each level C2–C7 (222 levels). Receiver-operator curves were used to assess the diagnostic value of each. Rater reliability was assessed for the measures. Results: The medial-lateral (ML) diameter (at mid-pedicle level) and calculated canal area (=anterior-posterior.×ML diameters) were the most accurate and highly reliable. ML diameter below 23.5 mm and calculated canal area below 300 mm2 generated 82% to 84% sensitivity and 67% to 68% sensitivity. No significant correlations were identified between age, height, weight, body mass in dex and gender for each of the CT measures. Conclusions: CT measures including ML dimensions were most predictive. This study is the first to identify an important role for the ML dimension in cases of slowly progressive compressive myelopathy. A ML reserve may be protective when the canal is progressively compromised in the anterior-posterior dimension.

Anterior Lumbar Interbody Fusion: Two-Year Results with a Modular Interbody Device

Keith Lynn Jackson,Chevas Yeoman,Woosik M. Chung,James L Chappuis,Brett Freedman 대한척추외과학회 2014 Asian Spine Journal Vol.8 No.5

Study Design: Retrospective case series. Purpose: To present radiographic outcomes following anterior lumbar interbody fusion (ALIF) utilizing a modular interbody device. Overview of Literature: Though multiple anterior lumbar interbody techniques have proven successful in promoting bony fusion, postoperative subsidence remains a frequently reported phenomenon. Methods: Forty-three consecutive patients underwent ALIF with (n=30) or without (n=11) supplemental instrumentation. Two patients underwent ALIF to treat failed posterior instrumented fusion. The primary outcome measure was presence of fusion as assessed by computed tomography. Secondary outcome measures were lordosis, intervertebral lordotic angle (ILA), disc height, subsidence, Bridwell fusion grade, technical complications and pain score. Interobserver reliability of radiographic outcome measures was calculated. Results: Forty-three patients underwent ALIF of 73 motion segments. ILA and disc height increased over baseline, and this persisted through final follow-up (p <0.01). Solid anterior interbody fusion was present in 71 of 73 motion segments (97%). The amount of new bone formation in the interbody space increased over serial imaging. Subsidence >4 mm occurred in 12% of patients. There were eight surgical complications (19%): one major (reoperation for nonunion/progressive subsidence) and seven minor (five subsidence, two malposition). Conclusions: The use of a modular interbody device for ALIF resulted in a high rate of radiographic fusion and a low rate of subsidence. The large endplate and modular design of the device may contribute to a low rate of subsidence as well as maintenance of ILA and lordosis. Previously reported quantitative radiographic outcome measures were found to be more reliable than qualitative or categorical measures.

Combat-Related Intradural Gunshot Wound to the Thoracic Spine: Significant Improvement and Neurologic Recovery Following Bullet Removal

Thijs M Louwes,William H Ward,Kendall H. Lee,Brett A Freedman 대한척추외과학회 2015 Asian Spine Journal Vol.9 No.1

The vast majority of combat-related penetrating spinal injuries from gunshot wounds result in severe or complete neurological deficit. Treatment is based on neurological status, the presence of cerebrospinal fluid (CSF) fistulas, and local effects of any retained fragment(s). We present a case of a 46-year-old male who sustained a spinal gunshot injury from a 7.62‑mm AK-47 round that became lodged within the subarachnoid space at T9–T10. He immediately suffered complete motor and sensory loss. By 24–48 hours postinjury, he had recovered lower extremity motor function fully but continued to have severe sensory loss (posterior cord syndrome). On post-injury day 2, he was evacuated from the combat theater and underwent a T9 laminectomy, extraction of the bullet, and dural laceration repair. At surgery, the traumatic durotomy was widened and the bullet, which was laying on the dorsal surface of the spinal cord, was removed. The dura was closed in a water-tight fashion and fibrin glue was applied. Postoperatively, the patient made a significant but incomplete neurological recovery. His stocking-pattern numbness and sub-umbilical searing dysthesia improved. The spinal canal was clear of the foreign body and he had no persistent CSF leak. Postoperative magnetic resonance imaging of the spine revealed contusion of the spinal cord at the T9 level. Early removal of an intra-canicular bullet in the setting of an incomplete spinal cord injury can lead to significant neurological recovery following even high-velocity and/or high-caliber gunshot wounds. However, this case does not speak to, and prior experience does not demonstrate, significant neurological benefit in the setting of a complete injury.

An Objective and Reliable Method for Identifying Sarcopenia in Lumbar Spine Surgery Patients: Using Morphometric Measurements on Computed Tomography Imaging

Marko Tomov,Mohammed Ali Alvi,Mohamed Elminawy,Bradford Currier,Michael Yaszemski,Ahmad Nassr,Paul Huddleston,Arjun Sebastian,Mohamad Bydon,Brett Freedman 대한척추외과학회 2020 Asian Spine Journal Vol.14 No.6

Study Design: A retrospective observational study.Purpose: Establish a quantifiable and reproducible measure of sarcopenia in patients undergoing lumbar spine surgery based on morphometric measurements from readily available preoperative computed tomography (CT) imaging. Overview of Literature: Sarcopenia—the loss of skeletal muscle mass—has been linked with poor outcomes in several surgical disciplines; however, a reliable and quantifiable measure of sarcopenia for future assessment of outcomes in spinal surgery patients has not been established.Methods: A cohort of 90 lumbar spine fusion patients were compared with 295 young, healthy patients obtained from a trauma da¬tabase. Cross-sectional vertebral body (VB) area, as well as the areas of the psoas and paravertebral muscles at mid-point of pedicles at L3 and L4 for both cohorts, was measured using axial CT imaging. Total muscle area-to-VB area ratio was calculated along with intraclass correlation coefficients for interobserver and intraobserver reliability. Finally, T-scores were calculated to help identify those patients with considerably diminished muscle-to-VB area ratios.Results: Both muscle mass and VB areas were considerably larger in males compared with those in females, and the ratio of these two measures was not enough to account for large differences. Thus, a gender-based comparison was made between spine patients and healthy control patients to establish T-scores that would help identify those patients with sarcopenia. The ratio for paravertebral muscle area-to-VB area at the L4 level was the only measure with good interobserver reliability, whereas the other three of the four ratios were moderate. All measurements had excellent correlations for intraobserver reliability.Conclusions: We postulate that a patient with a T-score <−1 for total paravertebral muscle area-to-VB area ratio at the L4 level is the most reliable method of all our measurements that can be used to diagnose a patient undergoing lumbar spine surgery with sarcopenia.

An Ovariectomy-Induced Rabbit Osteoporotic Model: A New Perspective

Nathan Robert Wanderman,Cindy Mallet,Hugo Giambini,Nirong Bao,Chunfeng Zhao,Kai-Nan An,Brett A. Freedman,Ahmad Nassr 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.1

Study Design: Experimental Animal Model. Purpose: The aim of our study was to validate a pure bilateral ovariectomy (OVX) female New Zealand white rabbit model of postmenopausal osteoporosis utilizing animal-sparing in vivo techniques for evaluating bone mineral density (BMD). We also sought to demonstrate that bilateral OVX in female New Zealand white rabbits can produce diminished BMD in the spinal column and simulate osteoporosis, without the need for adjuvant chemotherapeutic agents (i.e., no additional glucocorticosteroids or other drugs were used for stimulating accelerated BMD loss), which can be assessed by in vivo BMD testing. Overview of Literature: Multiple animal models of postmenopausal osteoporosis have been described. Rat ovariectomy models have been successful, but are limited by rats’ inability to achieve true skeletal maturity and a slight morphology that limits surgical instrumentation. Rabbit models have been described which do not have these limitations, but previous models have relied on adjunctive steroid therapy to achieve osteoporosis and have required animal sacrifice for bone mineral density assessment. Methods: Thirty-six skeletally mature female rabbits underwent bilateral OVX. BMD was measured using dual-energy X-ray absorptiometry on the metaphysis of the proximal tibia and distal femur, at baseline and 17 weeks postoperatively. Results: Mean BMD values were significantly reduced by 21.9% (p <0.05) in the proximal tibia and 11.9% (p <0.001) in the distal femur at 17 weeks. Conclusions: This study is the first to demonstrate a significant bone loss within four months of pure OVX in rabbits using animalsparing validation techniques. We believe that this OVX model is safe, reproducible, and can be employed to longitudinally evaluate the effect of anti-osteoporosis therapeutics and surgical interventions.

Does Subcutaneous Infiltration of Liposomal Bupivacaine Following Single-Level Transforaminal Lumbar Interbody Fusion Surgery Improve Immediate Postoperative Pain Control?

Marko Tomov,Kevin Tou,Rose Winkel,Ross Puffer,Mohamad Bydon,Ahmad Nassr,Paul Huddleston,Michael Yaszemski,Bradford Currier,Brett Freedman 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.1

Study Design: Retrospective case-control study using prospectively collected data. Purpose: Evaluate the impact of liposomal bupivacaine (LB) on postoperative pain management and narcotic use following standardized single-level low lumbar transforaminal lumbar interbody fusion (TLIF). Overview of Literature: Poor pain control after surgery has been linked with decreased pain satisfaction and increased economic burden. Unfortunately, opioids have many limitations and side effects despite being the primary treatment of postoperative pain. LB may be a form of pre-emptive analgesia used to reduce the use of postoperative narcotics as evidence in other studies evaluating its use in single-level microdiskectomies. Methods: The infiltration of LB subcutaneously during wound closure was performed by a single surgeon beginning in July 2014 for all single-level lumbar TLIF spinal surgeries at Landstuhl Regional Medical Center. This cohort was compared against a control cohort of patients who underwent the same surgery by the same surgeon in the preceding 6 months. Statistical analysis was performed on relevant variables including: morphine equivalents of narcotic medication used (primary outcome), length of hospitalization, Visual Analog Scale pain scores, and total time spent on a patient-controlled analgesia (PCA) pump. Results: A total of 30 patients were included in this study; 16 were in the intervention cohort and 14 were in the control cohort. The morphine equivalents of intravenous narcotic use postoperatively were significantly less in the LB cohort from day of surgery to postoperative day 3. Although the differences lost their statistical significance, the trend remained for total (oral and intravenous) narcotic consumption to be lower in the LB group. The patients who received the study intervention required an acute pain service consult less frequently (62.5% in LB cohort vs. 78.6% in control cohort). The amount of time spent on a PCA pump in the LB group was 31 hours versus 47 hours in the control group (p =0.1506). Conclusions: Local infiltration of LB postoperatively to the subcutaneous tissues during closure following TLIF significantly decreased the amount of intravenous narcotic medication required by patients. Well-powered prospective studies are still needed to determine optimal dosing and confirm benefits of LB on total narcotic consumption and other measures of pain control following major spinal surgery.