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1.  Surgical Treatment for Adult Spinal Deformity: Projected Cost Effectiveness at 5-Year Follow-Up 
The Ochsner Journal  2014;14(1):14-22.
Background
In the United States, expenditures related to spine care are estimated to account for $86 billion annually. Policy makers have set a cost-effectiveness benchmark of less than $100,000/quality adjusted life year (QALY), forcing surgeons to defend their choices economically. This study projects the cost/QALY for surgical treatment of adult spinal deformity at 5-year follow-up based on 2-year cost- and health-related quality-of-life (HRQOL) data.
Methods
In a review of 541 patients with adult spinal deformity, the patients who underwent revision or were likely to undergo revision were identified and cost of surgery was doubled to account for the second procedure; all other patients maintained the cost of the initial surgery. Oswestry Disability Index (ODI) was modeled by revision status based on literature findings. Total surgical cost was based on Medicare reimbursement. Chi square and student t tests were utilized to compare cost-effective and non–cost-effective patients.
Results
The average cost/QALY at 5-year follow-up was $120,311.73. A total of 40.7% of patients fell under the threshold of a cost/QALY <$100,000. Cost-effective patients had higher baseline ODI scores (45% vs 34% [P=0.001]), lower baseline total Scoliosis Research Society scores (2.89 vs 3.00 [P=0.04]), and shorter fusions (8.23 vs 9.87 [P=0.0001]).
Conclusion
We found 40.7% of patients to be below the threshold of cost effectiveness. Factors associated with reaching the threshold <$100,000/QALY were greater preoperative disability, diagnosis of idiopathic scoliosis, poor preoperative HRQOL scores, and fewer fusion levels.
PMCID: PMC3962303
Cost-benefit analysis; quality adjusted life years; quality of life; scoliosis; spine; surgical procedures–operative
3.  Exercise in the Management of Chronic Back Pain 
The Ochsner Journal  2014;14(1):101-107.
Background
Chronic back pain is one of the most common and expensive medical conditions facing today's population. Its costs are estimated to be as much as $100 billion in the United States alone. Causation is poorly understood and healthcare providers share little common language concerning this pain. In addition, costly medical diagnostic tests are performed that do little to inform treatment. In the era of evidence-based medicine, back pain healthcare providers must find better ways to communicate with one another.
Methods
The key to better communication is measurement within the context of an evidence-based, protocol-driven clinical rehabilitation model. Measurement is the key to better communication among providers treating spinal pain. Measurement means acquiring both patient-reported outcomes (PROs) and clinician-based outcomes (CBOs).
Results
Musculoskeletal strengthening of the lumbar and cervical extensors has been shown to significantly reduce pain and provide successful clinical results for patients suffering from chronic back and neck pain. Lumbar strengthening has been successful because it is a safe exercise, it is prescribed based on pretreatment evaluation, and it provides objective measurements.
Conclusion
Without measurement, clinical results rely more on opinion than on objectively prescribed courses of treatment. Although indirect measures (PROs) are typically presented in clinical papers and clinical reviews, they are not often used in normal physical therapy practices. Adding direct patient-performance measures (CBOs) creates a much clearer clinical picture. The key to understanding the value of clinical practice and its predictable impact on patient treatment is objective measurement.
PMCID: PMC3963038
Back muscles; exercise therapy; muscle strength; outcome assessment (health care); resistance training
4.  Neurologically Intact Patient Following Bilateral Facet Dislocation: Case Report and Review of Literature 
The Ochsner Journal  2014;14(1):108-111.
Background
Complete spinal cord lesions and quadriplegia occur in 50%-84% of patients with bilateral facet dislocation. We present a patient who suffered both bilateral facet dislocation and bilateral pedicle fractures while remaining neurologically intact. Based on this case and our literature review, we hypothesize that bilateral facet dislocations without neurological deficits are accompanied by significant associated fractures that facilitate the maintenance of cervical spine canal patency.
Case Report
After a fall down a flight of stairs, an 86-year-old woman presented to the hospital complaining of neck pain. She denied numbness and weakness of her extremities. On physical examination she was neurologically intact without focal sensory or motor deficits and with normal reflexes throughout. Computed tomography (CT) of her neck demonstrated bilateral C5-C6 facet dislocation with locking of the C6 superior articular process dorsal to the C5 inferior articular process, as well as corresponding bilateral C6 pedicle fractures. Additional acute fractures were identified on the thoracic CT. Magnetic resonance imaging demonstrated no spinal cord compression, edema, or hemorrhage. The patient had a C6-C7 anterior cervical discectomy and allograft fusion and a C5-T1 anterior cervical plate with screw fixation.
Conclusion
Because bilateral facet dislocations without neurological deficits are rare, the most appropriate surgical intervention is not evident. We believe the best choice as a first step is an anterior cervical discectomy and allograft fusion with plating.
PMCID: PMC3963039
Cervical vertebrae; decompression–surgical; spinal canal; spinal cord compression; traction
5.  Fetal Surgery: The Ochsner Experience with In Utero Spina Bifida Repair 
The Ochsner Journal  2014;14(1):112-118.
Background
Myelomeningocele is the most common form of congenital central nervous system defect that is compatible with life. Most patients with myelomeningocele have significant functional impairment of ambulation and bowel and bladder function, require permanent cerebrospinal fluid diversion with shunting, and have significant morbidity and mortality from hindbrain herniation (Chiari II malformation). The advent of intrauterine surgery has provided new opportunities to better address this lifelong debilitating disease.
Case Report
The patient was a 19-year-old gravida 2 para 1 at 22-6/7 weeks whose fetus was diagnosed with an open neural tube defect and further demonstrated to have ventriculomegaly and hindbrain herniation. Amniocentesis confirmed normal karyotype and the presence of acetylcholinesterase. After an intrauterine procedure, the patient underwent cesarean section at 35-5/7 weeks and delivered a male infant. His spinal incision was well healed at birth without any evidence of cerebrospinal fluid leakage, and his extremities were normal in appearance, range of motion, and movement. The infant also has maintained relatively normal, age-appropriate bowel and bladder function and has no obvious neurologic deficit.
Conclusion
As the benefit of fetal surgery becomes more widely accepted, quality of care and patient safety must be at the forefront of any institution's effort to offer fetal surgery. Given the current prevalence of spina bifida and the amount of resources required to treat this disease effectively either in utero or postnatally, it is our opinion that the treatment of spina bifida should be regionalized to tertiary referral centers with the interdisciplinary expertise to offer comprehensive treatment for all aspects of the disease and all phases of care for the patients.
PMCID: PMC3963040
Arnold-Chiari malformation; fetal therapies; hydrocephalus; hysterotomy; meningomyelocele; spinal dysraphism; ventriculoperitoneal shunt
6.  Successful Treatment of Occipital Neuralgia with Implantable Peripheral Nerve Stimulation in a Pacemaker-Dependent Patient 
The Ochsner Journal  2014;14(1):119-122.
Background
Peripheral nerve stimulation has been used to treat patients with occipital nerve–related chronic headaches who have been unsuccessful with less invasive therapeutic approaches. Patients with pacemaker-dependent cardiac conduction abnormalities require unique consideration prior to the implantation of peripheral nerve stimulators because the placement of the devices may lead to failure of the systems secondary to electromagnetic interference or crosstalk between the devices.
Case Report
An 86-year-old female who suffered from chronic right-sided cervicogenic headaches and neck pain had received only temporary relief from previous treatments. Additional comorbidities included longstanding pacemaker-dependent atrioventricular node conduction disease. Because the extent to which nerve stimulators electrically interact with pacemakers is unclear, we tunneled the leads to the lumbar region of the back and placed the generator on the contralateral side to the pacemaker to minimize the chance that the 2 devices would interfere. The patient has remained pain free for 1 year since implantation.
Conclusion
Although no current published trials evaluate the degree of interference between medical devices, case reports increasingly suggest that simultaneous implantation of a spinal cord stimulator and pacemaker is safe as long as precautions are taken and the devices are checked periodically, particularly when the devices are adjusted.
PMCID: PMC3963041
Implantable neurostimulators; neuralgia; pacemaker–artificial; transcutaneous electric nerve stimulation
8.  Caudal Vertebral Body Fractures Following Lateral Interbody Fusion in Nonosteoporotic Patients 
The Ochsner Journal  2014;14(1):123-130.
Background
The minimally invasive lateral transpsoas approach for lumbar fusions has become increasingly popular. However, vertebral body fractures have been reported after this procedure, particularly in patients with osteoporosis and patients undergoing multilevel fusions. We evaluated the risk factors for caudal vertebral body fractures in 2 nonosteoporotic patients with single-level disease.
Case Reports
Two patients presented with several years' history of incapacitating chronic low back pain and intermittent radicular pain. Diagnostic imaging in both cases demonstrated grade 1 degenerative spondylolisthesis. The patients underwent a lateral transpsoas interbody fusion, with lateral plate fixation in 1 patient and standalone lateral fusion in the other. The operations were performed without any incidents and both patients experienced immediate symptom relief. Both patients returned several weeks later with excruciating low back pain, without any postoperative history of trauma or heavy lifting. Diagnostic imaging in both patients showed a coronal fracture of the inferior vertebral body. The patients underwent urgent revision surgery involving posterior supplementation with pedicle screw and rod constructs and posterolateral fusion.
Conclusion
Caudal vertebral body fracture in patients with normal bone quality is a major potential complication after the minimally invasive lateral approach for lumbar fusions. Risk factors may include placement of a lateral plate, the size of the smaller anteroposterior cage, endplate violation, and oblique placement of the interbody cage.
PMCID: PMC3963043
Low back pain; psoas muscles; spinal fractures; spinal fusion; surgical procedures–minimally invasive
9.  Urgent Cesarean Section in a Patient with a Spinal Cord Stimulator: Implications for Surgery and Anesthesia 
The Ochsner Journal  2014;14(1):131-134.
Background
Spinal cord stimulation used in the treatment of chronic pain is offered to women of child-bearing age. This practice warrants special consideration on the part of the obstetricians and anesthesiologists charged with their care.
Case Report
We report the instance of a parturient with a spinal cord stimulator who presented for urgent cesarean section. In spite of the patient's daunting back examination, the suitability of neuraxial anesthesia for cesarean delivery was rapidly determined by accessing images in our centerwide electronic medical record system.
Conclusion
Accepted approaches to managing labor and delivery—such as neuraxial anesthesia and analgesia—need not be denied patients with spinal cord stimulators. Whenever possible, however, the pain specialist should communicate the specific characteristics of the implanted device to the team who will manage the patient in the peripartal period.
PMCID: PMC3963044
Anesthesia–spinal; cesarean section; pain management
10.  One-Stage Resection of Giant Invasive Thoracic Schwannoma: Case Report and Review of Literature 
The Ochsner Journal  2014;14(1):135-140.
Background
Schwannomas comprise approximately 25% of all spinal tumors, being the third most frequent soft-tissue tumor after hemangiomas and lipomas. Grade 5 invasive giant schwannomas erode the vertebral bodies, involve 2 or more levels, and invade the myofascial planes. Because 3 compartments are involved, these tumors represent a surgical challenge and frequently require staged surgeries with a multidisciplinary surgical team.
Case Report
We report the case of a 62-year-old female who presented with intermittent upper back pain for 3 years. A magnetic resonance imaging scan of the thoracic spine showed a mass invading the vertebral body, pedicle, and lamina of T4 and part of T3 and T5. Needle biopsy confirmed the diagnosis of schwannoma. The patient underwent surgery using a parascapular extracavitary costotransversectomy approach.
Conclusion
Giant invasive spinal schwannomas are rare in the thoracic spine, and surgical approaches usually have entailed multiple-stage surgeries with the assistance of other surgical specialties. Our 1-stage complete surgical resection of a giant invasive spinal schwannoma used a parascapular costotransversectomy approach that maintained spinal stability and thus avoided the need for instrumentation.
PMCID: PMC3963045
Instrumentation; laminectomy; neuroma; spinal fusion
12.  Lateral Lumbar Interbody Fusion for the Correction of Spondylolisthesis and Adult Degenerative Scoliosis in High-Risk Patients: Early Radiographic Results and Complications 
The Ochsner Journal  2014;14(1):23-31.
Background
Lateral lumbar interbody fusion (LLIF) is not associated with many of the complications seen in other interbody fusion techniques. This study used computed tomography (CT) scans, the radiographic gold standard, to assess interbody fusion rates achieved utilizing the LLIF technique in high-risk patients.
Methods
We performed a retrospective review of patients who underwent LLIF between January 2008 and July 2013. Forty-nine patients underwent nonstaged or staged LLIF on 119 levels with posterior correction and augmentation. Per protocol, patients received CT scans at their 1-year follow-up. Of the 49 patients, 21 patients with LLIF intervention on 54 levels met inclusion criteria. Two board-certified musculoskeletal radiologists and the senior surgeon (JZ) assessed fusion.
Results
Of the 21 patients, 6 patients had had previous lumbar surgery, and the cohort's comorbidities included osteoporosis, diabetes, obesity, and smoking, among others. Postoperative complications occurred in 12 (57.1%) patients and included anterior thigh pain and weakness in 6 patients, all of which resolved by 6 months. Two cases of proximal junctional kyphosis occurred, along with 1 case of hardware pullout. Two cases of abdominal atonia occurred. By CT scan assessment, each radiologist found fusion was achieved in 53 of 54 levels (98%). The radiologists' findings were in agreement with the senior surgeon.
Conclusion
Several studies have evaluated LLIF fusion and reported fusion rates between 88%-96%. Our results demonstrate high fusion rates using this technique, despite multiple comorbidities in the patient population. Spanning the ring apophysis with large LLIF cages along with supplemental posterior pedicle screw augmentation can enhance stability of the fusion segment and increase fusion rates.
PMCID: PMC3963047
Comorbidity; lumbar vertebrae; spinal fusion; surgical procedures–minimally invasive; tomography–x-ray computed
14.  Minimally Invasive Versus Open Transforaminal Lumbar Interbody Fusion for Degenerative Spondylolisthesis Grades 1-2: Patient-Reported Clinical Outcomes and Cost-Utility Analysis 
The Ochsner Journal  2014;14(1):32-37.
Background
Transforaminal lumbar interbody fusion (TLIF) is the standard surgical treatment for patients with lumbar degenerative spondylolisthesis who do not respond to a 6-week course of conservative therapy. A number of morbidities are associated with the conventional open-TLIF method, so minimally invasive surgery (MIS) techniques for TLIF (MIS-TLIF) have been introduced to reduce the trauma to paraspinal muscles and hasten postoperative recovery. Because providing cost-effective medical treatment is a core initiative of healthcare reforms, a comparison of open-TLIF and MIS-TLIF must include a cost-utility analysis in addition to an analysis of clinical effectiveness.
Methods
We compared patient-reported clinical functional outcomes and hospital direct costs in age-matched patients treated surgically with either open-TLIF or MIS-TLIF. Patients were followed for at least 1 year, and patient scores on the Oswestry Disability Index (ODI) and visual analog scale (VAS) were analyzed at 6 weeks, 6 months, and ≥1 year postoperatively in the 2 treatment groups.
Results
Compared to their preoperative scores, patients in both the open-TLIF and MIS-TLIF groups had significant improvements in the ODI and VAS scores at each follow-up point, but no significant difference in functional outcome occurred between the open-TLIF and MIS-TLIF groups (P=0.46). However, open-TLIF is significantly more costly compared to MIS-TLIF (P=0.0002).
Conclusion
MIS-TLIF is a more cost-effective treatment than open-TLIF for patients with degenerative spondylolisthesis and is equally effective as the conventional open-TLIF procedure, although further financial analysis—including an analysis of indirect costs—is needed to better understand the full benefit of MIS-TLIF.
PMCID: PMC3963049
Costs and cost analysis; outcome assessment; pain measurement; spinal fusion; spinal instrumentation; spondylolisthesis; surgical procedures–minimally invasive
15.  Minimally Invasive Laminectomy in Spondylolisthetic Lumbar Stenosis 
The Ochsner Journal  2014;14(1):38-43.
Background
Degenerative lumbar stenosis associated with spondylolisthesis is common in elderly patients. The most common symptoms are those of neurogenic claudication with leg pain. Surgery is indicated for those who fail conservative management. The generally accepted recommendation is to perform a laminectomy and a fusion at the involved level.
Methods
We reviewed our results for minimally invasive single-level decompression without fusion performed by the senior author in patients with symptomatic lumbar stenosis with spondylolisthesis with no dynamic instability from 2008 to 2011 at a single institution. Outcomes were measured using the visual analog scale (VAS), Prolo Economic Functional Rating Scale, and revised Oswestry Disability Index (ODI) at initial presentation and at 3-month, 6-month, and 1-year follow-up time points.
Results
Records for 28 patients (19 males, 9 females) were reviewed. The success rate, defined as improvement in pain and functional outcome without the need for surgical fusion, was 86%. VAS scores decreased by 6.3 points, Prolo scores increased by 3.5 points, and the ODI decreased by 31% at 1 year. All changes were statistically significant.
Conclusion
Minimally invasive decompression alone can be a reasonable alternative to decompression and fusion for patients with spondylolisthetic lumbar stenosis and neurogenic claudication with leg pain. Decompression without fusion should be considered for older patients and for patients who are not ideal fusion candidates.
PMCID: PMC3963050
Laminectomy; lumbar vertebrae; spinal stenosis; spondylolisthesis; surgical procedures–minimally invasive
16.  The Effects of Lumbar Facet Dowels on Joint Stiffness: A Biomechanical Study 
The Ochsner Journal  2014;14(1):44-50.
Background
Facet joint arthrosis may play a significant role in low back pain generation. The placement of facet dowels is a percutaneous treatment that aims to fuse the facets and increase joint stiffness. In this cadaveric study, we evaluated spine stiffness after facet dowel insertion in combination with several surgical procedures and determined which motions promote dowel migration.
Methods
Six fresh frozen lumbar spines were tested in flexion-extension, lateral bending, and axial rotation. Spine stiffness was determined for the intact specimens, after L4 laminectomy, and after bilateral L4-L5 facet dowel placement, respectively. One specimen underwent a unilateral transforaminal lumbar interbody fusion (TLIF) construct and another underwent extreme lateral interbody fusion (XLIF) graft (22 mm) placement, followed by placement of facet dowels. Afterwards, the specimens were subjected to 10,000 cycles of fatigue testing in flexion-extension or axial rotation.
Results
The overall decrease in stiffness after laminectomy was 4.6%. Facet dowel placement increased overall stiffness by 7.2%. The greatest increase was seen with axial rotation (13%), compared to flexion, extension, and lateral bending (9.5%, 2.3%, and 5.6%, respectively). The TLIF and XLIF plus dowel construct increased specimen stiffness to 266% and 163% of baseline, respectively. After fatigue testing, dowel migration was detected by computed tomography in the 2 uninstrumented specimens undergoing axial rotation cycling.
Conclusion
Facet dowels increase the stiffness of the motion segment to which they are applied and can be used in conjunction with laminectomy procedures to increase the stiffness of the joint. However, dowel migration can occur after axial rotation movements. Hybrid TLIF or XLIF plus facet dowel constructs have significantly higher stiffness than noninstrumented ones and may prevent dowel migration.
PMCID: PMC3963051
Biomechanics; foreign-body migration; instrumentation; laminectomy; low back pain; lumbar vertebrae; surgical procedures–minimally invasive
17.  Midline Minimally Invasive Placement of Spinal Cord Stimulators: A Technical Note 
The Ochsner Journal  2014;14(1):51-56.
Background
Spinal cord stimulators (SCSs) have conventionally been implanted through open approaches requiring extensive muscle dissection to perform laminectomies and permanently place the paddle lead. This approach could contribute to worsening the pain syndrome in patients who experience chronic pain. In an attempt to reduce operative times, minimize blood loss and postoperative pain, and ease the technical challenges of placing the paddle lead in the midline via a paramedian and off-midline incision, we designed a new minimally invasive surgery (MIS) technique to place the paddle lead using a tubular retractor system through a true midline approach.
Methods
We performed a retrospective review of all MIS paddle lead placements performed by the senior author between October 2010 and June 2013. Patient demographics; clinical indications for placement of paddle lead; location of paddle lead; and perioperative data including blood loss, length of surgery, and surgical and perioperative morbidity were recorded.
Results
Between October 2010 and June 2013, 78 patients had MIS placement of paddle lead SCSs. Patient ages ranged from 27 to 87 years old, with a mean age of 59. The most common levels for paddle lead placement were T8 and T9. No minor or major neurologic complications occurred in our patient population. No patient was readmitted after being discharged from the hospital and all surgeries were outpatient procedures. We had a migration rate comparable to open techniques and minimal blood loss.
Conclusion
Our technique is safe and effective and carries minimal surgical morbidity compared to standard open techniques for placement of SCSs.
PMCID: PMC3963052
Back pain; electric stimulation therapy; spinal cord; spinal cord stimulation; surgical procedures–minimally invasive
18.  Intraoperative Neurophysiological Monitoring for Minimally Invasive 1- and 2-Level Transforaminal Lumbar Interbody Fusion: Does It Improve Patient Outcome? 
The Ochsner Journal  2014;14(1):57-61.
Background
Despite the widespread use of intraoperative monitoring (IOM) in many types of spinal surgeries, an absence of data comparing monitored a nd unmonitored postoperative outcomes places IOM's efficacy into question. A lack of consensus among surgeons about when to use monitoring also raises concerns about its overuse in routine and low-risk procedures.
Methods
We performed a retrospective database review of 112 patients undergoing a 1- or 2-level minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF). Our analysis focused on patient demographics, use of IOM, length of surgery, hospital length of stay, the perioperative complication of pedicle screw malposition, and average hospital cost.
Results
For the 73 patients who underwent MIS-TLIF with intraoperative neuromonitoring, their hospital length of stay (P=0.8) and need for pedicle screw revisions (P=0.93) were not statistically significant compared to the 39 patients who underwent MIS-TLIF procedures without IOM. The incidence of reoperation was 5.48% and 5.13%, and average length of stay was 3.25 days and 3.13 days, respectively. However, the cost of surgery and the length of surgery were significantly higher in the monitored group compared to the nonmonitored group (P=0.008 and P=0.009, respectively).
Conclusion
IOM is widely used in spine surgery, but our retrospective review shows that its use does not necessarily decrease the incidence of malpositioning of pedicle screws. In fact, no statistical difference was detected in the incidence of screw malposition in the 2 groups of patients. On the other hand, IOM adds cost and increases the length of surgery. Because the use of IOM did not make a difference in the incidence of pedicle screw malpositioning and because of the comparative cost analysis for both groups of patients, we believe that the use of IOM for MIS-TLIF provides no added benefit.
PMCID: PMC3963053
Monitoring–intraoperative; spinal fusion; surgical procedures–minimally invasive
19.  Interlaminar Epidural Steroid Injection for Degenerative Lumbar Spinal Canal Stenosis: Does the Intervertebral Level of Performance Matter? 
The Ochsner Journal  2014;14(1):62-66.
Background
Interlaminar epidural steroid injections (ILESIs) are commonly employed in the management of patients with symptomatic degenerative lumbar spinal canal stenosis despite little experimental evidence to guide technique optimization. One untested performance parameter is the intervertebral level at which the ILESI should be performed for maximum patient relief.
Methods
This study randomized patients with symptomatic degenerative lumbar spinal canal stenosis to receive an ILESI at the level of maximal spinal canal stenosis or at a normal/less stenotic intervertebral site 2 intervertebral levels cephalad to the level of maximal stenosis. Pain with ambulation and Roland Morris Disability Questionnaire scores were collected prior to the procedure and at 1-, 4-, and 12-week follow-ups.
Results
Fifty-seven patients were enrolled. Thirty patients (Group 1) received an ILESI at the level of maximal stenosis; 27 patients (Group 2) received an ILESI at a less stenotic level. The mean baseline preprocedural maximal pain with ambulation and disability scores for the 2 groups were not significantly different (P=0.94 and P=0.13, respectively). Patients' pain with ambulation scores were significantly lower in Group 1 compared to Group 2 at 1 and 4 weeks postinjection, but they were not significantly lower at 12 weeks (1 week, P=0.045; 4 weeks, P=0.049; 12 weeks, P=0.08). The mean Roland Morris Disability Questionnaire scores at 1, 4, and 12 weeks postinjection were significantly lower in Group 1 as compared to Group 2 (P=0.001, P=0.009, P=0.003, respectively).
Conclusion
Results suggest that patient symptom improvement is optimized when the ILESI is performed at the intervertebral level of maximal stenosis.
PMCID: PMC3963054
Injections–epidural; low back pain; spinal stenosis
20.  Likelihood of Reaching Minimal Clinically Important Difference in Adult Spinal Deformity: A Comparison of Operative and Nonoperative Treatment 
The Ochsner Journal  2014;14(1):67-77.
Background
Few studies have examined threshold improvements in health-related quality of life (HRQOL) by measuring minimal clinically important differences (MCIDs) in treatment of adult spinal deformity. We hypothesized that patients undergoing operative treatment would be more likely to achieve MCID threshold improvement compared with those receiving nonoperative care, although a subset of nonoperative patients may still reach threshold.
Methods
We analyzed a multicenter, prospective, consecutive case series of 464 patients: 225 nonoperative and 239 operative. To be included in the study, patients had to have adult spinal deformity, be older than 18 years, and have both baseline and 1-year follow-up HRQOL measures (Oswestry Disability Index [ODI], Short Form-36 [SF-36] health survey, and Scoliosis Research Society-22 [SRS-22] questionnaire). We compared the percentages of patients achieving established MCID thresholds between operative and nonoperative groups using risk ratios (RR) with a 95% confidence interval (CI).
Results
Compared to nonoperative patients, surgical patients demonstrated significant mean improvement (P<0.01) and were more likely to achieve threshold MCID improvement across all HRQOL scores (ODI RR = 7.37 [CI 4.45, 12.21], SF-36 physical component score RR = 2.96 [CI 2.11, 4.15], SRS Activity RR = 3.16 [CI 2.32, 4.31]). Furthermore, operative patients were more likely to reach threshold MCID improvement in 2 or more HRQOL measures simultaneously and were less likely to deteriorate.
Conclusion
Patients in both the operative and nonoperative treatment groups demonstrated improvement in at least one HRQOL measure at 1 year. However, surgical treatment was more likely to result in threshold improvement and more likely to lead to simultaneous improvement across multiple measures of ODI, SF-36, and SRS-22. Although a subset of nonoperative patients achieved threshold improvement, nonoperative patients were significantly less likely to improve in multiple HRQOL measures and more likely to sustain MCID deterioration or no change.
PMCID: PMC3963055
Disability evaluation; pain management; quality of life; spinal cord diseases; surgical procedures–operative
22.  Adjacent Segment Disease Perspective and Review of the Literature 
The Ochsner Journal  2014;14(1):78-83.
Background
Adjacent segment disease has become a common topic in spine surgery circles because of the significant increase in fusion surgery in recent years and the development of motion preservation technologies that theoretically should lead to a decrease in this pathology. The purpose of this review is to organize the evidence available in the current literature on this subject.
Methods
For this literature review, a search was conducted in PubMed with the following keywords: adjacent segment degeneration and disease. Selection, review, and analysis of the literature were completed according to level of evidence.
Results
The PubMed search identified 850 articles, from which 41 articles were selected and reviewed. The incidence of adjacent segment disease in the cervical spine is close to 3% without a significant statistical difference between surgical techniques (fusion vs arthroplasty). Authors report the incidence of adjacent segment disease in the lumbar spine to range from 2% to 14%. Damage to the posterior ligamentous complex and sagittal imbalances are important risk factors for both degeneration and disease.
Conclusion
Insufficient evidence exists at this point to support the idea that total disc arthroplasty is superior to fusion procedures in minimizing the incidence of adjacent segment disease. The etiology is most likely multifactorial but it is becoming abundantly clear that adjacent segment disease is not caused by motion segment fusion alone. Fusion plus the presence of abnormal end-fusion alignment appears to be a major factor in creating end-fusion stresses that result in adjacent segment degeneration and subsequent disease. The data presented cast further doubt on previously established rationales for total disc arthroplasty, at least with regard to the effect of total disc arthroplasty on adjacent segment degeneration pathology.
PMCID: PMC3963057
Arthrodesis; arthroplasty; cervical vertebrae; intervertebral disc degeneration; lumbar vertebrae; spinal diseases; spinal fusion; total disc replacement
23.  Coccydynia: An Overview of the Anatomy, Etiology, and Treatment of Coccyx Pain 
The Ochsner Journal  2014;14(1):84-87.
Background
Despite its small size, the coccyx has several important functions. Along with being the insertion site for multiple muscles, ligaments, and tendons, it also serves as one leg of the tripod—along with the ischial tuberosities—that provides weight-bearing support to a person in the seated position. The incidence of coccydynia (pain in the region of the coccyx) has not been reported, but factors associated with increased risk of developing coccydynia include obesity and female gender.
Methods
This article provides an overview of the anatomy, physiology, and treatment of coccydynia.
Results
Conservative treatment is successful in 90% of cases, and many cases resolve without medical treatment. Treatments for refractory cases include pelvic floor rehabilitation, manual manipulation and massage, transcutaneous electrical nerve stimulation, psychotherapy, steroid injections, nerve block, spinal cord stimulation, and surgical procedures.
Conclusion
A multidisciplinary approach employing physical therapy, ergonomic adaptations, medications, injections, and, possibly, psychotherapy leads to the greatest chance of success in patients with refractory coccyx pain. Although new surgical techniques are emerging, more research is needed before their efficacy can be established.
PMCID: PMC3963058
Coccyx; pain–intractable; sacrococcygeal region
24.  Effective Spine Triage: Patterns of Pain 
The Ochsner Journal  2014;14(1):88-95.
Background
The most common cause of recurring lost time from work, low back pain is a huge burden on society. Medical training dictates that we must establish a cause for pain before we can treat it and then base our treatment on a recognized and agreed-upon pathology. But in the overwhelming majority of low back pain cases, the issue is nothing more than a minor mechanical malfunction, the inevitable consequence of normal wear and tear. The severity of the pain does not reflect the benign nature of the underlying problem and its limited extent makes a definitive diagnosis impossible. One important component of the solution is improved spinal triage. Using patterns or syndromes in the initial assessment of low back pain is gaining renewed interest and clinical acceptance.
Methods
Identifying a patient's pain pattern is achieved primarily through an assessment of the patient's history. The patient interview begins with a series of questions to determine the specific syndrome. A subsequent physical examination supports or refutes the findings in history. Combining information from the history with the findings of the physical examination, the clinician has the ability to rule out a number of potentially grim diagnoses.
Results
More than 90% of back pain patients have benign mechanical problems and their pain can be classified into 4 distinct patterns: 2 back-dominant patterns and 2 leg-dominant patterns.
Conclusion
A clinical perspective capable of recognizing a defined syndrome at first contact will lead to a better outcome. Most patients with low back pain can be treated successfully with simple, pattern-specific, noninvasive primary management. Patients without a pattern and those who do not respond as anticipated require further investigation and specialized care.
PMCID: PMC3963059
Low back pain; medical history taking; patient positioning; physical examination; triage

Results 1-25 (820)