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Thread: Regarding likely outcome on pain

  1. #91
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    Quote Originally Posted by hdugger View Post
    Do you have a sense of why their results are so different from this study:

    http://www.ncbi.nlm.nih.gov/pubmed/19365253?ordinalpos=1&itool=EntrezSystem2.PEntrez. Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.P ubmed_Discovery_RA&linkpos=2&log$=relatedarticles& logdbfrom=pubmed

    The UCSF center has almost three times the number of reoperations (25% compared to 9% at the Washington University site.) Even odder considering that the UCSF study covers significantly fewer years.

    Reoperation after primary fusion for adult spinal deformity: rate, reason, and timing.
    Mok JM, Cloyd JM, Bradford DS, Hu SS, Deviren V, Smith JA, Tay B, Berven SH.

    Department of Orthopedic Surgery, University of California, San Francisco, CA 94143-0728, USA.
    STUDY DESIGN: Retrospective cohort study of consecutive patients undergoing primary fusion with segmental fixation for adult spinal deformity. OBEJCTIVE: We sought to determine the survivorship of primary fusion for adult spinal deformity and identify patient-specific predictors of complications requiring reoperation. SUMMARY OF BACKGROUND DATA: Compared with the adolescent population, surgery for adult deformity is often more complex and technically difficult, contributing to a high reported rate of complications that can result in the need for reoperation. Reported complication rates vary widely. METHODS: From 1999-2004 all patients who underwent primary instrumented fusion for nonparalytic adult spinal deformity at a single center were included. Inclusion criteria included minimum age at surgery of 20 years and minimum fusion length of 4 motion segments. Surgical, demographic, and comorbidity data were recorded. Reoperation was defined as any additional surgery involving levels of the spine operated on during the index procedure and/or adjacent levels. Comparisons were performed between patients who required reoperation and those who did not. RESULTS: Eighty-nine patients met inclusion criteria. Endpoint (minimum 2 years follow-up or reoperation) was reached for 91%. Mean follow-up was 3.8 years. Cumulative reoperation rate was 25.8%. Survival was 86.4% at 1 year, 77.2% at 2 years, and 75.2% at 3 years. Reasons for reoperation included infection (n = 8), pseudarthrosis (n = 3), adjacent segment problems (n = 5), implant failure (n = 4), and removal of painful implants (n = 3). Multivariate analysis showed smoking was significantly higher in the reoperation group. CONCLUSION: Using a strict definition of reoperation for a well-defined cohort, in the presence of relevant risk factors, many patients undergoing primary fusion for adult spinal deformity required reoperation. The results indicate that complex medical and surgical factors contribute to the treatment challenges posed by patients with adult spinal deformity. This represents the largest cohort reported to date of patients undergoing primary fusion using third-generation instrumentation techniques.
    I don't know if the St. Louis paper was single center, or if they used the Spinal Deformity Study Group database (which includes the UCSF patients). It's difficult to know the exact details, but there's one obvious big difference. The SF study had a minimum age of 20, and the St. Louis study had a minimum age of 18. I suspect a lot of the St. Louis cohort was 18 or 19 years old (probably the most common age for AIS surgery).

    --Linda

  2. #92
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    Quote Originally Posted by LindaRacine View Post
    I don't know if the St. Louis paper was single center, or if they used the Spinal Deformity Study Group database (which includes the UCSF patients). It's difficult to know the exact details, but there's one obvious big difference. The SF study had a minimum age of 20, and the St. Louis study had a minimum age of 18. I suspect a lot of the St. Louis cohort was 18 or 19 years old (probably the most common age for AIS surgery).

    --Linda
    Wow. If that pans out it will stand on the continuum with the kids having very low revision rates as far as anyone knows. It will also be a very good incentive to have this surgery as early as possible.

    I'd like to see a graph of revision rate versus patient age. It might be a tighter correlation than even Cobb angle or sagittal balance. That would be very interesting indeed.
    Last edited by Pooka1; 01-03-2010 at 01:58 PM.
    Sharon, mother of identical twin girls with scoliosis

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  3. #93
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    Quote Originally Posted by hdugger View Post
    The St. Louis paper was single center.

    Do you have access to the entire papers? It would be interesting to look at the age distribution. Without that, I'd certainly like to know why UCSF is seeing so much worse results than Washington University.
    The answer, if it has to do with surgeon experience, might be incendiary and create a problem for new surgeons trying to break into the field.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  4. #94
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    Quote Originally Posted by Pooka1 View Post
    Wow. If that pans out it will stand on the continuum with the kids having very low revision rates as far as anyone knows. It will also be a very good incentive to have this surgery as early as possible.

    I'd like to see a graph of revision rate versus patient age. It might be a tighter correlation than even Cobb angle or sagittal balance. That would be very interesting indeed.
    Sharon...

    I'm not nearly as gung ho about surgery as you are, but thought you'd like this:

    Complications of spinal fusion for scheuermann kyphosis: a report of the scoliosis research society morbidity and mortality committee.

    Coe JD, Smith JS, Berven S, Arlet V, Donaldson W, Hanson D, Mudiyam R, Perra J, Owen J, Marks MC, Shaffrey CI.

    Silicon Valley Spine Institute, Campbell, CA 95008, USA. jcoe@svspine.com

    STUDY DESIGN: Retrospective review of a prospectively collected, multicentered database from the Scoliosis Research Society. OBJECTIVES: To evaluate incidences of complications in a series of spinal fusions for Scheuermann kyphosis (SK) and to assess whether the incidence of complications is associated with patient age and surgical approach. SUMMARY OF BACKGROUND DATA: Although there is some evidence that adolescents have lower complication rates for spinal deformity surgery, this has not been well-documented for SK. Moreover, there is a lack of consensus on surgical approach for the management of SK. METHODS: The Scoliosis Research Society morbidity and mortality database was queried to identify cases of SK from 2001 to 2004. Complications rates were analyzed based on patient age and surgical approach. Pediatric and adult patients were defined as <or=19 and >19 year old, respectively. RESULTS: A total of 683 procedures involving spinal fusion for SK were identified. Mean patient age was 21 years (range: 5-75 years), with the majority (73%) of patients <or=19 years old. Procedures included 338 (49%) posterior spinal fusions (PSF), 73 (11%) anterior spinal fusions (ASF), and 272 (40%) same-day ASF and PSF. Ninety-nine complications were reported (14%). The most common complication was wound infection (3.8%). The acute neurologic complication rate was 1.9%, including 4 spinal cord injuries (0.6%). The mortality rate was 0.6%. Complications were more common among adult (22%) compared with pediatric patients (12%) (P = 0.002). The overall incidence of complications did not differ significantly between the PSF (14.8%) and same-day ASF/PSF (16.9%) procedures (P = 0.5). CONCLUSION: The incidence of complications associated with spinal fusion for SK in adults is significantly greater than in pediatric patients. There were no significant differences in complication rates between PSF and same-day ASF/PSF procedures. These data may be used to counsel patients regarding complications associated with spinal fusion for SK in the hands of experienced spinal deformity surgeons.

  5. #95
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    Quote Originally Posted by hdugger View Post
    The St. Louis paper was single center.

    Do you have access to the entire papers? It would be interesting to look at the age distribution. Without that, I'd certainly like to know why UCSF is seeing so much worse results than Washington University.
    I've sent an email to Dr. Berven, so will hopefully have some insight soon. I don't have access from home (yet) for the full text.

  6. #96
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    Quote Originally Posted by hdugger View Post
    That may be, but I'd still like to know and I'd expect the surgeons at UCSF to want to know. There's an even more troubling alternate explanation, which is that the new instrumentation is requiring more reoperations. Intuitively, that doesn't make sense, but without the data we can't really say.
    Yes but if you look at the reasons for revision, they are not associated with the new instrumentation over and above the old as far as I know.

    ETA: WRT to pseudoarthrosis rate, I think it is known that that is much lower with the new instrumentation compared to the old, at least with kids. Infection rate is institution dependent as far as I know. And adjacent level failure is at least partially related to lowest instrumented vertebra with the older instrumentation... may not be related to that with the new.

    Linda probably knows more about this type of data.
    Last edited by Pooka1; 01-03-2010 at 02:23 PM.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
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    "We are all African."

  7. #97
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    Quote Originally Posted by hdugger View Post
    Do you have a sense of why their results are so different from this study:

    http://www.ncbi.nlm.nih.gov/pubmed/19365253?ordinalpos=1&itool=EntrezSystem2.PEntrez. Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.P ubmed_Discovery_RA&linkpos=2&log$=relatedarticles& logdbfrom=pubmed

    The UCSF center has almost three times the number of reoperations (25% compared to 9% at the Washington University site.) Even odder considering that the UCSF study covers significantly fewer years.

    Reoperation after primary fusion for adult spinal deformity: rate, reason, and timing.
    Mok JM, Cloyd JM, Bradford DS, Hu SS, Deviren V, Smith JA, Tay B, Berven SH.

    Department of Orthopedic Surgery, University of California, San Francisco, CA 94143-0728, USA.
    STUDY DESIGN: Retrospective cohort study of consecutive patients undergoing primary fusion with segmental fixation for adult spinal deformity. OBEJCTIVE: We sought to determine the survivorship of primary fusion for adult spinal deformity and identify patient-specific predictors of complications requiring reoperation. SUMMARY OF BACKGROUND DATA: Compared with the adolescent population, surgery for adult deformity is often more complex and technically difficult, contributing to a high reported rate of complications that can result in the need for reoperation. Reported complication rates vary widely. METHODS: From 1999-2004 all patients who underwent primary instrumented fusion for nonparalytic adult spinal deformity at a single center were included. Inclusion criteria included minimum age at surgery of 20 years and minimum fusion length of 4 motion segments. Surgical, demographic, and comorbidity data were recorded. Reoperation was defined as any additional surgery involving levels of the spine operated on during the index procedure and/or adjacent levels. Comparisons were performed between patients who required reoperation and those who did not. RESULTS: Eighty-nine patients met inclusion criteria. Endpoint (minimum 2 years follow-up or reoperation) was reached for 91%. Mean follow-up was 3.8 years. Cumulative reoperation rate was 25.8%. Survival was 86.4% at 1 year, 77.2% at 2 years, and 75.2% at 3 years. Reasons for reoperation included infection (n = 8), pseudarthrosis (n = 3), adjacent segment problems (n = 5), implant failure (n = 4), and removal of painful implants (n = 3). Multivariate analysis showed smoking was significantly higher in the reoperation group. CONCLUSION: Using a strict definition of reoperation for a well-defined cohort, in the presence of relevant risk factors, many patients undergoing primary fusion for adult spinal deformity required reoperation. The results indicate that complex medical and surgical factors contribute to the treatment challenges posed by patients with adult spinal deformity. This represents the largest cohort reported to date of patients undergoing primary fusion using third-generation instrumentation techniques.
    From Dr. Berven:

    I moderated this paper at the SRS and there were dramatic differences in the cohorts. The st Louis pts were MUCH younger and mostly AIS. Our pts were primarily degen scolis. The st Louis group had very few pts fused to the pelvis and most of ours were. Very different papers.

    By the way, I believe that Dr. Berven was referring to moderating the St. Louis paper at the SRS (not his own paper).
    Last edited by LindaRacine; 01-03-2010 at 07:24 PM.

  8. #98
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    Quote Originally Posted by LindaRacine View Post
    From Dr. Berven:

    I moderated this paper at the SRS and there were dramatic differences in the cohorts. The st Louis pts were MUCH younger and mostly AIS. Our pts were primarily degen scolis. The st Louis group had very few pts fused to the pelvis and most of ours were. Very different papers.
    Wow it is WAY beyond cool having Linda and her connections here. There is no way we bunnies would have known that absent Linda chasing that down though it might be obvious if we had the entire texts of both papers.

    So it seems that having the surgery before the degenerative changes correlates with a far lower revision rate. And it further seems that it is disadvantageous to wait until the fusion involves the pelvis, if it is at all avoidable, though the revision rate is still pretty low.

    This explanation from the surgeon is an object lesson on how you can't tell a damn thing from abstracts.
    Last edited by Pooka1; 01-03-2010 at 07:30 PM. Reason: spelling
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  9. #99
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    Quote Originally Posted by Ballet Mom View Post
    And there is even a fairly new study showing that there are increasing pain levels at five years versus two years.

    http://www.ncbi.nlm.nih.gov/pubmed/18449045

    Spine (Phila Pa 1976). 2008 May 1;33(10):1107-12.

    Adolescent idiopathic scoliosis patients report increased pain at five years compared with two years after surgical treatment.

    Upasani VV, Caltoum C, Petcharaporn M, Bastrom TP, Pawelek JB, Betz RR, Clements DH, Lenke LG, Lowe TG, Newton PO.

    Department of Orthopedic Surgery, University of California San Diego, San Diego, CA, USA.
    /
    /
    CONCLUSION: There was a statistically significant increase in reported pain from 2 to 5 years after surgical treatment; however, the etiology of worsening pain scores could not be elucidated. Given continued patient satisfaction, the clinical relevance of this small reduction remains unknown. Nevertheless, this observation deserves further evaluation and must be considered in relation to the natural history of this disease
    I think this talk from the 2009 IMAST conference in Vienna that dhugger posted recently addresses this earlier paper. Apparently, this earlier paper deals mostly with anterior surgeries. The newer paper deals with posterior where pain levels were NOT increased between 2 and 5 years. Still, 24 patients. How can that be significant?


    142. Adolescent Idiopathic Scoliosis Patients Treated with Pedicle
    Screw Constructs: Do the Favorable Two Year SRS-30 Outcomes
    Hold Up at Five Year Follow-up?
    Charles H. Crawford MD, Lawrence G. Lenke MD, Woojin Cho MD
    PhD, Ronald A. Lehman MD, Kathryn A. Keeler MD, Timothy R.
    Kuklo MD, Brian A. O’Shaughnessy MD, Michael S. Chang MD,
    Josh D. Auerbach, Brenda Sides MA, Christine Baldus RN MHS,
    Keith Bridwell MD
    USA

    Summary: In AIS patients treated with posterior pedicle screw
    constructs, radiographic parameters and SRS-30 outcomes were
    stable between the 2-year and 5-year follow-up period, except for
    a significant decline in the mental health domain. The significant
    improvements in self-image and function from preoperative to
    2-years post-operative were maintained at 5-year follow-up. Patient
    satisfaction remained high.

    Introduction: Studies have shown improvements in SRS outcomes
    from preop to 2yr postop in patients undergoing surgery for
    adolescent idiopathic scoliosis (AIS). The first report on 5yr SRS-
    24 outcomes in AIS showed increased pain subscores between 2yr
    and 5yr in a multi-center group of 49 AIS patients, 76% of whom
    underwent anterior procedures. (Upasani et al, Spine 2008) 5yr
    SRS-30 outcomes in AIS patients have not been reported. We
    hypothesized that posterior pedicle screw constructs (PPSC) would
    provide stable outcomes between 2yr and 5yr postop.
    Methods: 56 AIS pts from a single center treated with PPSC were
    analyzed for changes in SRS-30 questionnaires between 2yr and 5yr
    follow-up. Additionally, detailed radiographic measurements were
    obtained and correlated with changes in SRS-30 outcomes.

    Results: (Table 1) The avg age at surgery was 14+9. Female:male
    was 44:12. An avg 10.2 levels were instrumented with an avg of
    17.2 pedicle screws. The most frequent curve type was Lenke type
    1A (30.4%), followed by type 2A (12.5%). 39% of patients had
    a thoracoplasty procedure. Avg major Cobb measured 61° preop
    with correction to 22° at 5yr (66% correction). There were no
    significant radiographic or SRS outcome changes between 2yr
    and 5yr, except for a decrease in the mental health subscore (4.28
    vs 4.08,p=0.02). There was an insignificant trend towards more
    pain (4.28 vs 4.13,p=0.18) including 7 patients who had pain
    attributable to a recent injury (n=5) or a new job (n=2). Excluding
    these 7 patients there was no change in the 2yr to 5yr pain (4.32
    vs 4.30,p=0.85), while the decline in mental health remained
    significant (4.34 vs 4.10,p=0.02). Significant improvements in
    self-image and function from preop to 2yr were maintained at 5yr.
    Changes in mental health and pain were not significantly correlated
    with any demographic or radiographic variables.

    Conclusion: At 5yrs, the 2yr improvements in SRS subscores for
    function and self-image remained stable, although there was a
    decline in mental health in this young adult population. Contrary
    to a previous report of primarily anterior procedures, pain levels
    were not increased between 2yrs and 5yrs in patients treated with
    PPSC.

    Significance: This is the first report on 5yr SRS-30 outcomes in
    AIS patients.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  10. #100
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    Quote Originally Posted by Pooka1 View Post
    I think this talk from the 2009 IMAST conference in Vienna that dhugger posted recently addresses this earlier paper. Apparently, this earlier paper deals mostly with anterior surgeries. The newer paper deals with posterior where pain levels were NOT increased between 2 and 5 years. Still, 24 patients. How can that be significant?


    142. Adolescent Idiopathic Scoliosis Patients Treated with Pedicle
    Screw Constructs: Do the Favorable Two Year SRS-30 Outcomes
    Hold Up at Five Year Follow-up?
    Charles H. Crawford MD, Lawrence G. Lenke MD, Woojin Cho MD
    PhD, Ronald A. Lehman MD, Kathryn A. Keeler MD, Timothy R.
    Kuklo MD, Brian A. O’Shaughnessy MD, Michael S. Chang MD,
    Josh D. Auerbach, Brenda Sides MA, Christine Baldus RN MHS,
    Keith Bridwell MD
    USA

    Summary: In AIS patients treated with posterior pedicle screw
    constructs, radiographic parameters and SRS-30 outcomes were
    stable between the 2-year and 5-year follow-up period, except for
    a significant decline in the mental health domain. The significant
    improvements in self-image and function from preoperative to
    2-years post-operative were maintained at 5-year follow-up. Patient
    satisfaction remained high.

    Introduction: Studies have shown improvements in SRS outcomes
    from preop to 2yr postop in patients undergoing surgery for
    adolescent idiopathic scoliosis (AIS). The first report on 5yr SRS-
    24 outcomes in AIS showed increased pain subscores between 2yr
    and 5yr in a multi-center group of 49 AIS patients, 76% of whom
    underwent anterior procedures. (Upasani et al, Spine 2008) 5yr
    SRS-30 outcomes in AIS patients have not been reported. We
    hypothesized that posterior pedicle screw constructs (PPSC) would
    provide stable outcomes between 2yr and 5yr postop.
    Methods: 56 AIS pts from a single center treated with PPSC were
    analyzed for changes in SRS-30 questionnaires between 2yr and 5yr
    follow-up. Additionally, detailed radiographic measurements were
    obtained and correlated with changes in SRS-30 outcomes.

    Results: (Table 1) The avg age at surgery was 14+9. Female:male
    was 44:12. An avg 10.2 levels were instrumented with an avg of
    17.2 pedicle screws. The most frequent curve type was Lenke type
    1A (30.4%), followed by type 2A (12.5%). 39% of patients had
    a thoracoplasty procedure. Avg major Cobb measured 61° preop
    with correction to 22° at 5yr (66% correction). There were no
    significant radiographic or SRS outcome changes between 2yr
    and 5yr, except for a decrease in the mental health subscore (4.28
    vs 4.08,p=0.02). There was an insignificant trend towards more
    pain (4.28 vs 4.13,p=0.18) including 7 patients who had pain
    attributable to a recent injury (n=5) or a new job (n=2). Excluding
    these 7 patients there was no change in the 2yr to 5yr pain (4.32
    vs 4.30,p=0.85), while the decline in mental health remained
    significant (4.34 vs 4.10,p=0.02). Significant improvements in
    self-image and function from preop to 2yr were maintained at 5yr.
    Changes in mental health and pain were not significantly correlated
    with any demographic or radiographic variables.

    Conclusion: At 5yrs, the 2yr improvements in SRS subscores for
    function and self-image remained stable, although there was a
    decline in mental health in this young adult population. Contrary
    to a previous report of primarily anterior procedures, pain levels
    were not increased between 2yrs and 5yrs in patients treated with
    PPSC.

    Significance: This is the first report on 5yr SRS-30 outcomes in
    AIS patients.
    The fact that there was a significant difference in the mental health domain is a little odd.

  11. #101
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    I hope it isn't ledge walking...
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  12. #102
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    Quote Originally Posted by hdugger View Post
    Do you know what things the mental health domain measures?
    Depression, I think.

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