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142. Perioperative Physical Therapy: Spine Surgeons' Perspective
74S
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S–205S
significantly in any group. The posterior screw Group 3 was the only group to have a statistically significant, but clinically insignificant, change in C7 plumb to the sacrum. Anterior screw and rod instrumentation (Group 1)
Posterior hybrid (Group 2)
Posterior screw (Group 3)
p value ≤ 0.001
T2-T5
8 minus 0.5 ± 7
8 plus 2 ± 7
8 plus 3 ± 8
T2-T12
28 plus 7 ± 10
31 minus 0.3 ± 11
31 minus 2 ± 12
≤ 0.001
T5-T12
20 plus 8 ± 11
24 minus 2 ± 11
23 minus 5 ± 13
≤ 0.001
T10-L2
0.9 plus 0.6 ± 10
-0.8 plus 3 ± 13
0.2 minus 0.6 ± 11
0.13
Lumbar lordosis
-59 plus 4 ± 9
-63 minus 3 ± 12
-60 minus 4 ± 11
≤ 0.001
C7-Sacrum
-1 plus 0.2 ± 5
-2 minus 0.8 ± 5
-2 plus 1.5 ± 5
0.006
Table. Preoperative averages and average change (þ/-SD) in sagittal values (positive number indicates increase, negative indicates a decrease from pre- to 2-year postoperative)
CONCLUSIONS: Using ‘‘new’’ posterior screw instrumentation on Lenke 1 curves has had a negative effect on postoperative sagittal contour. The mid thoracic kyphosis and lumbar lordosis decreases in an already flat sagittal deformity, and proximal thoracic kyphosis is increased. ‘‘Old’’ posterior hybrid instrumentation is not as bad, and tends toward minimal change of the sagittal contour. ‘‘Older’’ anterior instrumentation recreates the best sagittal contour. Clearly, the attachment of the anchor in relation to the vertebral axis of rotation has a large effect. FDA DEVICE/DRUG STATUS: Posterior Pedicle Screws - immature patients: Not approved for this indication. doi: 10.1016/j.spinee.2009.08.171
142. Perioperative Physical Therapy: Spine Surgeons’ Perspective Michael Reed, DPT, OCS1, Ronald Donelson, MD2, Ted Dreisinger3, Venu Akuthota, MD4, Lawrence Frank, MD5, Stanley Herring, MD6, Heidi Prather, DO7, Joel Press, MD8, Jerome Schofferman, MD9; 1Palm Beach Gardens, FL, USA; 2Hanover, NH, USA; 3Troy, MI, USA; 4Aurora, CO, USA; 5Elmhurst, IL, USA; 6Seattle, WA, USA; 7Saint Louis, MO, USA; 8 Chicago, IL, USA; 9Daly City, CA, USA BACKGROUND CONTEXT: More than 600,000 spine surgeries are performed annually in the United States. Surprisingly, little research has been conducted on the perioperative procedures employed to augment recovery and secure superior outcomes. Non-operative rehabilitation and post-operative physical therapy are given minimal attention by clinical researchers. PURPOSE: The purpose of this study was to determine the spine surgeon’s perspective on the relative value of non-operative and peri-operative procedures for spine surgery and their perception of the physical therapist’s role in these efforts. STUDY DESIGN/SETTING: The survey was conducted at the 23rd Annual Meeting of the North American Spine Society (NASS) in Toronto, Canada, October 14-18, 2008. Participation in this study was voluntary and did not serve as a prerequisite to any other aspect of this conference. In addition, surgeons were not actively solicited or persuaded to participate in any way by the investigators. PATIENT SAMPLE: N/A. OUTCOME MEASURES: Two areas of interest were identified for this study, including preoperative physical therapy and post-surgical rehabilitation with an emphasis on the spine surgeon’s perspective on the role of physical therapy in perioperative care. A survey consisting of 15 questions was developed addressing these areas. METHODS: The survey was conducted at the 23rd Annual Meeting of the North American Spine Society (NASS) in Toronto, Canada, October 1418, 2008. Participation in this study was voluntary and did not serve as a prerequisite to any other aspect of this conference. In addition, surgeons were not actively solicited or persuaded to participate in any way by the investigators.
RESULTS: A Total of 198 surgeons (76.1% orthopedic surgeons and 23.9% neurosurgeons) started the survey with 193 (97.5%) completed. 54.3% of the respondents reported a minority of their patients had received some form of physical therapy (PT) prior to consult. 48.5% of the surgeon respondents reported that the majority of the time they refer patients to PT prior to surgery. Only 42.1% of the surgeon respondents indicate that current evidence supports the therapeutic benefit of preoperative PT. When asked ‘‘.is there a type of PT you prefer your preoperative patients undergo before you make your surgical decision?’’ 74.6% responded affirmatively. Preferences included core strengthening (87.3%), back strengthening (57.0%), McKenzie evaluation and treatment (35.2%), stretching (40.6%), aerobic training (35.8%), and functional activity training (33.3%). With respect to postoperative PT, 64.6% of the surgeon respondents send the majority of their patients to rehabilitation services. Post-surgically, 82.3% of the respondents have a preference on the type of PT. CONCLUSIONS: The survey results revealed that the vast majority of sugeons receive referrals and perform consultations on patients who have not received PT. The practicing spine surgeon is encumbered by having to manage this aspect of care. Surprisingly, only a minority of the surgeon respondents indicated that current evidence supports the therapeutic benefit of preoperative PT. Most surgeons prefer an active form of perioperative PT. Finally, most of the spine surgeon respondents appear to have a moderate to strong preference for the treating physical therapist. Responses were variable and inconsistent, highlighting the need for further research in these areas. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.172
144. Meta-Analysis on the Safety of Using a MRI on Patients with a Pacemaker John Finkenberg, MD; San Diego, CA, USA BACKGROUND CONTEXT: Osteoporotic compression fractures are occurring with greater frequency in the elderly and have resulted in more frequent prolonged hospitalizations for intractable back pain. Vertebral augmentation is the preferred treatment for acute/subacute fractures that do not respond to medications, bracing or therapy. The gold standard diagnostic test is an MRI as acute and subacute fractures show increased signals in the fractured bone on T2 and STIR images. Unfortunately, pacemaker patients are currently restricted from having MRI"s. Bone scans are not specific for localization and CT scans will not show if the vertebra fracture was recent. Four large independent studies from 2004-2008 were reviewed and a statistical meta-analysis was performed. A meta-analysis is required prior to considering a study of the safety and efficacy of performing a .3 T MRI on pacemaker patients that have intractable back pain. PURPOSE: To demonstrate that pacemaker patients can safely undergo a MRI scan if the correct protocol regarding pacemaker programming is performed. STUDY DESIGN/SETTING: Patients with pacemakers, excluding ICD dependent pacemakers, were given MRI’s when no other diagnostic test could be used to obtain critical care diagnostic information. Each patient was followed by a cardiologist and cleared for the procedure in each of the studies. A meta-analysis of the information was performed to determine the protocol and safety parameters that are necessary to follow when subjecting a pacemaker patient to a MRI scan. PATIENT SAMPLE: 280 patients underwent 358 MRI scans of multiple body regions. The patients had dependent and non-dependent pacemakers and ICD"s that were non-dependent. OUTCOME MEASURES: The patients were evaluated for pacing thresholds, lead impedance, P/R wave amplitude, device motion, sensation of heat and battery voltage changes. Post scan pacemaker interrogation was performed to confirm any changes in pacemaker function.
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S–205S
significantly in any group. The posterior screw Group 3 was the only group to have a statistically significant, but clinically insignificant, change in C7 plumb to the sacrum. Anterior screw and rod instrumentation (Group 1)
Posterior hybrid (Group 2)
Posterior screw (Group 3)
p value ≤ 0.001
T2-T5
8 minus 0.5 ± 7
8 plus 2 ± 7
8 plus 3 ± 8
T2-T12
28 plus 7 ± 10
31 minus 0.3 ± 11
31 minus 2 ± 12
≤ 0.001
T5-T12
20 plus 8 ± 11
24 minus 2 ± 11
23 minus 5 ± 13
≤ 0.001
T10-L2
0.9 plus 0.6 ± 10
-0.8 plus 3 ± 13
0.2 minus 0.6 ± 11
0.13
Lumbar lordosis
-59 plus 4 ± 9
-63 minus 3 ± 12
-60 minus 4 ± 11
≤ 0.001
C7-Sacrum
-1 plus 0.2 ± 5
-2 minus 0.8 ± 5
-2 plus 1.5 ± 5
0.006
Table. Preoperative averages and average change (þ/-SD) in sagittal values (positive number indicates increase, negative indicates a decrease from pre- to 2-year postoperative)
CONCLUSIONS: Using ‘‘new’’ posterior screw instrumentation on Lenke 1 curves has had a negative effect on postoperative sagittal contour. The mid thoracic kyphosis and lumbar lordosis decreases in an already flat sagittal deformity, and proximal thoracic kyphosis is increased. ‘‘Old’’ posterior hybrid instrumentation is not as bad, and tends toward minimal change of the sagittal contour. ‘‘Older’’ anterior instrumentation recreates the best sagittal contour. Clearly, the attachment of the anchor in relation to the vertebral axis of rotation has a large effect. FDA DEVICE/DRUG STATUS: Posterior Pedicle Screws - immature patients: Not approved for this indication. doi: 10.1016/j.spinee.2009.08.171
142. Perioperative Physical Therapy: Spine Surgeons’ Perspective Michael Reed, DPT, OCS1, Ronald Donelson, MD2, Ted Dreisinger3, Venu Akuthota, MD4, Lawrence Frank, MD5, Stanley Herring, MD6, Heidi Prather, DO7, Joel Press, MD8, Jerome Schofferman, MD9; 1Palm Beach Gardens, FL, USA; 2Hanover, NH, USA; 3Troy, MI, USA; 4Aurora, CO, USA; 5Elmhurst, IL, USA; 6Seattle, WA, USA; 7Saint Louis, MO, USA; 8 Chicago, IL, USA; 9Daly City, CA, USA BACKGROUND CONTEXT: More than 600,000 spine surgeries are performed annually in the United States. Surprisingly, little research has been conducted on the perioperative procedures employed to augment recovery and secure superior outcomes. Non-operative rehabilitation and post-operative physical therapy are given minimal attention by clinical researchers. PURPOSE: The purpose of this study was to determine the spine surgeon’s perspective on the relative value of non-operative and peri-operative procedures for spine surgery and their perception of the physical therapist’s role in these efforts. STUDY DESIGN/SETTING: The survey was conducted at the 23rd Annual Meeting of the North American Spine Society (NASS) in Toronto, Canada, October 14-18, 2008. Participation in this study was voluntary and did not serve as a prerequisite to any other aspect of this conference. In addition, surgeons were not actively solicited or persuaded to participate in any way by the investigators. PATIENT SAMPLE: N/A. OUTCOME MEASURES: Two areas of interest were identified for this study, including preoperative physical therapy and post-surgical rehabilitation with an emphasis on the spine surgeon’s perspective on the role of physical therapy in perioperative care. A survey consisting of 15 questions was developed addressing these areas. METHODS: The survey was conducted at the 23rd Annual Meeting of the North American Spine Society (NASS) in Toronto, Canada, October 1418, 2008. Participation in this study was voluntary and did not serve as a prerequisite to any other aspect of this conference. In addition, surgeons were not actively solicited or persuaded to participate in any way by the investigators.
RESULTS: A Total of 198 surgeons (76.1% orthopedic surgeons and 23.9% neurosurgeons) started the survey with 193 (97.5%) completed. 54.3% of the respondents reported a minority of their patients had received some form of physical therapy (PT) prior to consult. 48.5% of the surgeon respondents reported that the majority of the time they refer patients to PT prior to surgery. Only 42.1% of the surgeon respondents indicate that current evidence supports the therapeutic benefit of preoperative PT. When asked ‘‘.is there a type of PT you prefer your preoperative patients undergo before you make your surgical decision?’’ 74.6% responded affirmatively. Preferences included core strengthening (87.3%), back strengthening (57.0%), McKenzie evaluation and treatment (35.2%), stretching (40.6%), aerobic training (35.8%), and functional activity training (33.3%). With respect to postoperative PT, 64.6% of the surgeon respondents send the majority of their patients to rehabilitation services. Post-surgically, 82.3% of the respondents have a preference on the type of PT. CONCLUSIONS: The survey results revealed that the vast majority of sugeons receive referrals and perform consultations on patients who have not received PT. The practicing spine surgeon is encumbered by having to manage this aspect of care. Surprisingly, only a minority of the surgeon respondents indicated that current evidence supports the therapeutic benefit of preoperative PT. Most surgeons prefer an active form of perioperative PT. Finally, most of the spine surgeon respondents appear to have a moderate to strong preference for the treating physical therapist. Responses were variable and inconsistent, highlighting the need for further research in these areas. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.172
144. Meta-Analysis on the Safety of Using a MRI on Patients with a Pacemaker John Finkenberg, MD; San Diego, CA, USA BACKGROUND CONTEXT: Osteoporotic compression fractures are occurring with greater frequency in the elderly and have resulted in more frequent prolonged hospitalizations for intractable back pain. Vertebral augmentation is the preferred treatment for acute/subacute fractures that do not respond to medications, bracing or therapy. The gold standard diagnostic test is an MRI as acute and subacute fractures show increased signals in the fractured bone on T2 and STIR images. Unfortunately, pacemaker patients are currently restricted from having MRI"s. Bone scans are not specific for localization and CT scans will not show if the vertebra fracture was recent. Four large independent studies from 2004-2008 were reviewed and a statistical meta-analysis was performed. A meta-analysis is required prior to considering a study of the safety and efficacy of performing a .3 T MRI on pacemaker patients that have intractable back pain. PURPOSE: To demonstrate that pacemaker patients can safely undergo a MRI scan if the correct protocol regarding pacemaker programming is performed. STUDY DESIGN/SETTING: Patients with pacemakers, excluding ICD dependent pacemakers, were given MRI’s when no other diagnostic test could be used to obtain critical care diagnostic information. Each patient was followed by a cardiologist and cleared for the procedure in each of the studies. A meta-analysis of the information was performed to determine the protocol and safety parameters that are necessary to follow when subjecting a pacemaker patient to a MRI scan. PATIENT SAMPLE: 280 patients underwent 358 MRI scans of multiple body regions. The patients had dependent and non-dependent pacemakers and ICD"s that were non-dependent. OUTCOME MEASURES: The patients were evaluated for pacing thresholds, lead impedance, P/R wave amplitude, device motion, sensation of heat and battery voltage changes. Post scan pacemaker interrogation was performed to confirm any changes in pacemaker function.