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P101. Predictive Ability of Tapping Insertional Torque on Pedicle Screw Fixation Strength and Optimal Screw Size in the Thoracic Spine
166S
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S-205S
P100. Can Exercise-Only, Protocol-Driven Spinal Care Be as Effective as Standard Physical Therapy? Vert Mooney, MD1, Ted Dreisinger, PhD1, Kamshad Raiszadeh, MD2, Joe Verna, DC1, John Mayer, PhD, DC3; 1US Spine & Sport Foundation, San Diego, CA, USA; 2La Jolla Spine Institute, La Jolla, CA, USA; 3 University of South Florida, Tampa, FL, USA BACKGROUND CONTEXT: Therapeutic exercise aimed at strengthening the spinal musculature is an effective approach for non-operative spine care. It is unclear if combining strengthening exercise with other interventions improves clinical outcomes, or if the type of facility/provider which carries out this treatment affects outcomes. PURPOSE: The purpose of this study was to demonstrate the effectiveness of an exercise-only treatment approach for persistent spinal complaints. STUDY DESIGN/SETTING: Retrospective cohort study conducted in 2 outpatient centers. PATIENT SAMPLE: 307 patients with primarily chronic spinal pain disorders who were under care at two outpatient centers: standard physical therapy (PT, n 5 136) and exercise-only (n 5 171) were enrolled. The majority of PT patients were workers’ compensation, while all of the exerciseonly patients were private insurance with co-payments at each visit. OUTCOME MEASURES: Outcomes measured at baseline and followup included physical function (Multidimensional Task Ability Profile, MTAP, 0-200), pain intensity (VAS, 0-10), and pain drawing. METHODS: At both centers, treatment consisted of isolated strengthening exercise with equipment for the spinal musculature and other major muscles. The standardized exercise protocol focused on dynamic, progressive resistance exercise with gradual and measurable loading, and was typically administered 2X/week for up to 12 weeks. Patients in PT also received physical modalities such as manual, thermal, and electrical therapies 2-3X/week. Exercise-only treatment was carried out by exercise science staff, while PT was directed by physical therapists. RESULTS: The average time between baseline and follow-up was approximately 2-3 months. At follow-up, both groups demonstrated significant improvements in physical function and pain intensity (PT: baseline: MTAP 108.6642.1, VAS 5.262.4; follow-up: MTAP 118.9645.5; VAS 4.462.4. Exercise-only: baseline: MTAP 127.7640.1, VAS 5.262.4; follow-up: MTAP 151.4636.6; VAS 3.262.2). CONCLUSIONS: This study demonstrates that protocol-driven exercise therapy carried out by exercise science staff is as effective as usual PT including exercise and other modalities for management of persistent spinal complaints. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.359
P101. Predictive Ability of Tapping Insertional Torque on Pedicle Screw Fixation Strength and Optimal Screw Size in the Thoracic Spine Melvin Helgeson, MD1, Ronald Lehman, Jr., MD1, Anton Dmitriev1, Scott Luhmann, MD2; 1Washington, DC, USA; 2Washington University in St. Louis, San Antonio, MO, USA BACKGROUND CONTEXT: Correlation between pedicle screw insertional torque (IT) and pullout strength has been previously established; however, no study has assessed the optimum IT and screw size associated with tapping in the thoracic spine. Information gathered from determining if tap insertional torque correlates with pull out strength will aid in selecting the most optimal implant for biomechanical stability. PURPOSE: To determine if tapping insertional torque correlates with the optimal screw size when instrumenting with pedicle screws in the thoracic spine. STUDY DESIGN/SETTING: Human cadaveric study with fresh frozen thoracic specimens.
PATIENT SAMPLE: 12 fresh frozen cadaveric spines were harvested and checked to ensure they were free of metabolic/metastatic bone disease. OUTCOME MEASURES: N/A. METHODS: Initially, all thoracic pedicles (n542) were measured with digital calipers and a pilot study was performed (n512) to determine a tapping IT threshold value that correlated to optimal screw size. In each specimen, the tapping IT for the optimal screw size exceeded 2.5 in-lbs; therefore, this value served as the threshold for tapping IT. A value of 1.5 in-lbs. was selected for pair-wise comparison on the contralateral side. All thoracic pedicles (n530) were probed and tapped in the following sequence: 3.75 mm, 4.00 mm, 4.50 mm, 5.50 mm until the corresponding threshold value (Group 1: 1.5 in-lbs; Group 2: 2.5 in-lbs) was reached. Screw size was chosen by adding 1 mm to the tap size, which reached the threshold torque value. Torque was measured with each revolution during insertion of the tap or screw. RESULTS: The mean and peak screw IT were significantly greater in Group 2 (5.5þ1.0in-lbs; 8.9þ2.3in-lbs) compared to Group 1 (4.3þ1.6in-lbs; 7.5þ2.9 in-lbs). In both groups, the mean and peak IT of the last tap used, significantly correlated with the mean and peak screw IT (r50.705 and r50.544, respectively). Additionally, 60% of the screws predicted for Group 2, fell within 1.0 mm of the outer pedicle diameter versus only 27% of screws in Group 1. Interestingly, significant direct correlation between the pedicle width and the selected screw diameter was established for both groups (r50.605 and r50.699, respectively). CONCLUSIONS: Tapping insertional torque (IT) directly correlates with screw IT, and therefore can be used intraoperatively to determine the optimal screw size. Additionally, sequential tapping provides further guidance in determining optimal screw size. Using 2.5 in-lbs. as a threshold for tapping IT appears to be a viable predictor to obtain optimal screw placement in the thoracic spine. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.361
P102. Performance-Based Outcomes Following Lumbar Discectemy in Elite Professional Athletes in the National Football League Wellington Hsu, MD; University of California, Los Angeles, Chicago, IL, USA BACKGROUND CONTEXT: Although lumbar disc herniations (LDH) in National Football League (NFL) players have been treated for decades, to date, no studies have documented the clinical outcomes following surgical treatment. The elite professional athlete, who has significantly higher demands and expectations, may have a different prognosis after discectemy than the general population. PURPOSE: This study seeks to define the outcomes of lumbar discectemy in professional American football players. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: A population of 137 NFL players from 1979 to 2008 diagnosed with a lumbar disc herniation was identified (Table 1). 101 players underwent lumbar discectemy and 36 athletes were treated nonoperatively. Performance analysis was performed on 130 players who had at least 2-year follow-up. OUTCOME MEASURES: Data was recorded for games played, games started, and years played for each player cohort. When applicable, yards gained, touchdowns, interceptions, sacks, and field goals were compiled. Using a modification of a previously published scoring system1, the ‘‘performance score’’ for each player was calculated based upon these statistics per game played both before and after treatment of LDH. METHODS: Utilizing information provided by press releases, team injury reports, and newspaper archives, NFL players diagnosed with a LDH were identified. Individual team medical records, when available, were used to confirm this data. Return-to-play rates and performance outcomes were
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S-205S
P100. Can Exercise-Only, Protocol-Driven Spinal Care Be as Effective as Standard Physical Therapy? Vert Mooney, MD1, Ted Dreisinger, PhD1, Kamshad Raiszadeh, MD2, Joe Verna, DC1, John Mayer, PhD, DC3; 1US Spine & Sport Foundation, San Diego, CA, USA; 2La Jolla Spine Institute, La Jolla, CA, USA; 3 University of South Florida, Tampa, FL, USA BACKGROUND CONTEXT: Therapeutic exercise aimed at strengthening the spinal musculature is an effective approach for non-operative spine care. It is unclear if combining strengthening exercise with other interventions improves clinical outcomes, or if the type of facility/provider which carries out this treatment affects outcomes. PURPOSE: The purpose of this study was to demonstrate the effectiveness of an exercise-only treatment approach for persistent spinal complaints. STUDY DESIGN/SETTING: Retrospective cohort study conducted in 2 outpatient centers. PATIENT SAMPLE: 307 patients with primarily chronic spinal pain disorders who were under care at two outpatient centers: standard physical therapy (PT, n 5 136) and exercise-only (n 5 171) were enrolled. The majority of PT patients were workers’ compensation, while all of the exerciseonly patients were private insurance with co-payments at each visit. OUTCOME MEASURES: Outcomes measured at baseline and followup included physical function (Multidimensional Task Ability Profile, MTAP, 0-200), pain intensity (VAS, 0-10), and pain drawing. METHODS: At both centers, treatment consisted of isolated strengthening exercise with equipment for the spinal musculature and other major muscles. The standardized exercise protocol focused on dynamic, progressive resistance exercise with gradual and measurable loading, and was typically administered 2X/week for up to 12 weeks. Patients in PT also received physical modalities such as manual, thermal, and electrical therapies 2-3X/week. Exercise-only treatment was carried out by exercise science staff, while PT was directed by physical therapists. RESULTS: The average time between baseline and follow-up was approximately 2-3 months. At follow-up, both groups demonstrated significant improvements in physical function and pain intensity (PT: baseline: MTAP 108.6642.1, VAS 5.262.4; follow-up: MTAP 118.9645.5; VAS 4.462.4. Exercise-only: baseline: MTAP 127.7640.1, VAS 5.262.4; follow-up: MTAP 151.4636.6; VAS 3.262.2). CONCLUSIONS: This study demonstrates that protocol-driven exercise therapy carried out by exercise science staff is as effective as usual PT including exercise and other modalities for management of persistent spinal complaints. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.359
P101. Predictive Ability of Tapping Insertional Torque on Pedicle Screw Fixation Strength and Optimal Screw Size in the Thoracic Spine Melvin Helgeson, MD1, Ronald Lehman, Jr., MD1, Anton Dmitriev1, Scott Luhmann, MD2; 1Washington, DC, USA; 2Washington University in St. Louis, San Antonio, MO, USA BACKGROUND CONTEXT: Correlation between pedicle screw insertional torque (IT) and pullout strength has been previously established; however, no study has assessed the optimum IT and screw size associated with tapping in the thoracic spine. Information gathered from determining if tap insertional torque correlates with pull out strength will aid in selecting the most optimal implant for biomechanical stability. PURPOSE: To determine if tapping insertional torque correlates with the optimal screw size when instrumenting with pedicle screws in the thoracic spine. STUDY DESIGN/SETTING: Human cadaveric study with fresh frozen thoracic specimens.
PATIENT SAMPLE: 12 fresh frozen cadaveric spines were harvested and checked to ensure they were free of metabolic/metastatic bone disease. OUTCOME MEASURES: N/A. METHODS: Initially, all thoracic pedicles (n542) were measured with digital calipers and a pilot study was performed (n512) to determine a tapping IT threshold value that correlated to optimal screw size. In each specimen, the tapping IT for the optimal screw size exceeded 2.5 in-lbs; therefore, this value served as the threshold for tapping IT. A value of 1.5 in-lbs. was selected for pair-wise comparison on the contralateral side. All thoracic pedicles (n530) were probed and tapped in the following sequence: 3.75 mm, 4.00 mm, 4.50 mm, 5.50 mm until the corresponding threshold value (Group 1: 1.5 in-lbs; Group 2: 2.5 in-lbs) was reached. Screw size was chosen by adding 1 mm to the tap size, which reached the threshold torque value. Torque was measured with each revolution during insertion of the tap or screw. RESULTS: The mean and peak screw IT were significantly greater in Group 2 (5.5þ1.0in-lbs; 8.9þ2.3in-lbs) compared to Group 1 (4.3þ1.6in-lbs; 7.5þ2.9 in-lbs). In both groups, the mean and peak IT of the last tap used, significantly correlated with the mean and peak screw IT (r50.705 and r50.544, respectively). Additionally, 60% of the screws predicted for Group 2, fell within 1.0 mm of the outer pedicle diameter versus only 27% of screws in Group 1. Interestingly, significant direct correlation between the pedicle width and the selected screw diameter was established for both groups (r50.605 and r50.699, respectively). CONCLUSIONS: Tapping insertional torque (IT) directly correlates with screw IT, and therefore can be used intraoperatively to determine the optimal screw size. Additionally, sequential tapping provides further guidance in determining optimal screw size. Using 2.5 in-lbs. as a threshold for tapping IT appears to be a viable predictor to obtain optimal screw placement in the thoracic spine. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.361
P102. Performance-Based Outcomes Following Lumbar Discectemy in Elite Professional Athletes in the National Football League Wellington Hsu, MD; University of California, Los Angeles, Chicago, IL, USA BACKGROUND CONTEXT: Although lumbar disc herniations (LDH) in National Football League (NFL) players have been treated for decades, to date, no studies have documented the clinical outcomes following surgical treatment. The elite professional athlete, who has significantly higher demands and expectations, may have a different prognosis after discectemy than the general population. PURPOSE: This study seeks to define the outcomes of lumbar discectemy in professional American football players. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: A population of 137 NFL players from 1979 to 2008 diagnosed with a lumbar disc herniation was identified (Table 1). 101 players underwent lumbar discectemy and 36 athletes were treated nonoperatively. Performance analysis was performed on 130 players who had at least 2-year follow-up. OUTCOME MEASURES: Data was recorded for games played, games started, and years played for each player cohort. When applicable, yards gained, touchdowns, interceptions, sacks, and field goals were compiled. Using a modification of a previously published scoring system1, the ‘‘performance score’’ for each player was calculated based upon these statistics per game played both before and after treatment of LDH. METHODS: Utilizing information provided by press releases, team injury reports, and newspaper archives, NFL players diagnosed with a LDH were identified. Individual team medical records, when available, were used to confirm this data. Return-to-play rates and performance outcomes were