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P111. Neurological Outcome after Surgical Management of Adult Tethered Cord Syndrome
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S-205S are no biomechanical studies comparing the stability of a posterior pedicle screw-rod construct alone with that of a circumferential one using lateral mass screw-rods with anterior plating. PURPOSE: To determine whether substantially different biomechanical stability can be achieved in a cervical spine fracture model using a pedicle screw-rod construct alone versus a circumferential system using lateral mass screw-rods and anterior plating. STUDY DESIGN/SETTING: An in vitro biomechanical study comparing two stabilization constructs in a C5 burst fracture model. PATIENT SAMPLE: Eight human cadaveric cervical spines. OUTCOME MEASURES: Angular motion was recorded in flexion/extension, lateral bending, and axial rotation. Statistical significance was set at p50.05. METHODS: Eight human cadaveric cervical spines were divided into two groups. Group 1 received pedicle screws at C4 and C6 after removal of the C5-6 disc and C5 partial corpectomy to simulate a burst fracture. Group 2 received lateral mass screws at C4 and C6 and a dynamic anterior plate with placement of an acrylic spacer after corpectomy. Specimens were nondestructively tested. Angular motion was recorded under controlled loadings during flexion and extension, lateral bending, and axial rotation. RESULTS: No significant differences were seen in the initial biomechanical stability between the posterior and circumferential constructs. This was true in flexion/extension (p50.46), lateral bending (p5 0.73), and axial rotation (p5 0.64). There were also no differences after 200 cycles of fatigue testing in flexion/extension (p50.43), lateral bending (p50.87), and axial rotation (p50.63).
Range of Motion (Degrees) Mean Standard Deviation Flexion/Extension Pedicle Screws Circumferential Fixation Lateral Bending Pedicle Screws Circumferential Fixation Axial Rotation Pedicle Screws Circumferential Fixation
P Value
1.74 1.65
0.93 1.14
0.46
1.41 1.58
0.27 0.91
0.73
3.44 4.13
0.34 2.76
0.64
Figure 1. Intial Stability (50 cycles).
Range of Motion (Degrees) Flexion/Extension Pedicle Screws Circumferential Fixation
Mean
Standard Deviation
P Value
1.81
1.11
0.43
1.67
1.17
171S
P111. Neurological Outcome after Surgical Management of Adult Tethered Cord Syndrome Matthew McGirt, MD, Giannina Garces-Ambrossi, BASC, Scott Parker, BASC, Roger Samuels, BASC, Daniel Sciubba, MD, Ali Bydon, MD, George Jallo, MD, Ziya Gokaslan, MD; Johns Hopkins University, Baltimore, MD, USA BACKGROUND CONTEXT: Although incidences of post-surgical outcomes are well-known, rate and development of neurological improvement after first-time tethered cord release is incompletely understood. PURPOSE: We reviewed our institutional experience with surgical management of adult tethered cord syndrome to assess the time course of symptomatic improvement, and to identify patient subgroups most likely to experience improvement of motor symptoms. STUDY DESIGN/SETTING: Retrospective review of a single institution experience. PATIENT SAMPLE: Twenty-nine consecutive cases of first-time adult tethered cord release. OUTCOME MEASURES: Post-operative lower extremity weakness and gait, painful dysesthesias,and urinary symptoms. Time to improvement post-operatively. METHODS: We retrospectively reviewed 29 consecutive cases of firsttime adult tethered cord release. Clinical symptoms of pain, motor, and urinary dysfunction were evaluated 1 month and 3 months post-operatively, then every 6 months. Rates of improvement in pain, motor, or urinary dysfunction over time were identified, and presenting factors associated with motor symptom improvement were assessed via multivariate survival analysis (Cox model). RESULTS: Mean age was 38613 years. Etiology included 3 (10%) lipomyelomeningocele, 3 (10%) tight filum, 4 (14%) lumbosacral lipoma, 3 (10%) intra-dural tumor, 2 (7%) previous lumbosacral surgery, and 14 (48%) previous myelomeningocele repair. Mean length of symptoms pre-operatively was 567 months. Presentation included diffuse pain/parasthesias in bilateral lower-extremity [13 (45%)] or perineal distribution [18 (62%)], lower-extremity weakness [17 (59%)], gait difficulties [17 (60%)], or bladder dysfunction [14 (48%)]. Laminectomy included 2.560.7 levels and 9 (30%) received duraplasty. At 18 months post-operatively, 47% of patients had improved urinary symptoms, 69% had improved lower extremity weakness and gait, and 79% had decreased painful dysesthesias. Median time to improvement was least for pain (1month), then motor (2.3months), then urinary symptoms (4.3months), (p50.04), (Figure 1). For patients demonstrating improvement, 96% improved within 6 months post-operatively. Only 4% improved beyond one-year. In multivariate analysis, presenting with asymmetric lower extremity weakness(p50.0021, HR55.7) or lower-extremity hyper-reflexia (p50.037, HR54.1) was associated with motor improvement (Figure 2). CONCLUSIONS: In our experience, motor, pain, and urinary dysfunction improve in the majority of patients. The rate of symptomatic improvement was greatest for pain, followed by motor, then urinary improvement.
Lateral Bending Pedicle Screws
1.33
0.19
Circumferential Fixation
1.40
0.80
Axial Rotation Pedicle Screws Circumferential Fixation
3.64
0.41
4.46
3.22
0.87
0.63
Figure 2. Stability After Cyclic Loading (200 cycles)
CONCLUSIONS: We found no significant differences in initial stability and after cyclic loading of 200 cycles between a pedicle screw-rod construct and a circumferential one using lateral mass screws and an anterior plate in a cervical spine burst fracture model. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.370
Figure 1. Median time to improvement was least for pain (1month), then motor (2.3months), then urinary symptoms (4.3months), (p50.04).
172S
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S-205S
Patients who experienced improvement in any symptom had done so by 6months post-operatively. Patients with asymmetric motor symptoms or lower-extremity hyper-reflexia at presentation were most likely to improve in motor symptoms. These findings may help guide patient education and surgical decision-making.
RESULTS: Patient demographics were as follows: mean age 15.8 years, BMI 20.1, 42 males and 31 females. The distribution of diagnoses were: Cerebral Palsy (n520), Familial Dysautonomia (n510), Neurofibromatosis (n55), and Other (n538). Mean coronal curvature was: main thoracic 45.3 , thoracolumbar 44.2 . Total cost was significantly correlated with the largest structural curve (R2 50.13, p!0.03), levels fused (R2 50.14, p!0.01), length of hospital stay (R250.73, p!0.01), housestaff costs (R250.50, p!0.01), implants used (R250.21, p!0.01), neuromonitoring (R250.11, p!0.01), OR charges (R250.73, p!0.01), PT/OT/SPL (R2 50.49, p!0.0001), and Room/ICU (R250.82, p!0.0001). Total cost was also correlated with reimbursement (r5.26, p!0.0001). Total cost was not related to total operative time, blood loss, BMI, or the number of screws/hooks used. The hospital was reimbursed 45% of total charges and 99% of total costs.
Figure 2. In multivariate analysis, presenting with asymmetric lower extremity weakness (p50.0021, HR55.7) or lower-extremity hyper-reflexia (p50.037, HR54.1) was associated with motor improvement.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. Figure.
doi: 10.1016/j.spinee.2009.08.371
P112. Cost Analysis of Neuromuscular Scoliosis Correction Surgery in 73 Consecutive Cases Jonathan Kamerlink, MD1, Kushagra Verma, MS2, Shaun Xavier, MD2, Marc Ialenti, BA2, Joseph Dryer, MD2, David Feldman, MD2, Baron Lonner, MD2; 1New York University, New York, NY, USA; 2NYU Hospital for Joint Diseases, New York, NY, USA BACKGROUND CONTEXT: Although achieving clinical success is the main goal in the surgical treatment of neuromuscular scoliosis (NMS), it is becoming increasingly important to do so in a cost-effective manner. PURPOSE: This study sets out to determine the costs, charges, and reimbursements associated with hospitalization for NMS correction surgery at one institution. STUDY DESIGN/SETTING: Retrospective hospital cost, charge, and reimbursement analysis. PATIENT SAMPLE: 13,470 individual costs and individual charges including overall reimbursements on 73 consecutive patients who underwent surgical treatment for NMS between 2006-2007 at a single institution. OUTCOME MEASURES: Patient’s costs, charges, and reimbursement as well as their demographic, surgical, and radiographic components. METHODS: We performed a retrospective reviewed of 13,470 individual costs and individual charges including overall reimbursements on 73 consecutive patients who underwent surgical treatment for NMS between 2006-2007 at a single institution. Pertinent demographic, surgical, and radiographic data were recorded for each patient. Analysis was done with correlations analysis and linear regression for comparisons between groups.
CONCLUSIONS: Implants accounted for the highest percentage of total cost (31.6%) followed by ICU and inpatient room cost (28.4%), and bone graft (14.5%). The implants used, length of stay, ICU, operating room, and use of physical therapy were identified as the most significant independent predictors of higher total cost in this patient population. An accurate analysis of surgical and hospital cost, charge, and reimbursement for NMS is of paramount importance to ensure future equitable allocation of financial resources in this patient population and to provide opportunities for cost containment. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.372
P113. Cervical Transforaminal Injections Kamran Aflatoon, DO; Southern California Spine and Orthopedic Oncology Institiute, Newport Beach, CA, USA BACKGROUND CONTEXT: Radicular symptoms in the upper extremities are most commonly related to either cervical disc herniation or foraminal stenosis. Those who do not respond to medications or therapy may become candidates for epidural injections prior to being indicated for surgical intervention. PURPOSE: There is not much information in the literature regarding patients with workman’s compensation claim (WC) and their response to transforaminal injections. We have gathered a group of patients with non litigated WC having cervical radiculopathy and documented disc herniation in the cervical spine.
Range of Motion (Degrees) Mean Standard Deviation Flexion/Extension Pedicle Screws Circumferential Fixation Lateral Bending Pedicle Screws Circumferential Fixation Axial Rotation Pedicle Screws Circumferential Fixation
P Value
1.74 1.65
0.93 1.14
0.46
1.41 1.58
0.27 0.91
0.73
3.44 4.13
0.34 2.76
0.64
Figure 1. Intial Stability (50 cycles).
Range of Motion (Degrees) Flexion/Extension Pedicle Screws Circumferential Fixation
Mean
Standard Deviation
P Value
1.81
1.11
0.43
1.67
1.17
171S
P111. Neurological Outcome after Surgical Management of Adult Tethered Cord Syndrome Matthew McGirt, MD, Giannina Garces-Ambrossi, BASC, Scott Parker, BASC, Roger Samuels, BASC, Daniel Sciubba, MD, Ali Bydon, MD, George Jallo, MD, Ziya Gokaslan, MD; Johns Hopkins University, Baltimore, MD, USA BACKGROUND CONTEXT: Although incidences of post-surgical outcomes are well-known, rate and development of neurological improvement after first-time tethered cord release is incompletely understood. PURPOSE: We reviewed our institutional experience with surgical management of adult tethered cord syndrome to assess the time course of symptomatic improvement, and to identify patient subgroups most likely to experience improvement of motor symptoms. STUDY DESIGN/SETTING: Retrospective review of a single institution experience. PATIENT SAMPLE: Twenty-nine consecutive cases of first-time adult tethered cord release. OUTCOME MEASURES: Post-operative lower extremity weakness and gait, painful dysesthesias,and urinary symptoms. Time to improvement post-operatively. METHODS: We retrospectively reviewed 29 consecutive cases of firsttime adult tethered cord release. Clinical symptoms of pain, motor, and urinary dysfunction were evaluated 1 month and 3 months post-operatively, then every 6 months. Rates of improvement in pain, motor, or urinary dysfunction over time were identified, and presenting factors associated with motor symptom improvement were assessed via multivariate survival analysis (Cox model). RESULTS: Mean age was 38613 years. Etiology included 3 (10%) lipomyelomeningocele, 3 (10%) tight filum, 4 (14%) lumbosacral lipoma, 3 (10%) intra-dural tumor, 2 (7%) previous lumbosacral surgery, and 14 (48%) previous myelomeningocele repair. Mean length of symptoms pre-operatively was 567 months. Presentation included diffuse pain/parasthesias in bilateral lower-extremity [13 (45%)] or perineal distribution [18 (62%)], lower-extremity weakness [17 (59%)], gait difficulties [17 (60%)], or bladder dysfunction [14 (48%)]. Laminectomy included 2.560.7 levels and 9 (30%) received duraplasty. At 18 months post-operatively, 47% of patients had improved urinary symptoms, 69% had improved lower extremity weakness and gait, and 79% had decreased painful dysesthesias. Median time to improvement was least for pain (1month), then motor (2.3months), then urinary symptoms (4.3months), (p50.04), (Figure 1). For patients demonstrating improvement, 96% improved within 6 months post-operatively. Only 4% improved beyond one-year. In multivariate analysis, presenting with asymmetric lower extremity weakness(p50.0021, HR55.7) or lower-extremity hyper-reflexia (p50.037, HR54.1) was associated with motor improvement (Figure 2). CONCLUSIONS: In our experience, motor, pain, and urinary dysfunction improve in the majority of patients. The rate of symptomatic improvement was greatest for pain, followed by motor, then urinary improvement.
Lateral Bending Pedicle Screws
1.33
0.19
Circumferential Fixation
1.40
0.80
Axial Rotation Pedicle Screws Circumferential Fixation
3.64
0.41
4.46
3.22
0.87
0.63
Figure 2. Stability After Cyclic Loading (200 cycles)
CONCLUSIONS: We found no significant differences in initial stability and after cyclic loading of 200 cycles between a pedicle screw-rod construct and a circumferential one using lateral mass screws and an anterior plate in a cervical spine burst fracture model. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.370
Figure 1. Median time to improvement was least for pain (1month), then motor (2.3months), then urinary symptoms (4.3months), (p50.04).
172S
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S-205S
Patients who experienced improvement in any symptom had done so by 6months post-operatively. Patients with asymmetric motor symptoms or lower-extremity hyper-reflexia at presentation were most likely to improve in motor symptoms. These findings may help guide patient education and surgical decision-making.
RESULTS: Patient demographics were as follows: mean age 15.8 years, BMI 20.1, 42 males and 31 females. The distribution of diagnoses were: Cerebral Palsy (n520), Familial Dysautonomia (n510), Neurofibromatosis (n55), and Other (n538). Mean coronal curvature was: main thoracic 45.3 , thoracolumbar 44.2 . Total cost was significantly correlated with the largest structural curve (R2 50.13, p!0.03), levels fused (R2 50.14, p!0.01), length of hospital stay (R250.73, p!0.01), housestaff costs (R250.50, p!0.01), implants used (R250.21, p!0.01), neuromonitoring (R250.11, p!0.01), OR charges (R250.73, p!0.01), PT/OT/SPL (R2 50.49, p!0.0001), and Room/ICU (R250.82, p!0.0001). Total cost was also correlated with reimbursement (r5.26, p!0.0001). Total cost was not related to total operative time, blood loss, BMI, or the number of screws/hooks used. The hospital was reimbursed 45% of total charges and 99% of total costs.
Figure 2. In multivariate analysis, presenting with asymmetric lower extremity weakness (p50.0021, HR55.7) or lower-extremity hyper-reflexia (p50.037, HR54.1) was associated with motor improvement.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. Figure.
doi: 10.1016/j.spinee.2009.08.371
P112. Cost Analysis of Neuromuscular Scoliosis Correction Surgery in 73 Consecutive Cases Jonathan Kamerlink, MD1, Kushagra Verma, MS2, Shaun Xavier, MD2, Marc Ialenti, BA2, Joseph Dryer, MD2, David Feldman, MD2, Baron Lonner, MD2; 1New York University, New York, NY, USA; 2NYU Hospital for Joint Diseases, New York, NY, USA BACKGROUND CONTEXT: Although achieving clinical success is the main goal in the surgical treatment of neuromuscular scoliosis (NMS), it is becoming increasingly important to do so in a cost-effective manner. PURPOSE: This study sets out to determine the costs, charges, and reimbursements associated with hospitalization for NMS correction surgery at one institution. STUDY DESIGN/SETTING: Retrospective hospital cost, charge, and reimbursement analysis. PATIENT SAMPLE: 13,470 individual costs and individual charges including overall reimbursements on 73 consecutive patients who underwent surgical treatment for NMS between 2006-2007 at a single institution. OUTCOME MEASURES: Patient’s costs, charges, and reimbursement as well as their demographic, surgical, and radiographic components. METHODS: We performed a retrospective reviewed of 13,470 individual costs and individual charges including overall reimbursements on 73 consecutive patients who underwent surgical treatment for NMS between 2006-2007 at a single institution. Pertinent demographic, surgical, and radiographic data were recorded for each patient. Analysis was done with correlations analysis and linear regression for comparisons between groups.
CONCLUSIONS: Implants accounted for the highest percentage of total cost (31.6%) followed by ICU and inpatient room cost (28.4%), and bone graft (14.5%). The implants used, length of stay, ICU, operating room, and use of physical therapy were identified as the most significant independent predictors of higher total cost in this patient population. An accurate analysis of surgical and hospital cost, charge, and reimbursement for NMS is of paramount importance to ensure future equitable allocation of financial resources in this patient population and to provide opportunities for cost containment. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.372
P113. Cervical Transforaminal Injections Kamran Aflatoon, DO; Southern California Spine and Orthopedic Oncology Institiute, Newport Beach, CA, USA BACKGROUND CONTEXT: Radicular symptoms in the upper extremities are most commonly related to either cervical disc herniation or foraminal stenosis. Those who do not respond to medications or therapy may become candidates for epidural injections prior to being indicated for surgical intervention. PURPOSE: There is not much information in the literature regarding patients with workman’s compensation claim (WC) and their response to transforaminal injections. We have gathered a group of patients with non litigated WC having cervical radiculopathy and documented disc herniation in the cervical spine.