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P176. Variability in Surgeon Selection of Bone Grafts: A Survey of Graft Selection in Posterolateral Spine Fusion
204S
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S-205S
1990 and 2007. Primary variables analyzed were surgical indications and technique, complications, and functional outcomes. PATIENT SAMPLE: 124 cases of en bloc thoracic spine sarcoma excision performed at two national/tertiary referral centers institutions 1990 and 2007. OUTCOME MEASURES: Neurologic Complications, Margins and Operative Complications are reported. METHODS: Retrospective chart and imaging review s of 124 cases of en bloc thoracic spine sarcoma excision performed at two institutions between 1990 and 2007. RESULTS: Marginal margins were achieved in all cases. Pre-operative angiography identified the artery of Adamkiewicz in 24 patients. This artery was ligated in all patients with no neurologic sequelae. PostOperative Angiography was conducted in four patients for whom the artery of Adamkiewitz was taken at surgery. In all cases a new or collateral artery of adekiewitz was identified. Four patients underwent pre-operative embolization a mean of 16 hours prior to surgical resection. Intra-operative coagulopathy was noted in 3 of 4 patients undergoing embolization compared to less than 30 percent of those not undergoing embolization. CONCLUSIONS: Pre-operative angiography to identify the artery of Adamkiewicz may not be necessary in patients undergoing en bloc excision of spinal sarcomas. Our experience demonstrates that surgical ligation of this vessel has a low risk of neurologic sequelae. Pre-operative embolization may increase the risk of coagulopathy at the time of surgical resection. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
grafts, illustrated by 48 combinations in the healthy host and 52 combinations in the host with co-morbidities. In the healthy host, 43.2% of surgeons selected ICBG, local bone, or ICBG with local bone, compared with 27.5% in the host with co-morbidities. Overall, 41.6% and 39.5% of surgeons harvested ICBG in the healthy host and host with co-morbidities, respectively. There was a significant increase in the use of multiple graft materials in the host with co-morbidities (70.9% vs. 59.1%;p50.001). rhBMP usage increased in the host with co-morbidities compared to the healthy host (37.6% vs. 17.7%;p50.000). Bone graft extenders such as osteoconductive matrix (OCM), demineralized bone matrix (DBM), bone marrow aspirate (BMA), and platelet rich plasma (PRP) were most often used in combination with autograft and/or rhBMP. In the healthy host, OCM, DBM, BMA, and PRP were selected 23.4%, 11.5%, 11.9%, and 1.3% of the time. Factors that were independent predictors of graft choice include years in practice, fellowship training, relationship with industry, and geography. CONCLUSIONS: Graft selection in common spine surgery scenarios is highly variable. Specific factors were independent predictors of graft choice, and these factors were characteristic of eminence-based decisionmaking rather than evidence-based choice. This survey illustrates a lack of uniformity of bone graft material selection among surgeons in the same clinical scenario and highlights the need for further studies to better define efficacy and value in order to guide an evidence-based choice. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.437
doi: 10.1016/j.spinee.2009.08.436
P176. Variability in Surgeon Selection of Bone Grafts: A Survey of Graft Selection in Posterolateral Spine Fusion Sigurd Berven, MD1, Steven Glassman, MD2, John Dimar, II, MD2; 1 University of California, San Francisco, San Francisco, CA, USA; 2 University of Louisville, Louisville, KY, USA BACKGROUND CONTEXT: Surgeon decision-making for bone graft choices in posterolateral fusion surgery is guided by limited evidence on clinical efficacy and outcomes. The choice of graft material may be influenced by factors other than clinical evidence. PURPOSE: The purpose of this study was to measure variability in surgeons’ choice of graft materials for posterolateral fusion. STUDY DESIGN/SETTING: Prospective Observational study of surgeon responses to clinical scenarios of posterolateral spine fusion with tabulation of graft choices. Survey was administered on line by an independent party. PATIENT SAMPLE: 516 spine surgeons responded to the on line survey. OUTCOME MEASURES: Category of bone graft material chosen, including iliac crest graft, local bone, allograft, osteoconductive matrices, bone marrow aspirate, platelet rich preparations, and recombinant proteins. METHODS: A survey on grafting materials in spinal fusion was administered electronically by an independent party to spine surgeons. The survey evaluated the use of bone grafting materials for an open lumbar decompression and instrumented posterolateral fusion in a healthy host and also in a host with co-morbidities. Respondents were asked to select from a list of 10 bone grafting categories including autograft (ICBG or local), rhBMP, and extenders. Factors that are independent predictors of bone graft choice were identified using multiple regression analysis. RESULTS: Of 516 responding surgeons, 460 completed the survey for the healthy host scenario and 429 completed the survey for the host with comorbidities. There was a high degree of variability in the selection of bone
P177. The Effect of Operative Position During Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Does it Influence Sagittal and Axial Alignment of the Thoracic Spine? Jahangir Asghar, MD1, Amer Samdani, MD2, Patrick Cahill, MD3, David Clements, MD1, Randal Betz, MD4; 1Philadelphia, PA, USA; 2Johns Hopkins University, Baltimore, MD, USA; 3Merion Station, PA, USA; 4 Temple University, Philadelphia, PA, USA BACKGROUND CONTEXT: There exists a complex inter-coupling of planar deformity in adolescent idiopathic scoliosis. Hence, the correction of all 3 planes during PSF for AIS remains a challenge. PURPOSE: This study was to examine the effects of the position of the chest roll on thoracic kyphosis and its influence on axial alignment of the thoracic spine. STUDY DESIGN/SETTING: Retrospective Radiographic review. PATIENT SAMPLE: Patients with Adolescent Idiopathic Scoliosis who underwent a Posterior spinal fusion. OUTCOME MEASURES: Radiographic measurments: Cobb angles, Sagittal measurements, Rib ratio. METHODS: This is a retrospective review of 21 consecutive patients with Lenke 1, 2, 3and 4 AIS curves whom positioned prone on the Jackson (Orthopaedic Systems, Inc., Union City, CA) spinal table. The chest roll were positioned with the roll being approximately 2 cm below sternal notch (ST) Roll and subsequently repositioned just proximal to the level of the xiphoid process (Xi). Lateral radiograph were taken. In addition, axial measurements with a scoliometer and the rib hump index on radiograph were recorded. A statistical analysis using SPSS software was performed to measure for significant differences between the groups. RESULTS: The mean coronal deformity on standing AP radiograph was 58 degrees with the median apex of the deformity at T9. The mean erect standing thoracic kyphosis measurements were 9.2 degrees. The Scoliometer reading on the Adam’s forward bend was 21.2 degrees. In the prone,
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S-205S
1990 and 2007. Primary variables analyzed were surgical indications and technique, complications, and functional outcomes. PATIENT SAMPLE: 124 cases of en bloc thoracic spine sarcoma excision performed at two national/tertiary referral centers institutions 1990 and 2007. OUTCOME MEASURES: Neurologic Complications, Margins and Operative Complications are reported. METHODS: Retrospective chart and imaging review s of 124 cases of en bloc thoracic spine sarcoma excision performed at two institutions between 1990 and 2007. RESULTS: Marginal margins were achieved in all cases. Pre-operative angiography identified the artery of Adamkiewicz in 24 patients. This artery was ligated in all patients with no neurologic sequelae. PostOperative Angiography was conducted in four patients for whom the artery of Adamkiewitz was taken at surgery. In all cases a new or collateral artery of adekiewitz was identified. Four patients underwent pre-operative embolization a mean of 16 hours prior to surgical resection. Intra-operative coagulopathy was noted in 3 of 4 patients undergoing embolization compared to less than 30 percent of those not undergoing embolization. CONCLUSIONS: Pre-operative angiography to identify the artery of Adamkiewicz may not be necessary in patients undergoing en bloc excision of spinal sarcomas. Our experience demonstrates that surgical ligation of this vessel has a low risk of neurologic sequelae. Pre-operative embolization may increase the risk of coagulopathy at the time of surgical resection. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
grafts, illustrated by 48 combinations in the healthy host and 52 combinations in the host with co-morbidities. In the healthy host, 43.2% of surgeons selected ICBG, local bone, or ICBG with local bone, compared with 27.5% in the host with co-morbidities. Overall, 41.6% and 39.5% of surgeons harvested ICBG in the healthy host and host with co-morbidities, respectively. There was a significant increase in the use of multiple graft materials in the host with co-morbidities (70.9% vs. 59.1%;p50.001). rhBMP usage increased in the host with co-morbidities compared to the healthy host (37.6% vs. 17.7%;p50.000). Bone graft extenders such as osteoconductive matrix (OCM), demineralized bone matrix (DBM), bone marrow aspirate (BMA), and platelet rich plasma (PRP) were most often used in combination with autograft and/or rhBMP. In the healthy host, OCM, DBM, BMA, and PRP were selected 23.4%, 11.5%, 11.9%, and 1.3% of the time. Factors that were independent predictors of graft choice include years in practice, fellowship training, relationship with industry, and geography. CONCLUSIONS: Graft selection in common spine surgery scenarios is highly variable. Specific factors were independent predictors of graft choice, and these factors were characteristic of eminence-based decisionmaking rather than evidence-based choice. This survey illustrates a lack of uniformity of bone graft material selection among surgeons in the same clinical scenario and highlights the need for further studies to better define efficacy and value in order to guide an evidence-based choice. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.437
doi: 10.1016/j.spinee.2009.08.436
P176. Variability in Surgeon Selection of Bone Grafts: A Survey of Graft Selection in Posterolateral Spine Fusion Sigurd Berven, MD1, Steven Glassman, MD2, John Dimar, II, MD2; 1 University of California, San Francisco, San Francisco, CA, USA; 2 University of Louisville, Louisville, KY, USA BACKGROUND CONTEXT: Surgeon decision-making for bone graft choices in posterolateral fusion surgery is guided by limited evidence on clinical efficacy and outcomes. The choice of graft material may be influenced by factors other than clinical evidence. PURPOSE: The purpose of this study was to measure variability in surgeons’ choice of graft materials for posterolateral fusion. STUDY DESIGN/SETTING: Prospective Observational study of surgeon responses to clinical scenarios of posterolateral spine fusion with tabulation of graft choices. Survey was administered on line by an independent party. PATIENT SAMPLE: 516 spine surgeons responded to the on line survey. OUTCOME MEASURES: Category of bone graft material chosen, including iliac crest graft, local bone, allograft, osteoconductive matrices, bone marrow aspirate, platelet rich preparations, and recombinant proteins. METHODS: A survey on grafting materials in spinal fusion was administered electronically by an independent party to spine surgeons. The survey evaluated the use of bone grafting materials for an open lumbar decompression and instrumented posterolateral fusion in a healthy host and also in a host with co-morbidities. Respondents were asked to select from a list of 10 bone grafting categories including autograft (ICBG or local), rhBMP, and extenders. Factors that are independent predictors of bone graft choice were identified using multiple regression analysis. RESULTS: Of 516 responding surgeons, 460 completed the survey for the healthy host scenario and 429 completed the survey for the host with comorbidities. There was a high degree of variability in the selection of bone
P177. The Effect of Operative Position During Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Does it Influence Sagittal and Axial Alignment of the Thoracic Spine? Jahangir Asghar, MD1, Amer Samdani, MD2, Patrick Cahill, MD3, David Clements, MD1, Randal Betz, MD4; 1Philadelphia, PA, USA; 2Johns Hopkins University, Baltimore, MD, USA; 3Merion Station, PA, USA; 4 Temple University, Philadelphia, PA, USA BACKGROUND CONTEXT: There exists a complex inter-coupling of planar deformity in adolescent idiopathic scoliosis. Hence, the correction of all 3 planes during PSF for AIS remains a challenge. PURPOSE: This study was to examine the effects of the position of the chest roll on thoracic kyphosis and its influence on axial alignment of the thoracic spine. STUDY DESIGN/SETTING: Retrospective Radiographic review. PATIENT SAMPLE: Patients with Adolescent Idiopathic Scoliosis who underwent a Posterior spinal fusion. OUTCOME MEASURES: Radiographic measurments: Cobb angles, Sagittal measurements, Rib ratio. METHODS: This is a retrospective review of 21 consecutive patients with Lenke 1, 2, 3and 4 AIS curves whom positioned prone on the Jackson (Orthopaedic Systems, Inc., Union City, CA) spinal table. The chest roll were positioned with the roll being approximately 2 cm below sternal notch (ST) Roll and subsequently repositioned just proximal to the level of the xiphoid process (Xi). Lateral radiograph were taken. In addition, axial measurements with a scoliometer and the rib hump index on radiograph were recorded. A statistical analysis using SPSS software was performed to measure for significant differences between the groups. RESULTS: The mean coronal deformity on standing AP radiograph was 58 degrees with the median apex of the deformity at T9. The mean erect standing thoracic kyphosis measurements were 9.2 degrees. The Scoliometer reading on the Adam’s forward bend was 21.2 degrees. In the prone,