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Thursday, September 27, 2018 8:30 AM–9:30 AM Best Papers
The Spine Journal 18 (2018) S50 S69 tion, dural tears, and neurological injury were statistically comparable. Among medical complications, postoperative acute renal failure was more frequently associated with outpatient ACDF than inpatient (OR 1.25, CI 1.06–1.49, p=.010), while the rates of major thromboembolic, respiratory, and cardiovascular events were statistically comparable. CONCLUSIONS: Outpatient spine surgery is growing increasingly popular due to changes in health care delivery and greater attention to cost reduction and improved efficiency. Data collected from a national private insurance database demonstrates greater risk of perioperative surgical complications associated with outpatient ACDF, including revision anterior and posterior fusion, as well as higher risk for postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2018.06.369
105. In vivo biomechanics of cervical spine manipulation William Anderst; Pittsburgh, PA, USA BACKGROUND CONTEXT: Neck pain is one of the most commonly reported symptoms in primary care settings, and a major contributor to increasing health care costs. Cervical manipulation is a common and clinically effective intervention for neck pain. However, the in vivo biomechanics of manipulation are unknown due to the inability to accurately measure intervertebral kinematics in vivo during the manipulation. PURPOSE: The objectives were to characterize manual forces and facet joint gapping during cervical spine manipulation and to assess changes in clinical and functional outcomes after manipulation. It was hypothesized that patient-reported pain would decrease and intervertebral range of motion would increase after manipulation. STUDY DESIGN/SETTING: Laboratory-based prospective observational study. PATIENT SAMPLE: A total of 15 patients with acute mechanical neck pain (5 M, 10 F; average age 40±14 years). OUTCOME MEASURES: Amount and rate of cervical facet joint gapping during manipulation, amount and rate of force applied during manipulation, change in intervertebral range of motion from before to after manipulation, change in pain after manipulation. METHODS: Initially, all participants completed a visual analog pain scale (0-10). Participants then performed full range of motion (ROM) flexion or extension, rotation, and lateral bending while seated within a custom biplane radiography system. Synchronized biplane radiographs were collected at 30 images/second for 3 seconds during each movement trial. Next, synchronized, 2.0 ms duration pulsed biplane radiographs were collected at 160 images/second for 0.8 seconds during the manipulation. The manipulation was performed by a licensed chiropractor using the thumb cervical extension technique. For the final five participants, two pressure sensors placed on the thumb of the chiropractor (Novel pliance system) recorded pressure at 160 Hz. After manipulation, all participants repeated the full ROM movement testing and once again completed the visual analog pain scale. A validated volumetric model-based tracking process that matched subject-specific bone models (from CT) to the biplane radiographs was used to track bone motion during manipulation with submillimeter accuracy. Facet joint gapping was calculated as the average distance between adjacent articular facet surfaces. Pre- to postmanipulation changes were assessed using paired t-tests. RESULTS: The facet gap increased 0.98±0.30 mm during manipulation. The average rate of facet gapping was 7.4±2.9 mm/s. The peak force and rate of force application during manipulation were 65±4 N and 445 ±105 N/s. Pain score improved from 3.7 before manipulation to 2.0 after manipulation (p<.001). Intervertebral range of motion significantly increased after manipulation by 1.4° (p=.005), 2.2° (p=.01) and 4.1° (p<.001) at the C4/C5, C5/C6 and C6/C7 motion segments, respectively, during flexion/extension, by 1.4° (p=.007),1.2° (p=.035) and 1.0° (p=.003)
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at the C3/C4, C4/C5 and C6/C7 motion segments, respectively, during rotation, and by 0.7° (p=.01) and 1.0° (p=.04) at the C4/C5 and C5/C6 motion segments, respectively, during lateral bending. CONCLUSIONS: This study is the first to measure facet gapping during cervical manipulation on live humans. These results improve our understanding of the basic in vivo biomechanics of spinal manipulation. Continuing this line of research will allow clinicians and researchers to design better interventions that reliably and sufficiently impact the key mechanisms behind manipulation. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2018.06.370
106. Do preoperative epidural steroid injections increase the risk of infection after lumbar spine surgery? Tyler M. Kreitz, MDa, William L. Crutcherb, Gregory D. Schroeder, MDc, John J. Mangan III, MD, MHAd, Christopher K. Kepler, MD, MBAb, Mark F. Kurd, MDe, Kris E. Radcliff, MDf, D. Greg Anderson, MDg, Alan S. Hilibrand, MDg; a Thomas Jefferson University Hospital, Philadelphia, PA, USA; b Philadelphia, PA, USA; c Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA; d Thomas Jefferson University Hospital, Department of Orthopaedic Surgery, Philadelphia, PA, USA; e Rothman Institute, Bryn Mawr, PA, USA; f Rothman Institute, Thomas Jefferson University, Egg Harbor Township, PA, USA; g Rothman Institute, Philadelphia, PA, USA BACKGROUND CONTEXT: Lumbar radiculopathy occurs in up to 5% of the population accounting for significant morbidity. Lumbar epidural corticosteroid injections (ESI) may provide diagnostic and therapeutic benefit in the nonoperative management of radiculopathy. However, concern exists regarding whether preoperative ESI's might predispose surgical patients to an increased risk of postoperative infection. PURPOSE: To determine an association and temporal relationship between preoperative ESI and postoperative infection in a large population of patients undergoing lumbar surgery. STUDY DESIGN/SETTING: Retrospective review of all patients who underwent elective lumbar surgery for radiculopathy or stenosis at a single institution between 2000 and 2017 with at least 90 days follow-up. PATIENT SAMPLE: All patients who underwent lumbar surgery were identified in our institutional database by ICD and CPT code. Those who underwent preoperative lumbar ESI were also identified by CPT code. Patients were categorized as no ESI, preoperative ESI less than 30 days, 30-90 days, and greater than 90 days before surgery. Pre- and postoperative clinical data was available in a single electronic medical record. OUTCOME MEASURES: The primary outcome measure was postoperative infection requiring reoperation within 90 days of index procedure. Postoperative infections were identified by ICD code and confirmed by operative report for each patient. METHODS: Of the patients who underwent lumbar spine surgery, those who received preoperative lumbar ESI were identified. Postoperative infection rates were determined by ICD code and operative report. All demographic information including age, sex, body mass index (BMI) and Charlson Comorbidity Index (CCI) was determined. Comparison and regression analysis was used to determine an association between preoperative ESI exposure, demographics, comorbidities, and postoperative infection. RESULTS: A total of 15,011 patients who underwent elective lumbar surgery were included. Of these, 197 (1.3%) were diagnosed with postoperative infection. Of the identified patients, 595 had lumbar ESI within 30 days of surgery, 1709 within 30-90 days of surgery, and 2036 greater than 90 days before surgery. Overall, there was a marginally higher rate of infection among the cohort of patients who had a preoperative ESI that did not reach statistical significance (1.54% vs. 1.22%, p=.118). Among the temporal subgroups, there was no significant difference in postoperative infection rates between those patients who had ESI within 30 days of
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.
105. In vivo biomechanics of cervical spine manipulation William Anderst; Pittsburgh, PA, USA BACKGROUND CONTEXT: Neck pain is one of the most commonly reported symptoms in primary care settings, and a major contributor to increasing health care costs. Cervical manipulation is a common and clinically effective intervention for neck pain. However, the in vivo biomechanics of manipulation are unknown due to the inability to accurately measure intervertebral kinematics in vivo during the manipulation. PURPOSE: The objectives were to characterize manual forces and facet joint gapping during cervical spine manipulation and to assess changes in clinical and functional outcomes after manipulation. It was hypothesized that patient-reported pain would decrease and intervertebral range of motion would increase after manipulation. STUDY DESIGN/SETTING: Laboratory-based prospective observational study. PATIENT SAMPLE: A total of 15 patients with acute mechanical neck pain (5 M, 10 F; average age 40±14 years). OUTCOME MEASURES: Amount and rate of cervical facet joint gapping during manipulation, amount and rate of force applied during manipulation, change in intervertebral range of motion from before to after manipulation, change in pain after manipulation. METHODS: Initially, all participants completed a visual analog pain scale (0-10). Participants then performed full range of motion (ROM) flexion or extension, rotation, and lateral bending while seated within a custom biplane radiography system. Synchronized biplane radiographs were collected at 30 images/second for 3 seconds during each movement trial. Next, synchronized, 2.0 ms duration pulsed biplane radiographs were collected at 160 images/second for 0.8 seconds during the manipulation. The manipulation was performed by a licensed chiropractor using the thumb cervical extension technique. For the final five participants, two pressure sensors placed on the thumb of the chiropractor (Novel pliance system) recorded pressure at 160 Hz. After manipulation, all participants repeated the full ROM movement testing and once again completed the visual analog pain scale. A validated volumetric model-based tracking process that matched subject-specific bone models (from CT) to the biplane radiographs was used to track bone motion during manipulation with submillimeter accuracy. Facet joint gapping was calculated as the average distance between adjacent articular facet surfaces. Pre- to postmanipulation changes were assessed using paired t-tests. RESULTS: The facet gap increased 0.98±0.30 mm during manipulation. The average rate of facet gapping was 7.4±2.9 mm/s. The peak force and rate of force application during manipulation were 65±4 N and 445 ±105 N/s. Pain score improved from 3.7 before manipulation to 2.0 after manipulation (p<.001). Intervertebral range of motion significantly increased after manipulation by 1.4° (p=.005), 2.2° (p=.01) and 4.1° (p<.001) at the C4/C5, C5/C6 and C6/C7 motion segments, respectively, during flexion/extension, by 1.4° (p=.007),1.2° (p=.035) and 1.0° (p=.003)
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at the C3/C4, C4/C5 and C6/C7 motion segments, respectively, during rotation, and by 0.7° (p=.01) and 1.0° (p=.04) at the C4/C5 and C5/C6 motion segments, respectively, during lateral bending. CONCLUSIONS: This study is the first to measure facet gapping during cervical manipulation on live humans. These results improve our understanding of the basic in vivo biomechanics of spinal manipulation. Continuing this line of research will allow clinicians and researchers to design better interventions that reliably and sufficiently impact the key mechanisms behind manipulation. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2018.06.370
106. Do preoperative epidural steroid injections increase the risk of infection after lumbar spine surgery? Tyler M. Kreitz, MDa, William L. Crutcherb, Gregory D. Schroeder, MDc, John J. Mangan III, MD, MHAd, Christopher K. Kepler, MD, MBAb, Mark F. Kurd, MDe, Kris E. Radcliff, MDf, D. Greg Anderson, MDg, Alan S. Hilibrand, MDg; a Thomas Jefferson University Hospital, Philadelphia, PA, USA; b Philadelphia, PA, USA; c Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA; d Thomas Jefferson University Hospital, Department of Orthopaedic Surgery, Philadelphia, PA, USA; e Rothman Institute, Bryn Mawr, PA, USA; f Rothman Institute, Thomas Jefferson University, Egg Harbor Township, PA, USA; g Rothman Institute, Philadelphia, PA, USA BACKGROUND CONTEXT: Lumbar radiculopathy occurs in up to 5% of the population accounting for significant morbidity. Lumbar epidural corticosteroid injections (ESI) may provide diagnostic and therapeutic benefit in the nonoperative management of radiculopathy. However, concern exists regarding whether preoperative ESI's might predispose surgical patients to an increased risk of postoperative infection. PURPOSE: To determine an association and temporal relationship between preoperative ESI and postoperative infection in a large population of patients undergoing lumbar surgery. STUDY DESIGN/SETTING: Retrospective review of all patients who underwent elective lumbar surgery for radiculopathy or stenosis at a single institution between 2000 and 2017 with at least 90 days follow-up. PATIENT SAMPLE: All patients who underwent lumbar surgery were identified in our institutional database by ICD and CPT code. Those who underwent preoperative lumbar ESI were also identified by CPT code. Patients were categorized as no ESI, preoperative ESI less than 30 days, 30-90 days, and greater than 90 days before surgery. Pre- and postoperative clinical data was available in a single electronic medical record. OUTCOME MEASURES: The primary outcome measure was postoperative infection requiring reoperation within 90 days of index procedure. Postoperative infections were identified by ICD code and confirmed by operative report for each patient. METHODS: Of the patients who underwent lumbar spine surgery, those who received preoperative lumbar ESI were identified. Postoperative infection rates were determined by ICD code and operative report. All demographic information including age, sex, body mass index (BMI) and Charlson Comorbidity Index (CCI) was determined. Comparison and regression analysis was used to determine an association between preoperative ESI exposure, demographics, comorbidities, and postoperative infection. RESULTS: A total of 15,011 patients who underwent elective lumbar surgery were included. Of these, 197 (1.3%) were diagnosed with postoperative infection. Of the identified patients, 595 had lumbar ESI within 30 days of surgery, 1709 within 30-90 days of surgery, and 2036 greater than 90 days before surgery. Overall, there was a marginally higher rate of infection among the cohort of patients who had a preoperative ESI that did not reach statistical significance (1.54% vs. 1.22%, p=.118). Among the temporal subgroups, there was no significant difference in postoperative infection rates between those patients who had ESI within 30 days of
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.