31. Static vs. dynamic plating of multilevel anterior cervical discectomy and fusion: does it matter?

31. Static vs. dynamic plating of multilevel anterior cervical discectomy and fusion: does it matter?

Proceedings of the NASS 19th Annual Meeting / The Spine Journal 4 (2004) 3S–119S 18S time. In contrast, the PVS measurements at the C5–6 levels incr...

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Proceedings of the NASS 19th Annual Meeting / The Spine Journal 4 (2004) 3S–119S

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time. In contrast, the PVS measurements at the C5–6 levels increased over the same time period. This correlated with a concurrent caudal descent of the LEJ from C3 to C5 (Pearson coefficient, r⫽⫺0.83 when compared to C6; r⫽⫹0.89 when compared to C2). Male subjects had statistically greater PVS values than female subjects at C1, C2, C3, and C6 (p⬍0.05). Whereas PVS values of 0–5 year old subjects were significantly greater than those of 6–19 year old subjects at the C2-C4 levels, the opposite trend was present at the C5–6 levels (p⬍0.01). CONCLUSIONS: Based on the normal caudal descent of the LEJ, C2 and C6 appear to be reliable levels when measuring prevertebral soft tissues. That is, in comparison to the effect of LEJ excursion on mid-cervical levels (C3–5), soft tissue measurements taken at C2 and C6 are less likely to vary significantly over time. Mean PVS values in addition to two standard deviations at C2 and C6 (which represent 95% of the population), result in values of 6 mm and 14 mm, respectively. Values greater than 6 mm at C2, and 14 mm at C6 should, therefore, be considered abnormal cutoff values in pediatric patients. The normal PVS standards presented in this study may help differentiate between normal and abnormal soft tissue swelling in pediatric patients with suspected cervical spine trauma. DISCLOSURES: No disclosures. CONFLICT OF INTEREST: No Conflicts. doi: 10.1016/j.spinee.2004.05.030

4:09 30. Treatment of anterior cervical pseudoarthrosis outcomes of posterior fusion vs. anterior revision Leah Carreon1, Steven Glassman2, John Dimar, II2, Mitchell Campbell2; 1 Leatherman Spine Center, Louisville, KY, USA; 2University of Louisville, Louisville, KY, USA BACKGROUND CONTEXT: Posterior fusion has been advocated as the most effective treatment of anterior cervical pseudoarthrosis. Authors cite the benefits of increased stability and avoiding the risk of dissection through anterior scar tissue. Despite these advantages, posterior fusion is a more extensive procedure from the standpoint of perioperative and postoperative recovery. PURPOSE: To compare the results of posterior fusions to revision anterior fusions for repair of anterior cervical pseudoarthrosis. STUDY DESIGN/SETTING: Retrospective case series from a single institution. PATIENT SAMPLE: 120 patients seen from 1992 to 2001 with at least two year follow-up were included in this review. All had symptomatic nonunion documented on xray, CTscan or Tomograms. Twenty-seven had repeat anterior procedures and 93 had posterior procedures. OUTCOME MEASURES: NA METHODS: All available hospital and office charts were reviewed. RESULTS:

n Tobacco use Mean follow-up (yrs) Time to first revision (mos) ORT (min) EBL (cc) LOS No. of 2nd revisions Time between revisions (mos)

Re-ASF

PSF

27 13 3.5 (2–11)

93 51 4.4 (2–10)

28.7 (1.9–115.3)

26.5 (1.6–135.9)

136.2 (49–232) 106.1 (50–240) 3.2 (2–7) 12

138 (35–356) 283.4 (70–1300) 7 (4–15) 2

11 (9.2–12.4)

31 (12–50)

Fig. 1.

CONCLUSIONS: Based on these results, posterior fusion is more effective in treating anterior cervical pseudoarthrosis than revision anterior fusion. The higher fusion rate and lower incidence of repeat revision surgery offset the increased blood loss and longer recovery time associated with posterior cervical fusions. DISCLOSURES: Device or drug: Lateral Mass Plates. Status: Approved for this indication. Device or drug: Anterior cervical plates. Status: Approved for this indication. CONFLICT OF INTEREST: Authors (SG, JDI, MC) Consultant: Consultant for Medtronic Sofamor Danek; Authors (SG, JDI, MC) Other: Author receives royalties from Medtronic Sofamor Danek; Authors (SG, JDI, MC) Grant Research Support: Author receives Grant Research Support from Medtronic Sofamor Danek. doi: 10.1016/j.spinee.2004.05.031 4:16 31. Static vs. dynamic plating of multilevel anterior cervical discectomy and fusion: does it matter? Christian Du Bois, MD1, Patrick Bolt, MD2*, Andrew Todd, MD2, Purnendu Gupta, MD2, F. Todd Wetzel, MD3, Frank Phillips, MD1; 1 Rush University / Rush- Presbyterian-St. Luke’s Medical Center, Chicago, IL, USA; 2University of Chicago, Chicago, IL, USA; 3Temple University School of Medicine, Philadelphia, PA, USA BACKGROUND CONTEXT: Anterior plate fixation is frequently used after anterior cervical and discectomy and fusion (ACDF). Although good results with few complications have been reported with plates across a single level, less consistent results have been reported with plates spanning multiple disc levels. Recently, dynamic plates that allow for controlled settling across the construct have been popularized to allow for loading of the graft to promote fusion. To date these proposed benefits have been largely theoretical and there are no studies confirming any benefits over more traditional static plates. PURPOSE: To assess whether dynamic plating of multi-level ACDFs offers any clinical or radiographic advantage over the more simple static cervical plates. STUDY DESIGN/SETTING: A retrospective, matched cohort study. PATIENT SAMPLE: 63 consecutive patients who underwent primary ACDF at two or three operative levels between 1997 and 2002 for either cervical radiculopathy or myelopathy. OUTCOME MEASURES: Clinical outcomes were assessed using Odom’s scores. Radiographic measurements of fusion, construct settling, and plate impingement of adjacent mobile levels were performed by two observers. METHODS: From 1997 to 2002, 63 patients underwent 2 or 3-level ACDF with either static or dynamic plate fixation. Minimum follow-up was one year. A statically locked plating system (Orion) was used in 27 patients, and a dynamic plating system (Atlantis) was used in 36. 42 two-level fusions and 21 three level procedures were included. Plate migration and settling was evaluated using lateral radiographs at 0, 3, 6, and 12 months. The plate length was used to standardize all sequential radiographic measurements. Fusion status was assessed by 2 independent observers using a three point grading system (inter-observer reliability 83%). Clinical outcome was measured using Odom criteria. RESULTS: There were no significant differences between the static and the dynamically plated groups when assessed for the number of levels treated, graft type, gender, patient smoking history, workman’s compensation, or litigation status. At 12 month radiographic follow-up there was no difference in settling across the fusion construct between the static and dynamic plates (p⫽0.619). Plate proximity to the adjacent mobile discs was similar between the two groups at 12 months. There were 0 and 4 radiographic non-unions in the statically and dynamically plated groups, respectively. This difference reached significance (p⫽0.031). Of the 4 Atlantis non-unions, 3 were two level fusions, 3 utilized allograft, and one patient was a smoker. Functional outcome ratings were similar between

Proceedings of the NASS 19th Annual Meeting / The Spine Journal 4 (2004) 3S–119S the groups (p⫽0.716) and good or excellent result were seen in 83% of those treated with a static plate and 82% of those with a dynamic plate. CONCLUSIONS: This study failed to show any advantage of a dynamic plate over static plating after multi-level ACDF. By one year post-operatively the amount of settling across the constructs as well as the proximity of the plate to the adjacent mobile discs was similar. We did observe a statistically higher rate of non-union with dynamic plating. Clinical outcome was similar across the groups. This study does not support the use of a dynamic plate over a simpler, less expensive static plate to stabilize multilevel ACDF. DISCLOSURES: Device or drug: Atlantis cervical plate (Medtronic Sofamor Danek). Status: Approved for this indication. Device or drug: Status: Orion cervical plate (Medtronic Sofamor Danek). Status: Approved for this indication. CONFLICT OF INTEREST: No Conflicts. doi: 10.1016/j.spinee.2004.05.032

Wednesday, October 27, 2004 3:55–4:35 PM Concurrent Sessions 1B: Psychosocial 3:55 32. Are MMPI profiles being misused to deny surgical treatment? Cindy Kidner1, Tom Mayer2*, Robert Gatchel2; 1PRIDE Research Foundation, Dallas, TX, Dallas, TX, USA; 2University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA BACKGROUND CONTEXT: The Minnesota Multiphasic Personality Inventory (MMPI) has long been a standard part of chronic disabling workrelated spinal disorder (CDWRSD) assessment and a guide to treatment. Recently, some surgeons have relied on MMPI profiles to deny surgery for patients felt psychologically unfit, but who are otherwise excellent operative candidates. While some studies have indicated that profiles such as the Conversion V or Neurotic Triad are useful for predicting surgical failure, others do not. PURPOSE: To examine prevalence and risk prediction of 4 common MMPI profiles in a CDWRSD population, a large majority of whom have had spine surgery or are potential candidates. STUDY DESIGN/SETTING: A prospective cohort study. PATIENT SAMPLE: A cohort of 1,489 consecutive CDWRSD patients were tested with the MMPI. Most fell into one of 4 MMPI-2 profiles. The Floating Profile (FP) group (n⫽792) showed 4 or more clinical scale elevations (Tⵧ score 65); the Conversion V (CV) group (n⫽158) had elevations of Scales 1 and 3 only; the Neurotic Triad (NT) group (n⫽132) showed elevations on clinical Scales 1, 2, and 3 exclusively; a Normal (NO) group (n⫽103) showed no clinical scale elevations. The remaining 304 patients had 1–3 elevations in a variety of less common patterns. OUTCOME MEASURES: At pre-treatment, patients were assessed with a structured clinical interview for the DSM-IV psychiatric diagnosis (SCIDIV). One year after treatment, a structured clinical interview identified work status, health utilization and other socioeconomic outcomes. METHODS: All patients completed a 5–7 week functional restoration program in a multidisciplinary setting. RESULTS: Though thought to occur commonly in chronic pain populations, the prevalence of CV (10.6%) or NT (8.9%) represent only a small part of this CDWRSD population. While the NO group represents an insignificant prevalence (6.9%), the relatively unknown FP (53.2%) represents a majority of this CDWRSD population. The FP group was 14 times (OR⫽14.2, p⬍.001) and the NT group 6.6 times likely to have an Axis I (major psychiatric) diagnosis than the NO group, while the CV, group did not show a significant difference in risk. Compared with the NO group, the FP group was 14 times more likely to have a mood disorder, 12 times more likely to have depression, and 15 times more likely to have an anxiety

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disorder. The FP group was almost 5 times (OR⫽4.7, p⬍.001) more likely than the NO group to have an Axis II (personality disorder) diagnosis, while the CV and NT groups did not show a significant increase in risk. Despite significant differences in levels of psychopathology, the groups did not differ significantly in one-year socioeconomic outcomes. CONCLUSIONS: The present study shows that CDWRSD patients averaging 17 months of disability who commonly respond to treatment by returning to work, still show a high prevalence of psychopathology. Only 6.9% have NO profiles, while a very small percent (10.6% and 8.9%) show the traditional “red flag” CV or NT profiles. Surprisingly, 53.2% of patients demonstrate multiple elevations, closely correlated to high rates of psychopathology, but not to risk of poor socioeconomic outcomes. There is no support for the idea that any MMPI profile can predict surgery or rehab treatment outcomes; hence, the MMPI should not be used as a “screening criterion” to deny surgery or rehab. The commonly used CV and NT profiles have a low prevalence and psychopathology correlation in CDWRSD. DISCLOSURES: No disclosures. CONFLICT OF INTEREST: No Conflicts. doi: 10.1016/j.spinee.2004.05.033 4:02 33. Preferences for and expectations of surgical and nonsurgical treatment among patients with intervertebral disc herniation Jon Lurie, MD1, Sigurd Berven2, Anna Tosteson, ScD1, Jennifer J. Gibson, MS1, Tor Tosteson, ScD1, James Weinstein, DO, MS1; 1 Dartmouth Medical School, Lebanon, NH, USA; 2University of California, San Francisco, San Francisco, CA, USA BACKGROUND CONTEXT: Patient expectations about treatment effectiveness have been shown to have important, though complex, relationships with clinical outcomes and satisfaction. PURPOSE: We explored the preferences and expectations of patients entering an observational cohort study of surgery and non-surgical treatments for intervertebral disc herniation (IDH). STUDY DESIGN/SETTING: Survey analysis of the observational cohort of the Spine Patient Outcomes Research Trial. PATIENT SAMPLE: The cohort consisted of 740 patients with IDH enrolled in the observational cohort of the Spine Patient Outcomes Research Trial. OUTCOME MEASURES: Preferences and expectations measured on 5point scales. METHODS: Baseline treatment preference was assessed on a 5 point scale (1⫽“definitely prefer surgery” to 5⫽“definitely prefer non-surgical treatment”). Expectations of treatment outcome for symptom improvement, functional improvement, and adverse treatment outcomes were assessed on a 5 point scale (1⫽“no chance (0%)” to 5⫽“Certain (100%)”). Adjusted and unadjusted analyses were performed with ANCOVA for continuous variables and logistic regression for categorical variables. RESULTS: Two thirds of subjects preferred surgical treatment. Those preferring surgery had greater strength of preference: 75% “Definite” preference vs. 25% “Definite” preference among non-surgery group. Those preferring surgery were somewhat younger (mean age 40 vs 43, p⫽0.001), had less education (high school or less 27% vs 20%, p⫽0.003), were less likely to be working (57% vs. 71%, p⫽0.002), were more likely to be receiving narcotics (58% vs 32%, p⬍0.001), were less concerned about surgical risks (9% vs 49%, p⬍0.001) and more likely to report that nonsurgical treatment had not been effective. Patients with longer duration of symptoms or worse SF-36 physical and mental health summary scores had higher expectations of net benefit from surgery versus non-surgical treatment. Overall optimism regarding outcome was lower in patients with lower education levels, longer duration of symptoms, and worse physical and mental health. CONCLUSIONS: Participants with more severe and longer lasting symptoms, less education and greater psychosocial distress had lower expectations for a good outcome overall but greater expectations and preference for surgery relative to non-surgical treatment.