Rick Sasso, MD

When most people think of spine surgery – they may typically think that this requires a few nights in the hospital. But just as other types of surgery have become less invasive and surgical techniques and post-operative care have become increasingly sophisticated, more spine surgeries may be performed on an outpatient basis. Typically, outpatient surgery is defined as a surgical procedure where the patient is discharged to go home within a few hours of the procedure.

A recent study that I participated in evaluated the postoperative data of 645 spine surgery patients who underwent an anterior cervical discectomy and spinal fusion (ACDF). Information was gathered following the patient’s spine surgery procedure, to determine the safety of performing ACDF on an outpatient basis. Of the data reviewed for the 645 patients, only two developed acute complications. These complications were present/symptomatic within four hours of post spine surgery, within the mandatory procedure protocol for postoperative observation. For those patients that were readmitted following discharge, 80% were a result of pain or nausea. 

The study did conclude that a single level cervical discectomy and spinal fusion (ACDF) can be safely performed on an outpatient basis. This is more so, if the patient has an allograft donation (bone graft from a bone bank donation) rather than grafting bone from their iliac crest (hip). 

The result of this study was published in the Journal of Spinal Disorders & Techniques. 

In a recent blog entry, I highlighted information from a study that I participated in and an article I co-authored, “Quality of Spinal Motion with Cervical Disc Arthroplasty.” This blog entry will define a few key terms used in that abstract/study.

Kinematic Study – This is the study of the motion of the body, not taking into consideration the effects of mass or force on the motion.

Cervical Arthroplasty – Refers to the spine surgery procedure where a damaged cervical disc is removed and replaced by an artificial cervical disc. 

Spinal Fusion – Often this procedure is referred to as ACDF, standing for anterior cervical discectomy and fusion. This is the spine surgical procedure where a damaged cervical disc is removed. To preserve the space within the vertebral bodies a bone graft is then placed where the damaged disc was removed. This bone graft is either from the patient’s hip bone (iliac crest) referred to as an autograft donation or from a bone bank (allograft). Then a spinal plate and screws are attached to the vertebral bodies immediately above and below the graft. 

An article that I co-authored, published in the Journal of Spinal Disorders & Techniques, summarized a study on cervical spinal motion at the adjacent discs (adjacent segment motion) following spinal arthroplasty with a Bryan Cervical Disc as compared to a spinal fusion.  Radiographic analysis was used to measure this motion prior to surgery, and at designated intervals post-surgery. 

For an abstract of this study, visit this link. 

I recently co-authored a book that is now available on Amazon or through the publisher.  The book, entitled Spinal Arthroplasty: The Preservation of Motion, provides detailed information about spinal arthroplasty.  This medical education book includes information about cervical artificial discs and lumbar artificial discs that are used in the spine surgical treatment of cervical and lumbar degenerative disc disease.

A few chapter titles include: 

• History of Spinal Fusion
• History of Motion-Sparing Surgery
• Spinal Anatomy
• Spinal Biomechanics
• The Effects of Fusion and Motion Sparing Procedures on the Biomechanics of the Spine
• Biomaterials in Spinal Arthroplasty
• Total Disc Arthroplasty: Clinical Indications and Surgical Approach
• Cervical Arthroplasty: Biomechanics, Design Considerations, Clinical Outcome
  

In a prior blog entry, I highlighted a few of the talks I participated in at the annual Scoliosis Research Society meeting. The acronym for this annual continuing medical education meeting is IMAST, and stands for International Meeting on Advanced Spine Techniques.

This international meeting brings experts on spine surgery from all over the world to discuss the latest surgical techniques, devices as well as it provides a forum to provide the latest on research in progress.

The overall educational objectives of this meeting are listed below.

At the completion of this program, participants should be able to:

1. Assess the most recent advances in surgical techniques for the treatment of spinal disorders and when to use them, in the interest of providing optimal patient care.

2. Analyze the indications and potential complications for various spine fixation systems including spinal arthroplasty.

3. Recognize emerging technology that has the potential to improve patient outcomes for specific indications and populations.

4. Understand when it may be appropriate to use biologic options to enhance spinal fusion.

At a recent annual continuing medical education meeting sponsored by The Scoliosis Research Society, I was an invited instructor. This conference was the 17^th International Meeting on Advanced Spine Techniques and was held in Toronto. This educational meeting is considered one of the premier international spine meetings held annually for spine surgeons, and it is an honor to be asked to be one of the limited faculty members.

At this meeting, I presented the results of a spine research study for an investigational device that I am participating in. This study is related to the cervical spine and deals with cervical motion technology. A few other continuing medical education activities that I participated in included:

·         Gave a presentation on occipitocervical fixation and biomechanics.

·         Moderated a round table discussion on cervical reconstruction.

·         Participated in a fundamentals session on the cervical spine and discussed posterior cervical decompression and fusion.

One spine surgery research study that I participated in - compared the post-operative results of cervical arthroplasty and arthrodesis on approximately 500 patients. The objective of this study was to compare any side effects of patients undergoing a cervical arthroplasty with the implantation of a Bryan Cervical Artificial Disc to those patients that underwent a spinal fusion.

In this study, of which there were 31 institutions where patients underwent spine surgery, there were 242 patients who received the Bryan Cervical Artificial Disc and 221 patients that underwent cervical discectomy and spinal fusion. Patients that participated in this study were over 21 years of age, had single level cervical degenerative disc disease causing radiculopathy or myelopathy as well as a few other clinical indicators. Once identified, these patients were evaluated before spine surgery and post-operatively at regular intervals beginning one and one half months following spine surgery up to 2 years. 

This study concluded that both procedures are safe, and that there is not a significant difference in adverse effects with the newer arthroplasty procedure utilizing the Bryan Cervical Artificial Disc when compared to the traditional surgical option of spinal fusion.

 To read the complete study,link here.

While at the American Academy of Orthopaedic Surgeon’s annual continuing medical education meeting, I also gave a few other talks/podium presentations.  These presentations were:

"Does smoking have an impact on fusion rate in single level ACDF with allograft and plate fixation?"

“Does early return to work following arthroplasty and ACDF

result in adverse outcomes?"

While at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS) in New Orleans, in addition to presiding as President of the Federation of Spine Societies spine specialty day, I also gave a few talks on cervical radiculopathy.

The first session that I moderated was on the current concepts in cervical radiculopathy.  The objective of this continuing medical education session was to provide the most up-to-date information on the pathophysiology, diagnosis and treatment of cervical disc disorders, including the role of selective nerve root sleeve injections and artificial disc replacement.

Another session that I served as a faculty member for was the spine instructional course lecture entitled, “The Degenerative Cervical Spine: What You Need to Know.”  This presentation provided an overview of cervical degenerative diseases and addressed the patient evaluation and treatment options, including anterior, posterior and non-operative options.

The American Academy of Orthopaedic Surgeons (AAOS) held their annual continuing medical education meeting in New Orleans, in early March.  In addition to attending the annual continuing medical education meeting, I also had the honor of coordinating and hosting the spine specialty day. The spine specialty day presented a common forum by the Federation Societies, of which I am the president.  The Federation Societies is comprised of four spine-focused organizations, and includes the Cervical Spine Research Society, North American Spine Society, Scoliosis Research Society and the American Spinal Injury Association.  

A few of the educational objectives for the day included discussing the current concepts in the diagnosis and management of spinal disorders, and to review and update the clinical results and complications of the new technologies and concepts.  The information was presented in the form of instructional presentations, discussions, papers and debates. 

Highlighted topics were presented by each society within the Federation.  During the day in the North American Spine Societies section, I presented a talk on cervical disc replacement, and for the American Spinal Injury Association I discussed spinal cord injury and the appropriate time for decompression. 

In my last few blog entries, I discussed scoliosis. In this blog entry, I am including a few scoliosis resources for more in-depth information about scoliosis.  

Scoliosis Research Society

National Scoliosis Foundation

iScoliosis
National Institute of Arthritis and Musculoskeletal and Skin Diseases
 

Often time’s patients that have idiopathic scoliosis may also have a visible rib deformity that may be present following corrective spine surgery.  The traditional spine surgical procedure to correct this has been open thoracoplasty.  A newer, minimally invasive procedure used is video- assisted thoracoplasty.  This procedure is less invasive than the traditional spine surgical procedure.

Many times with scoliosis - no treatment is needed.  Once a patient is diagnosed with scoliosis it is important to observe and monitor the curve during the patient’s growing years.  Factors that affect what type of treatment is recommended include the age of the patient and how much growth they have left, the degree and pattern of the curve, and the type of scoliosis. 

Treatment options may range from observation to surgery.  If it is decided that the patient will be observed; they will be evaluated approximately every six months while the patient is still growing.  At this time, the degree of the curve will be assessed.

Bracing is a treatment option to prevent the curve from progressing.  This is recommended if the patient has an idiopathic curve, is still growing and:

• Has a curve greater than 25 degrees,
• Has two more years of potential growth remaining and the curve is between 20 and 29 degrees, (and if female has not had her first menstrual period) or
• Has a curve that is between 20 and 29 degrees and is progressing.   

This blog entry is part of a series on scoliosis, and will address commonly asked questions about screenings.

At what age should I have my children screened for scoliosis and how frequently should this be done?

In that scoliosis is typically diagnosed between the ages of 10 and 16, I generally recommend that parents have their children screened for scoliosis as a part of their annual physical.  Depending on the school system, the school nurse may do scoliosis screenings as part of their wellness / health initiatives. 

Are there any visible symptoms of scoliosis that I can look for in my child? 

There are a few visible symptoms that as a parent you may notice in your child.  Some of these visible signs may be uneven shoulders, or a protrusion of one or both of the shoulder blades, an elevated hip, or uneven waist.  Sometimes, you may notice clothes do not fit properly – that pant legs may appear longer on one side than the other.  If you notice any of these symptoms in your child, it is recommended to talk to your family doctor.    

What is the screening test called that is commonly performed – when you are bending forward?

This is one of the most common initial screening tests for scoliosis and is called the Adam’s Forward Bending Test.  For this test, the individual puts his or her feet together,  leans forward and bends at the waist 90 degrees.  Often times, they are asked to put their hands together like they are diving.  The screener will then look at the spine for any abnormal curvatures and asymmetry of the trunk.  This screening can tell if there is a curve – but not the degree of the curve.

How do you determine the degree of spinal curvature?

If an initial screening such as the Adam’s Forward Bending Test indicated that they was a curvature – further testing then measures the degree of the spinal curvature.  To determine this – an X-ray of the spine is taken.  A process called the Cobb Method is then used to measure the amount of spinal curvature. 

With the Cobb method of measuring spinal curvature, lines are drawn on the X-ray parallel to the end plates of the vertebral bodies at the beginning and end of the curve.  A perpendicular line is then drawn – and the angle between these two lines equals the degree of curvature – called the Cobb measurement.  It is important to note, that the actual measurement can vary 3 to 5 degrees, depending upon the exact positioning of the patient for the X-ray.  That is why major treatment decisions are not made on one single X-ray.

In these next series of blog entries – I will answer common questions about scoliosis – including the diagnosis, and provide an overview of the treatment options both medical and surgical treatments.

The Scoliosis Research Society defines scoliosis as a lateral deviation of the normal vertical line of the spine, which is greater than ten degrees when measured by an X-ray.  Scoliosis is often referred to as “curvature of the spine.”

According to the National Scoliosis Foundation (NSF), scoliosis affects 2-3% of the population.  The common age for onset is 10-15 years, old and it affects both genders equally although females are eight times more likely to have a greater degree of curvature that requires treatment the NSF indicates.  Although scoliosis is not heredity, there is an increased likelihood of an individual being diagnosed with scoliosis if a family member has had it. 

The different types of scoliosis include:

§         Idiopathic Scoliosis – This is where scoliosis occurs without a known cause.  This is the most common type of scoliosis.

§         Congenital Scoliosis – This is when an individual is born with scoliosis as a result of the vertebrae not being properly formed during pregnancy.  This malformation occurs within the first six weeks of embryonic formation.

§          Neuromuscular Scoliosis – This is caused as a result of a neurological disorder such as muscular dystrophy that results in a weak trunk and the individual can not support the weight of their body.

§         Adult Scoliosis – This is when scoliosis is diagnosed in an individual as an adult.  It can either be undiagnosed scoliosis when the individual was younger or the result of age-related degeneration.  An example of age-related scoliosis is osteoporosis. 

If you have a question on scoliosis that you would like answered in this series of blog entries, please send your question to info@indianaspinegroup.com. 

In October, I was a faculty member at the 8^th Annual Symposium on “Innovative Techniques in Spine Surgery.” This continuing education meeting, hosted in Phoenix, addressed the innovative and emerging technologies of spinal surgery including; arthroplasty, minimally invasive procedures, motion sparring technologies and biologics.  At this meeting I gave a talk on Lumbar Artificial Disc Replacement, and presented the results of the FDA studies for the Cervical Artificial Disc.

This education program was sponsored by the Organization of Spinal Teaching and Research.  The purpose of this group is to facilitate education and discussion among spine care providers and industry and this organization includes leaders in the field of spine surgery and technology that utilize the most advanced and effective technology available for the treatment of spinal disorders.

A lot of patients ask me about the differences with arthroplasty (cervical artificial disc) and spinal fusion; as well as how does the cervical artificial disc work. A few years ago, I was interviewed by Barbara Lewis on Sound Medicine. This segment titled, “New Artificial Cervical Discs”, can be heard by visiting this link. 

A few topics discussed during this interview included:

• Comparison of a spinal fusion to cervical artificial disc,
• More detailed information about the cervical artificial disc,
• Comparison of cervical artificial disc to artificial hip and knee,
•  The future of cervical artificial disc.

In my prior blog entry, I talked about the Bryan Cervical Artificial Disc study that has recently concluded.  To evaluate patient outcomes and functionality for this spine study, one measurement used was the neck disability index (NDI).  With this assessment, patients provide a self-evaluation and answer a series of questions of how their neck pain affects their ability to manage everyday life. 

Previously, I blogged about the research results of a spine patient study – which evaluated the clinical outcomes of patients who received a Bryan Cervical Disc compared to those that had a standard spinal fusion at 24-months post-operatively. I recently completed a new study, which evaluated these patients 48-months post-operatively. This study will soon be published.

In this study – the functional outcomes of patients at 48-months (4 years) following their spine surgery was evaluated. This study had two groups of patients – one group received a spinal fusion (Anterior Cervical Discectomy and Fusion - ACDF) and the other group received the Bryan cervical artificial disc prosthesis. This spine surgery was for the treatment of radiculopathy and myelopathy, after minimally invasive spine procedures were determined ineffective.

There were 47 patients enrolled in this spine study. Of this group, 21 were enrolled in the Bryan cervical disc arm of the study and their mean age was 40.  In the group that received a spinal fusion (control group), there were 26 participants and their mean age was 43.

This study concluded that patients that received the Bryan Artificial Cervical Disc at 48-months, when compared to the control group:

•     Had less neck and arm pain,
•     Greater mobility,
•     Less adjacent segment degeneration, and
•     Lower secondary operation rate.