Joon Y. Lee

Study Design. Patient survey. Objective. To evaluate patient perspective on surgeons as consultants for industry and medical device manufacturers. Summary of Background Data. Relationships between surgeons and medical device manufacturers are becoming increasingly common. Little is known, however, about how patients perceive these relationships. Methods. Patients in the waiting area of an orthopedic surgery clinic were given a simple 1-page, 8-question anonymous questionnaire. Their responses were tabulated and analyzed for 3 variables: gender, age, and education level. Results. A total of 245 patients completed the questionnaire. An overwhelming majority (94.3%) believed that surgeon-industry relationship is beneficial to patients, and a majority (66.5%) of patients thought that physicians should be compensated for this role. Women were more likely than men to want this relationship to be regulated by physicians instead of the government or hospitals. Patients older than 55 years were less likely to be in favor of physicians being compensated than younger patients. The more educated the patient, the less likely he/she was in favor of allowing physicians to regulate physician-industry relationship. Conclusion. Patients support surgeons in the role of consultants for industry. Gender, age, and education level influence the way that patients perceive this issue.

Open door laminoplasty is a commonly performed procedure for the treatment of cervical spine pathology. One complication of this procedure is closure of the hinge and subsequent restenosis. A simple and effective method of using suture anchors to stabilize posterior elements has been previously described. The aim of this paper is to describe our experience using 2.0-mm suture anchors to maintain canal expansion. Results of 42-consecutive patients who were treated with a modified cervical open-door laminoplasty were reviewed. The modification involves the use of original Hirabayashi technique, but augmenting the canal expansion with 2.0-mm suture anchors at C3, C5, and C7 levels. Additionally, nonabsorbable sutures are placed at C4 and C6 levels as described by Hirabayashi. The technical issues and short-term radiographic outcomes were evaluated. None of the 42 patients who had the door secured with 2.0-mm suture anchors had closure of the hinge. Additionally, the suture anchors maintained their position without loosening or "pull-outs" on postoperative follow-up radiographs. There were 3 short-term complications: 1 was a small dural-tear which was repaired intraoperatively without further sequelae, and the other 2 were both epidural hematomas that required emergent return to the operating room for evacuation. All 3 patients had an uneventful recovery without a new neurologic deficit. This paper reviews a simple and effective method for maintaining canal expansion in open-door laminoplasty. Because of its technical simplicity, 2.0-mm suture anchors may be a safer alternative than other devices currently popular for this purpose.

Study Design. A retrospective review of neurophysiologic alerts during anterior cervical surgery. Objectives. To examine incidence and types of neurophysiologic alerts and their correlation with new postoperative neurologic deficits after anterior cervical discectomy or corpectomy procedures. Summary of Background Data. Although multimodality neurophysiologic monitoring has been shown to predict iatrogenic neurologic injuries in scoliosis surgeries, their role in degenerative or trauma-related anterior cervical spine surgery is still unclear. Materials and Methods. We retrospectively reviewed 1,445 patients who underwent anterior cervical discectomy or corpectomy and arthrodesis with neurophysiologic monitoring that included transcranial electrical motor-evoked potentials (tceMEP), somatosensory-evoked potentials (SSEP), and spontaneous electromyography (EMG). Intraoperative alerts were analyzed for type, perceived cause, actions taken to reverse or minimize the possible spinal cord injury, and any new postoperative neurologic deficits. Results. There were 267 (18.4%) procedures that had either minor (spontaneous, sustained EMG) or major (tceMEP/SSEP amplitude reduction) alerts. Patients who underwent corpectomies had 28% increased risk of having a major neurophysiologic alert compared with those who had discectomies. Diagnosis of cervical spondylotic myelopathy or trauma increased the risk of having a major neurophysiologic alert 30% and 76%, respectively, compared with cervical radiculopathy. Eight surgeries were aborted due to persistent tceMEP/SSEP amplitude loss, but none resulted in new postoperative neurologic deficits. Two patients had halo-vest applied due to early termination of surgery. One of these patients ultimately could not receive definitive surgical stabilization. Discussion and Conclusion. Diagnosis of cervical spondylotic myelopathy or trauma and cervical corpectomy procedures increase the risk for having major intraoperative alerts. In case of persistent tceMEP/SSEP amplitude loss, consider delaying potentially harmful interventions, such as premature termination of the procedure or methylprednisolone infusion, until a new neurologic deficit is verified with an awake-clinical examination.

Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been tested as a bone-graft substitute in randomized, prospective clinical trials since 19971–4. In certain procedures, its efficacy with regard to both arthrodesis rates and clinical outcome has equaled that obtained with iliac crest bone graft. The United States Food and Drug Administration recently approved the use of rhBMP-2 as a bone-graft replacement during anterior lumbar interbody arthrodesis in conjunction with a tapered, threaded intervertebral cage (LT-CAGE; Medtronic Sofamor Danek, Minneapolis, Minnesota). Although the Food and Drug Administration has approved the use of rhBMP-2 only in conjunction with the LT-CAGE device, an off-label use of rhBMP-2 with structural allograft bone in anterior lumbar interbody arthrodesis has been reported. A pilot clinical trial in which allograft bone dowels and an rhBMP-2-soaked absorbable collagen sponge were used for lumbar interbody arthrodesis demonstrated favorable outcomes and good arthrodesis rates3. There have been some concerns about the potential up-regulation of osteoclastic activity leading to rapid resorption of the allograft when the allograft is used with rhBMP-2. Some of this concern originates from the fact that rhBMP-2 can stimulate differentiation and enhance survival of some populations of osteoclasts5. However, thus far, this concern has not been clearly validated in basic science or clinical investigations. In fact, rhBMP-2 has been used to enhance healing of allograft fractures in rats6 and to enhance the biomechanical properties of allograft-native bone interface in dogs7. We report a case in which a femoral ring spacer filled with an rhBMP-2-soaked sponge was retrieved from a woman who had undergone a combined anterior and posterior spinal reconstruction but had early dislodgment of the interbody graft. To our knowledge, this is the first report of retrieval and analysis of an rhBMP-2-soaked collagen sponge in contact with allograft bone. Our patient was informed that data concerning the case would be submitted for publication. A sixty-one-year-old woman presented to our institution chiefly because of incapacitating back pain and worsening bilateral thigh and calf pain while walking. Three years earlier, she had undergone lumbar laminectomy without arthrodesis as treatment for similar symptoms. A diagnosis of neurogenic claudication, postlaminectomy instability, and progressive scoliosis was made on the basis of the clinical and radiographic findings. The patient underwent a combined anterior and posterior reconstruction of the thoracolumbar spine and a revision lumbar decompression. The first stage of the procedure included an anterior interbody release and arthrodesis from L2 to L5. A thorough discectomy was done at each of these levels, with the end plates of the vertebral bodies prepared to bleeding bone. INFUSE bone graft (1.5 mg of rhBMP-2/mL; Medtronic Sofamor Danek) was reconstituted according to the manufacturer's instructions and placed onto a collagen sponge sheet (3 × 4 in [7.62 × 10.16 cm]). The sheet was then divided into three sections and packed into three femoral ring allografts. The allograft-rhBMP-2 spacers were inserted into the disc spaces of L2-L3, L3-L4, and L4-L5 to promote arthrodesis as well as to support the anterior column. The second stage of the procedure included an L2 to L5 revision laminectomy and foraminotomies as well as posterior spinal arthrodesis with instrumentation from T6 to L5 with iliac crest bone graft. The patient recovered uneventfully postoperatively and was discharged from the hospital in stable condition. Three months after the procedure, the patient fell and presented with new-onset low-back pain. Lumbar radiographs revealed that the anterior half of the femoral ring allograft was protruding from the L4-L5 interspace.