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Biomedical subjects

Alexander R Vaccaro

Publications and source records attributed to Alexander R Vaccaro.

At least 19 recordsLinked to original sources
PubMed2003

Impact of neck and arm pain on overall health status.

STUDY DESIGN: A prospective, multicenter, cross-sectional analysis of data from the National Spine Network database. OBJECTIVES: To compare the relative impact of radicular and axial symptoms associated with disease of the cervical spine on general health as measured by the SF-36 Health Survey, and to compare the impact of these symptoms among patients of varying age and symptom duration. BACKGROUND: Degenerative disorders of the cervical spine can cause debilitating symptoms of neck and arm pain. Physicians generally treat radiculopathy more aggressively than axial neck pain alone, although it has never been shown that the presence of radiculopathy leads to a greater impairment of physical and mental function. MATERIALS AND METHODS: SF-36 Health Survey data were collected from all consenting patients seen within the National Spine Network. Patients with symptoms referable to the cervical spine (as per their physician) were included (n = 1,809). SF-36 scores for all eight scales (bodily pain (BP), vitality (VT), general health (GH), mental health (MH), physical function (PF), role physical (RP), role emotional (RE), and social function (SF), and two summary scales (Physical Component Summary [PCS] and Mental Component Summary [MCS]) were calculated. Age/gender normative scores were subtracted from the scale scores to produce a negative "impact" score, which reflected how far below normal health status these patients were. Patients were grouped according to location of symptoms (axial only, radicular only, or axial and radicular), age (younger than 40, 40 to 60, and older than 60 years), and symptom duration (acute: <6 wk; subacute: 6 wk-6 mo; and chronic: >6 mo). SF-36 scores were compared between all groups using analysis of variance and multiple comparisons with Bonferroni adjustment. RESULTS: Patients who presented with both axial and radicular symptoms had the lowest SF-36 scores relative to age and gender norms. These scores were significantly lower than those for patients with only axial or only radicular symptoms across all eight subscales (P < 0.05- P < 0.0001). Scores for patients with only axial pain were significantly lower than for patients with only radicular pain for VT (P < 0.04) and GH (P < 0.004). Patients younger than 40 and those between ages 40 to 60 years were significantly more impacted by their symptoms than patients older than 60 years for all eight scales (P < 0.01). PCS scores were similar for acute, subacute, and chronic groups, whereas MCS scores were significantly worse for patients with chronic pain. CONCLUSIONS: Combined neck and arm pain were much more disabling than either symptom alone. Younger patients (younger than 40 or 40-60) were more affected by these symptoms than patients older than 60 years. In addition, as symptom duration increased, a negative impact on mental health was observed, although chronic symptoms did not affect physical health. This study suggests that patients with a significant component of axial pain in conjunction with cervical radiculopathy should be considered the most affected of all patients with cervical spondylosis. Given the evidence that the treatment methods at the disposal of physicians are effective, this study suggests that prompt treatment of these patients may help avoid the harmful effects of chronic symptoms on mental functioning, especially among younger patients who were found to be more impacted by the symptoms.

Adult↗
PubMed2003

A pilot safety and efficacy study of OP-1 putty (rhBMP-7) as an adjunct to iliac crest autograft in posterolateral lumbar fusions.

The ability of bone morphogenetic proteins (BMPs) to induce bone formation has led to an increasing interest in the potential for their use in fusion surgery. The purpose of this multi-center clinical pilot study was to evaluate the safety of one such BMP-osteogenic protein 1, in the form of OP-1 putty-combined with autograft for intertransverse process fusion of the lumbar spine in patients with symptomatic spinal stenosis and degenerative spondylolisthesis following spinal decompression. Twelve patients with spinal stenosis and degenerative lumbar spondylolisthesis underwent laminectomy and partial or complete medial facetectomy as required for decompression of the neural elements followed by intertransverse process fusion by placing iliac crest autograft and OP-1 putty between the decorticated transverse processes. No instrumentation was used. Patients were followed clinically using the Oswestry scale and radiographically using static and dynamic radiographs to assess their fusion status. Independent and blinded radiologists assessed the films for the presence of bridging bone between the transverse processes and measured translation and angulation on dynamic films using digital calipers. In addition to bridging bone, less than or equal to 5 degrees of angular motion and less than or equal to 2 mm of translation were required to classify the patients as successfully fused, as per the definition of successful fusion provided by the FDA for use in clinical trials involving investigational devices to attain spinal fusion. Radiographic outcome was compared to a historical control (autograft alone fusion without instrumentation for the treatment of degenerative spondylolisthesis). All adverse events were recorded prospectively. The results showed 9 of the 12 patients (75%) obtained at least a 20% improvement in their preoperative Oswestry score, while 6 of 11 patients (55%) with radiographic follow-up achieved a solid fusion by the criteria used in this study. Bridging bone on the anteroposterior film was observed in 10 of the 11 patients (91%). No systemic toxicity, ectopic bone formation, recurrent stenosis or other adverse events related to the OP-1 putty implant were observed. A successful fusion was observed in slightly over half the patients in this study, using stringent criteria without adjunctive spinal instrumentation. This study did not demonstrate the superiority of OP-1 combined with autograft over an autograft alone historical control, in which the fusion rate was approximately 45%. The lack of adverse events related to the OP-1 putty implant in this study is in agreement with other studies supporting the safety of bone morphogenetic proteins in spinal surgery.

Aged↗
PubMed2003

Risk factors for surgical site infection in the patient with spinal injury.

STUDY DESIGN: A retrospective chart review of 1561 patients with spinal injury was conducted over a 4-year period. OBJECTIVES: To determine the rate of surgical site infection in the spinal trauma population, to compare infection rates after spinal operations for elective and traumatic indications, and to identify risk factors for postoperative wound infections in the traumatic subpopulation. SUMMARY OF BACKGROUND DATA: Surgical site infection after spinal operations is a dreaded complication. Risk factors have been investigated previously, but the subset of patients with acute traumatic spinal injury may be distinct. METHODS: The hospital's infection control program was used to identify surgical site infections after spinal operations, and infection rates were calculated. Data including patient characteristics, severity of injury indicators, surgical factors, and perioperative management factors were collected for the patients presenting with acute spinal injury over a 4-year period. RESULTS: Postoperative wound infections developed in 24 of 256 patients. This infection rate of 9.4% was significantly (P < 0.001) higher than for elective spinal operations during the same period (3.7%). Risk factors found to be independently significant included delay until operation, increased postoperative intensive care unit stay, single (neurosurgical or orthopedic) versus combined operative team. CONCLUSIONS: Risk factors for surgical site infection in the acute trauma setting are identified. Two surgical teams may be involved without causing a higher rate of infection.

Acute Disease↗
PubMed2003

Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion.

STUDY DESIGN: This retrospective, questionnaire-based investigation evaluated iliac crest bone graft (ICBG) site morbidity in patients having undergone a single-level anterior cervical discectomy and fusion (ACDF) procedure performed by a single surgeon (T.J.A.). OBJECTIVE: To evaluate acute and chronic problems associated with anterior ICBG donation, particularly long-term functional outcomes and impairments caused by graft donation. SUMMARY OF BACKGROUND DATA: Anterior cervical discectomy and fusion procedures frequently use autologous anterior ICBG to facilitate osseous union. Although autologous ICBG offers several advantages over alternative grafting materials, donor site morbidity can be significant. Acute and chronic complications of donor sites have been reported, yet there are currently no reports of long-term functional outcomes after autologous anterior ICBG donation after single-level ACDF. METHODS: A questionnaire was mailed to 187 consecutive patients who were retrospectively identified to have undergone autologous anterior ICBG harvest for single-level ACDF between 1994 and 1998. The questionnaire divided items into symptomatic (acute and chronic) and functional assessments. Patients answered yes, no, or not applicable; pain was assessed with a Visual Analogue Scale (VAS). RESULTS: Surveys were completed either by mail or follow-up telephone interview by 134 patients (71.6%). Average follow-up was 48 months (range, 24-72 months). Acute symptoms were reported at the following rates: ambulation difficulty, 50.7%; extended antibiotic usage, 7.5%; persistent drainage, 3.7%; wound dehiscence, 2.2%; and incision and drainage, 1.5%. The chronic symptom questionnaire demonstrated a high degree of satisfaction with the cosmetic result (92.5%). Pain at the donor site was reported by 26.1% of patients with a mean VAS score of 3.8 in 10, and 11.2% chronically use pain medication. Twenty-one patients (15.7%) reported abnormal sensations at the donor site, but only 5.2% reported discomfort with clothing. A unique functional assessment revealed current impairments at the following rates: ambulation, 12.7%; recreational activities, 11.9%; work activities, 9.7%; activities of daily living, 8.2%; sexual activity, 7.5%; and household chores, 6.7%. CONCLUSIONS: A large percentage of patients report chronic donor site pain after anterior ICBG donation, even when only a single-level ACDF procedure is performed. Moreover, long-term functional impairment can also be significant. Patients should be counseled regarding these potential problems, and alternative sources of graft material should be considered.

Activities of Daily Living↗
PubMed2003

Indications, techniques, and outcomes of posterior surgery for chronic low back pain.

This article summarizes a number of issues surrounding the diagnosis, indications, and techniques of posterior lumbar spine surgery for chronic low back pain. It would not be entirely unjustified for a spine surgeon to adhere to a totally avoidant approach to chronic low back pain, rationalized by a reasonably legitimate nihilism regarding the presently available means of diagnosing and surgically managing low back pain [64]. Judging by the number of lumbar fusions performed in North America and the tremendous intellectual and financial investment currently being made in technologies to enhance spinal fusion, such an approach is evidently not achieving wide-spread acceptance on this continent. A rationale approach is therefore required for the many low back pain sufferers with degenerative disk disease who arrive in the office having exhausted almost every imaginable form of nonoperative therapy. Every effort should be made to establish a pathoanatomic etiology of the back pain with a combination of diagnostic modalities. Surgical intervention should be approached cautiously and only after extensive dialog with the patient to establish realistic goals and expectations. Posteriorly performed interbody fusion procedures may provide a high fusion rate and satisfactory clinical outcomes for this challenging problem, although further research is necessary to determine more conclusively the role of surgery and the relative effectiveness of the various arthrodesis techniques.

Chronic Disease↗
PubMed2003

Acute sports-related spinal cord injury: contemporary management principles.

Improvements in helmet and equipment design have led to significant decreases in overall injury incidence, but no available helmet can prevent catastrophic injury to the neck and cervical spine. The most effective strategy for preventing this type of injury appears to be careful instruction, training, and regulations designed to eliminate head-first contact. The incidence of football-related quadriplegia has decreased from a peak of 13 cases per one million players between 1976 and 1980 to 3 per million from 1991 to 1993, mostly as a result of systematic research and an organized effort to eliminate high-risk behavior. An episode of transient quadriparesis does not appear to be a risk factor for catastrophic spinal cord injury. Torg reported that 0 of 117 quadriplegics in the National Football Head and Neck Injuries Registry recalled a prior episode of transient quadriparesis, and 0 of the 45 patients originally studied in his transient quadriparesis cohort have subsequently suffered quadriplegia. The significance of developmental spinal stenosis is unclear. Plain radiographic identification of a narrow spinal canal in a player sustaining cervical cord neurapraxia warrants further evaluation by MRI to rule out functional stenosis. The presence of actual cord deformation or compression on MRI should preclude participation in high-risk contact or collision sports.

Acute Disease↗
PubMed2003

Physical and monetary costs associated with autogenous bone graft harvesting.

Although autogenous iliac bone is frequently used for bone graft, many well-documented complications are associated with this procedure-including chronic pain; nerve, arterial, and ureteral injury; herniation of abdominal contents; sacroiliac joint instability; pelvic fractures; hematoma; and infection. An understanding of the morbidities associated with bone graft harvesting and of the strategies for avoiding them is imperative for surgeons using this grafting source. In addition, although synthetic grafting materials are considered relatively expensive compared with autogenous sources, the majority of physicians are unaware of the actual direct and indirect costs associated with autogenous bone graft harvesting. Contemporary allograft and synthetic grafting composites are being developed to optimize and surpass the native qualities of autogenous sources (ie, osteogenesis, osteoinductivity, osteoconductivity). Careful comparison of the cost of these alternative sources with the physical and monetary costs of autogenous bone graft will undoubtedly make allograft, recombinant, synthetic graft composites the logical choice in the very near future.

Anesthesia↗
PubMed2003

Adult degenerative lumbar scoliosis.

Degenerative scoliosis of the lumbar spine affects a significant number of adults. Although the etiology of this condition is not clear, the most commonly implicated causes include osteoporosis and degenerative disc disease. Clinically, patients with this condition most commonly complain of axial low back pain, but they may also present with radicular complaints. This pain may be generated directly by the facet joints or may be due to nerve root impingement or traction. Imaging of this spinal deformity should include both plain radiographs and computed tomographic myelography. Nonoperative therapy is ideal, but surgery is indicated for severe radicular symptoms refractory to conservative management or for progression of the curve. Ideally, surgical treatment should consist of decompression and fusion with segmental instrumentation.

Adult↗
PubMed2002

Intraoperative neurophysiologic detection of iatrogenic C5 nerve root injury during laminectomy for cervical compression myelopathy.

STUDY DESIGN: A retrospective and prospective study was conducted to investigate intraoperative neurophysiologic monitoring during cervical laminectomy to detect iatrogenic C5 nerve root palsy. OBJECTIVE: To evaluate the usefulness of various intraoperative neuromonitoring methods for identifying C5 nerve root palsy. SUMMARY OF BACKGROUND DATA: One unsolved complication after laminectomy or laminoplasty for cervical compression myelopathy is C5 nerve root palsy. It can go undetected even in the presence of intraoperative neuromonitoring with conventional upper extremity mixed nerve or dermatomal somatosensory-evoked potentials or transcranial motor-evoked potentials, recording typically from hand muscles. METHODS: The intraoperative neuromonitoring data of 200 patients who underwent cervical laminectomy for myelopathy between 1998 and 2000 were reviewed for C5 nerve root palsy. Retrospective studies were conducted for the first 132 patients, who were monitored with conventional techniques including ulnar and posterior tibial nerve somatosensory-evoked potentials, C5-C7 dermatomally evoked potentials, and transcranial electrical motor-evoked potentials recorded from hand and leg muscles. Prospective studies then were applied to the remaining 68 patients, for whom transcranial electrical motor-evoked potentials and spontaneous electromyography were monitored from deltoid and biceps muscles in the wake of undetected C5 nerve root palsy from conventional neurophysiologic monitoring methods. RESULTS: In the retrospective cohort, six patients presented after surgery with C5 nerve root palsy showing unilateral deltoid muscle paralysis despite entirely unremarkable conventional somatosensory-evoked potentials, dermatomally evoked potentials, and transcranial electrical motor-evoked potentials from hand and leg muscles. For the prospective cohort, two patients experienced postoperative iatrogenic C5 motor nerve root palsy. Impending C5 nerve root injuries after laminectomy were successfully identified in both patients showing significant changes in deltoid and biceps transcranial electrical motor-evoked potentials and spontaneous electromyography, thereby averting more serious consequence. There were no false-negative and false-positive results. CONCLUSIONS: In an effort to reduce postoperative C5 nerve root palsy, the clinician should consider intraoperative deltoid and biceps transcranial electrical motor-evoked potential and spontaneous electromyography monitoring whenever there is potential for iatrogenic C5 nerve root injury.

Adult↗
PubMed2002

Image-guided spine surgery: a cadaver study comparing conventional open laminoforaminotomy and two image-guided techniques for pedicle screw placement in posterolateral fusion and nonfusion models.

STUDY DESIGN: A randomized comparison of conventional and image-guided technology techniques for pedicle screw placement was performed. OBJECTIVE: To evaluate the accuracy of thoracolumbosacral pedicle screw placement in simulated posterior fusion and nonfusion models via conventional and image-guided surgical techniques. SUMMARY OF BACKGROUND DATA: Computer-assisted image-guided technology has been promoted as a means for theoretically improving the accuracy of spinal instrumentation placement, especially when visual landmarks are obscured. METHODS: Seven embalmed cadaveric spines were cleared of all posterior soft tissue and mounted. The posterior elements of four spines were obscured so as to simulate a fusion mass using a synthetic bone cement. Three nonobscured spines also were instrumented. Pedicle screws were placed from T6 to S1 in two obscured specimens (24 screws) using a computer-assisted image-guided system, in one obscured specimen from T6 to S1 (12 screws) using a fluoroscopically assisted system, and in one obscured specimen from T6 to S1 (14 screws) using a conventional open laminoforaminotomy technique. In addition, pedicle screws were placed from T6 to S1 using a fluoroscopically assisted technique in two unobscured specimens (36 screws), and from from T6 to S1 (14 screws) via a laminoforaminotomy technique in one unobscured specimen. Pedicle violation was assessed by computed tomography scanning and direct visual inspection. The degree of screw misplacement noted visually was quantified with an electronic caliper. RESULTS: Pedicle screws placed via open laminoforaminotomy resulted in a pedicle cortex breach rate of 21.43% in fused specimens and 14.29% in nonfused specimens. Screws placed in the nonfused model (two cadavers) via fluoroscopically assisted methods had pedicle cortical breaches, respectively, in 6.25% and 10% of the specimens, whereas the same method was noted to have a 8.33% violation rate in the fusion model. Finally, computed tomography-based image-guided placement through a simulated fusion mass resulted in no pedicle wall violations. CONCLUSIONS: Accuracy of pedicle screw placement in the thoracolumbosacral spine is improved with the use of image-guided methods, particularly guidance by computed tomography. This is especially relevant clinically when the anatomy is obscured or altered as a result of inflammatory spondyloarthropathy (e.g., ankylosing spondylitis in which spontaneous fusions obscure surgical landmarks for pedicle access), or when used postsurgically in the setting of a posterolateral fusion.

Bone Screws↗
PubMed2002

Early halo immobilization of displaced traumatic spondylolisthesis of the axis.

STUDY DESIGN: A retrospective study evaluating early halo immobilization of Types II and IIA hangman's fractures. OBJECTIVE: To determine the treatment efficacy of early halo immobilization of Type II and IIA hangman's fractures. SUMMARY OF BACKGROUND DATA: The treatment of hangman's fractures with traction reduction is well established, but the time required in traction before the institution of halo-vest immobilization is controversial. METHODS: A retrospective review of all patients admitted to a level one spinal cord injury center between 1986 and 1999 with either a Type II or IIA hangman's fracture was performed. Initial and final radiographs were measured for translation and angulation. The need for reapplication of traction was also recorded. RESULTS: There were a total of 27 Type II and four Type IIA fractures. Of the Type II fractures, 21 went onto union after early halo immobilization. Six patients required reapplication of traction reduction because of fracture displacement. The Type IIA fractures all progressed to union. The discerning factor between the failure group and the success group was the initial degree of angulation on lateral cervical radiography. The patients requiring reapplication of traction had an initial fracture angulation of 12 degrees or greater. CONCLUSIONS: Early halo immobilization after traction reduction of Type II and IIA hangman's fractures is an effective method of management. Type II fractures with an angulation of greater than or equal to 12 degrees may require an extended period of traction to ensure adequate long-term fracture alignment.

Adolescent↗
PubMed2002

Recombinant human osteogenic protein-1 (bone morphogenetic protein-7) as an osteoinductive agent in spinal fusion.

STUDY DESIGN: The data related to spinal applications of osteogenic protein-1 presented at national meetings or published in peer-reviewed literature are reviewed. OBJECTIVES: To review the available data related to the use of osteogenic protein-1 for spinal arthrodesis. REVIEW OF BACKGROUND DATA: Osteogenic protein-1 (bone morphogenetic protein-7) is a member of the bone morphogenetic protein family and has shown strong osteoinductivity in vivo. METHODS: The background related to osteogenic protein-1 for spinal applications and the known studies presented at national meetings or published in the peer-reviewed literature are reviewed. RESULTS: Osteogenic protein-1 is able to achieve solid bony fusion of the spine in both the anterior and posterolateral environments in animal studies and has a good safety profile. Early human trials appear to be promising. CONCLUSIONS: Animal studies support the ability of osteogenic protein-1 to enhance or replace autograft for spinal arthrodesis in both the posterolateral and interbody environment. Human trials ultimately will provide data to clarify the optimal role of osteogenic protein-1 in human spinal surgery.

Animals↗
PubMed2002

Pedicle screws with high electrical resistance: a potential source of error with stimulus-evoked EMG.

STUDY DESIGN: Clinically relevant aspects of pedicle screws were subjected to electrical resistance testing. OBJECTIVES: To catalog commonly used pedicle screws in terms of electrical resistance, and to determine whether polyaxial-type pedicle screws have the potential to create a high-resistance circuit during stimulus-evoked electromyographic testing. SUMMARY OF BACKGROUND DATA: Although stimulus-evoked electromyography is commonly used to confirm the accuracy of pedicle screw placement, no studies have documented the electrical resistance of commonly used pedicle screws. METHODS: Resistance measurements were obtained from eight pedicle screw varieties (5 screws of each type) across the screw shank and between the shank and regions of the screw that would be clinically accessible to stimulus-evoked electromyographic testing with a screw implanted in a pedicle. To determine measurement variability, resistance was measured three times at each site and with the crown of the polyaxial-type screw in three random positions. RESULTS: Resistance across the screw shank ranged from 0 to 36.4 ohms, whereas resistance across the length of the monoaxial-type screws ranged from 0.1 to 31.8 ohms. Resistance between the hexagonal port and shank of polyaxial-type screws ranged from 0 to 25 ohms. In contrast, resistance between the mobile crown and shank of polyaxial-type screws varied widely, ranging from 0.1 ohms to an open circuit (no electrical conduction). Polyaxial-type screws demonstrated an open circuit in 28 of 75 measurements (37%) and a high-resistance circuit (exceeding 1000 ohms) in 5 of 75 measurements (7%). CONCLUSIONS: Polyaxial-type pedicle screws have the potential for high electrical resistance between the mobile crown and shank, and therefore may fail to demonstrate an electromyographic response during stimulus-evoked electromyographic testing in the setting of a pedicle breech. To avoid false-negative stimulus-evoked electromyographic testing, the cathode stimulator probe should be applied to the hexagonal port or directly to the screw shank, and not to the mobile crown.

Alloys↗
PubMed2002

Comparative gene expression profiling of normal and degenerative discs: analysis of a rabbit annular laceration model.

STUDY DESIGN: A rabbit annular laceration model was used to investigate intervertebral disc gene expression in normal and lacerated discs. OBJECTIVES: To determine and compare the pattern of expression of potentially important genes in normal and lacerated discs and to determine if the changes in gene expression were similar to human degenerative discs. SUMMARY OF BACKGROUND DATA: Little is known regarding gene expression in normal or degenerating disc tissue. METHODS: Eighteen rabbits were subjected to annular laceration of the L1-L2 and L2-L3 discs while two rabbits served as sham controls. Control and lacerated discs were harvested 1 week, 3 weeks, and 6 weeks following surgery and subjected to histologic examination and gene expression analysis using the reverse transcription-polymerase chain reaction (RT-PCR). The genes studied included collagen Type I (Col I), collagen Type II (Col II), decorin, fibronectin (FN), interleukin-1a (IL-1alpha), bone morphogenetic protein 2 (BMP-2), Fas, matrix metalloproteinase 1 (MMP-1), matrix metalloproteinase 9 (MMP-9), matrix metalloproteinase 13 (MMP-13), and tumor necrosis factor (TNF). Expression levels of each gene were normalized to that of glyceraldehyde-3-phosphate dehydrogenase (GADPH), a constitutively expressed gene. RESULTS: Histology confirmed progressive degeneration of the discs over the 6-week study period. Different patterns of gene expression were observed in control and lesioned discs. Annular laceration caused a marked upregulation (two- to eightfold) of the expression of Col I, Col II, FN, MMP-1, MMP-9, MMP-13, and Fas genes, whereas that of BMP-2, IL-1alpha, and TNF genes was unaffected. Expression of the decorin gene was downregulated approximately sixfold after annular laceration. CONCLUSION: Annular laceration in this animal model resulted in marked changes in gene expression. Upregulation of gene expression was observed for some molecules found at high concentration in human degenerated discs, suggesting similarities to human disc degeneration at the molecular level. This supports the need for further study of the genes found to be activated by annular laceration.

Animals↗
PubMed2002

Spine infections: variations in incidence during the academic year.

STUDY DESIGN: A prospective analysis of variations in monthly spinal infection rates at a spinal cord injury center with resident and fellow involvement in surgical care. OBJECTIVE: To analyze the association between resident and fellow participation in spinal surgery and the incidence of perioperative wound infection over the academic year. SUMMARY OF BACKGROUND DATA: It has been hypothesized that resident and fellow participation in surgical procedures may account for increased wound complications. Previous spinal infection studies have not addressed variations in the incidence of perioperative wound infections over the academic year. METHODS: All cases of postoperative spinal infections at a spinal cord injury center from January 1994 through December 1997 were analyzed to determine whether monthly variations reflect the changes in surgical house officer experience through the academic year. RESULTS: A statistically significant (P < 0.027) increase in the incidence of spinal infection was demonstrated for the month of January. No other significant variations in the monthly incidence of spinal infection existed. No significant differences were found when the data were analyzed: year-to-year (P < 0.727), season-to-season (P < 0.204), 4-month resident rotation (P < 0.061), and 6-month fellow rotation (P < 0.075). CONCLUSION: A significantly higher incidence of spinal infection (10.5%) was observed for the month of January. Because January does not represent the start of a new resident or fellow rotation, there appears to be no association between the incidence of perioperative spinal wound infections and the level of experience of the surgical house officers in a regional spinal cord injury center.

Academic Medical Centers↗
PubMed2002

Patient education on the internet: opportunities and pitfalls.

The Internet, an increasingly pervasive part of our culture, has vastly increased the rate at which information is disseminated. Unfortunately, a substantial portion of medical information on the Internet is false or misleading. Realizing this, many patients would like their physicians to help guide their online searches for medical information, but most physicians do not feel comfortable enough with the Internet to provide this service. A recent poll by Cyberdialogue (2000) found that 70% of all patients would like their physicians to recommend a health care web site for their condition, but that only 4% of patients receive such a recommendation. In recommending medical web sites, physicians need to consider the quality of the web site, the quality of the content, and especially the ethics of the site. The most important ethical standard a web site must meet is the clear separation of its editorial comment from promotional material. Patients do not have enough knowledge to distinguish unbiased information from information designed to push a product or service. There are organizations such as the Health on the Net Foundation and the E-Health Code of Ethics that have established clear quality and ethical criteria, but very few resources exist for these organizations to use in policing the sites that claim to adhere to their criteria. The National Institutes of Health recently started a consumer web site (www.medlineplus.gov) that takes web sites that adhere to their stringent criteria and places them on their web site, thus ensuring proper compliance. Patient education from sources other than face-to-face contact with a physician should be seen as an adjunct to the medical practice of physicians, and not as competition. Information is a form of therapy, and should lead to better referrals, more realistic outcome expectations, better treatment compliance, and better outcomes. As long as patients are referred to information that is unbiased, well-written, and not proprietary, their decision making should be enhanced, bringing them into the decision-making loop. This allows the patient to be much more involved with his or her care. As the medical profession changes from a "gatekeeper" model to a patient choice model, patient education will take on a much greater role.

Bioethics↗
PubMed2002

Halovest dynamic loads: full crossover comparison of three vest types.

STUDY DESIGN: Ten cervical spine trauma subjects were studied during halovest treatment. Each subject wore each of three different vests. OBJECTIVES: To compare the effect of vest design on loads between halo and vest during various activities. SUMMARY OF BACKGROUND DATA: Complications during halovest use may be related to vest design, a variety of which are available. Loads between halo and vest have been shown to vary with activity type, but no comparison between vest types has been reported previously. METHODS: Loads between the halo and the vest were measured during performance of activities of daily living and during load application to the halo, using custom-built four-channel transducers and a PC-based data acquisition system. RESULTS: Substantial variations between subjects exist in loads between the halo and the vest. At rest, neck distraction loads were significantly greater for the supine posture than for either the sitting or standing postures. Loads applied to the halo by the investigators are carried by the neck and not by the structure connecting the halo to the vest. During activities of daily living all four measured load components are generally nonzero. During activities of daily living substantial differences in loads occurred between vest types. For all activities of daily living combined, the relative neck distraction load values were as follows: 4PAD 100%, Bremer 159%, and PMT 180%. CONCLUSIONS: Previous evidence supports a connection between certain complications of halovest wear (such as pin loosening) and loads on the pins. This study shows that different halovests are associated with quite different loads between the vest and the halo (and thus loads on the pins and the neck). This is encouraging for prospective, clinical comparison of different halovests and for improvements in clinical performance through halovest design improvements.

Activities of Daily Living↗