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Bradley K Weiner

Publications and source records attributed to Bradley K Weiner.

13 recordsLinked to original sources
PubMed2006

Matching patient-specific expectations with physician-specific outcomes: towards transparency in treatment decision-making and consent.

This article hypothesizes that while the principles of evidence-based practice should serve as a guiding ideal for physicians, the manner in which this practice style is commonly implemented may be insufficient to the provision of truly informed decision-making and consent - especially in cases where outcomes are inextricably tied to technique, such as in the surgical subspecialities. Specifically, current methods of 'shared decision making' fail to adequately incorporate patient-specific expectations and physician-specific outcomes. A 'next-step', aimed at matching such expectations with outcomes is suggested and a method for implementation is presented.

Arthritis↗
PubMed2006

Patient preferences regarding spine surgical decision making.

STUDY DESIGN: Patient surveys to determine preferences in surgical decision making. OBJECTIVE: To evaluate spine patient preferences regarding physician and patient roles in surgical decision making and to discuss the ethical considerations that arise. SUMMARY OF BACKGROUND DATA: Since the 1980s, there has been a push toward increasing patient autonomy and self-determination, and away from the paternalism of the past. Commensurate with this shift, patients have been encouraged to take the primary active role in surgical decision making. To date, there is little empirical evidence regarding how deeply patients want to be involved in this decision-making process. METHODS: A total of 200 consecutive patients seen at our academic spine center were administered 1 of 2 questionnaires (previously validated) aimed at determining patient preferences about how clinical decision making should take place. RESULTS: Patients felt strongly that complete risk information be provided. The majority of patients felt that the physician, rather than the patient, should make the basic treatment decision, and the great majority felt that the physician should make the technical decisions regarding treatment. CONCLUSIONS: Spine surgical patients often prefer to defer surgical decision making to their surgeons. In clinical scenarios where there is little controversy and the evidence is clear, this results in little consequence, assuming that the surgeon aims to provide evidence-based care. In scenarios with greater controversy and less clear evidence, the choice of treatment offered by the surgeon may be based on factors outside of the available science, and, accordingly, efforts should be made to educate fully the patient and to help the patient make his/her own decision based on personal values regarding outcomes.

Adult↗
PubMed2006

Difficult medical problems: on explanatory models and a pragmatic alternative.

Despite the significant improvements in the treatment of many pathologic processes witnessed over the past century, some particularly difficult medical problems persist. Some of these problems, perhaps best exemplified by chronic low back pain/degenerative disc disease, are characterized by unclear underlying etiologies and less than desirable outcomes of treatment in spite of considerable intellectual and financial investment. Faced with these disorders, many physicians rely on 'explanatory models', such as the traditional Biomedical model or the Biopsychosocial model, to provide a perspective from which to aim research, diagnosis, and treatment programs. The strength of the Biomedical model is its proven success as a roadmap for diagnosis and treatment of a multitude of diseases over the past two centuries. Its weakness lies in its failure to fully include psychosocial factors which have proven to be powerful co-factors of disease in modern society. The Biopsychosocial model has filled this void, but carries with it the potential to blur more straightforward biomedical models of causation (and their straight-forward treatments), questions about whether it is a falsifiable scientific theory, and whether it further 'medicalizes' those being treated. In this paper, we expand and detail the strengths and weaknesses of using these explanatory models and conclude by presenting a 'pragmatic alternative' hypothesis.

Diagnosis↗
PubMed2006

Transforaminal lumbar interbody fusion: an independent assessment of outcomes in a difficult patient population.

BACKGROUND: Transforaminal lumbar interbody fusion is becoming increasingly popular for the surgical treatment of lumbar degenerative conditions. However, the outcomes following the procedure have only begun to be evaluated. MATERIAL/METHODS: The authors reviewed all patients previously treated by TLIF at our tertiary center with minimum two year follow-up. Between 1997 and 2001, twenty-seven patients underwent the procedure. They were evaluated clinically and radiographically at regular intervals for a minimum two years following surgery and longer term follow-up was carried out by telephone interview. Long-term follow-up was undertaken by an independent assessor (a spine surgeon not directly involved in the patient's care) and outcomes were assessed using the measure designed by Macnab/McCulloch/An. Follow-up averaged 30 months and ranged from 24 to 42 months. RESULTS: All but two patients obtained a solid radiographic arthrodesis and complications were few. However, only eleven patients obtained excellent or good clinical results, while 16 had fair or poor outcomes. CONCLUSIONS: TLIF is a technically demanding procedure which can be done with relatively few complications and offers excellent rates of arthrodesis. However, the outcomes of the procedure and indications for the procedure in difficult patient populations clearly require further study.

Adult↗
PubMed2005

Lateral lumbar disc herniations treated with a paraspinal approach: an independent assessment of longer-term outcomes.

In this independent review, at an average of 5.5 years after surgical excision of a lateral zone disc herniation using a paraspinal approach, 51 of 60 patients (85%) were satisfied with the results. Pain was eliminated in 36 (60%) and reduced in all but 3 (5%). Two-thirds of patients had no residual weakness or numbness. Thirty patients (50%) developed some new low-grade back pain, 17 (28%) developed some radicular pain, 9 (19%) developed some degree of radiographic instability, and 9 (15%) required further operative procedures. Based on this information, surgeons should be able to provide realistic expectations for their patients regarding outcomes. Based on our review of the literature, results using the paraspinal window appear similar, but not superior, to other available techniques, and the choice of approach should be based on the comfort of the surgeon.

Aged↗
PubMed2004

The profit motive and spine surgery.

STUDY DESIGN: The profit motive and market medicine have had a significant impact on clinical practice and research in the field of spine surgery. An overview of current concerns is presented. OBJECTIVE: The objective of this study was to provide those involved in the study and treatment of spinal disorders with a critical overview of the effects of the profit motive on our practices. SUMMARY OF BACKGROUND DATA: Historically, the profit motive has been viewed as eroding the standards of spine surgery, encouraging surgeons to operate aggressively and researchers to bias their results. Although there are legitimate concerns regarding the role played by such market forces, the profit motive exerts several quite positive effects on spine surgery as well. METHODS: Negative and positive aspects of the profit motive in spine surgery are explored along with alternative approaches. RESULTS: The profit motive in spine surgery can result in unnecessary surgery, as well as the push to market of unproven technologies. Yet, without a robust profit motive, it is unclear where sufficient funding could be found to support research and education, and to underwrite the advancement of new technologies. CONCLUSIONS: The profit motive significantly influences the way we practice and conduct research in spine surgery. To minimize the negative aspects of the profit motive, spine surgeons and researchers must refrain from being used by companies to rush products to market and/or compromising patient care out of self-interest.

Biomedical Research↗
PubMed2003

Efficacy of autologous growth factors in lumbar intertransverse fusions.

STUDY DESIGN AND OBJECTIVES: A retrospective, consecutive series with "blinded" radiographic review was performed to evaluate two groups undergoing lumbar fusion: one with and one without autologous growth factors (AGF). SUMMARY OF BACKGROUND DATA: AGF has been shown to promote bone formation in vitro and in vivo in animal studies. Accordingly, it has been promoted to augment lumbar intertransverse fusions. To date, however, no controlled studies have been performed to assess its ability to do so in humans. This article presents the first such study. MATERIALS AND METHODS: Two groups were studied. The control group consisted of 27 consecutive patients who underwent a single-level intertransverse lumbar fusion using iliac crest bone graft for either degenerative disk disease (DDD) or degenerative spondylolisthesis from January 1999 to November 1999. The AGF group consisted of 32 consecutive patients undergoing an identical procedure for the same indications with iliac crest bone graft augmented with AGF from January 2000 to November 2000. Fusions were assessed radiographically at 1 and 2 years by two independent spine surgeons on AP and lateral flexion/extension radiographs. RESULTS: The fusion rate for the control group was 24 of 27, or 91%. The fusion rate for the AGF group was 18 of 32 or 62%. CONCLUSIONS: In this study, the use of AGF resulted in inferior rates of arthrodesis compared with autogenous bone graft alone. Although it is important to note there are several techniques available to produce AGF and that the concentration of AGF may differ between individuals, based on the authors' findings, they cannot recommend the use of AGF for this indication until further clinical studies, perhaps altering these variables, prove otherwise.

Adult↗
PubMed2003

The case of James A. Garfield: a historical perspective.

In 1881, President James A. Garfield was shot in the back and died 79 days later. During this time, many controversies arose that had repercussions for years to come. Who was to manage the President's care? A prominent local physician took on the case, but after Garfield's death, he was highly criticized for inappropriate care and for excluding more highly qualified surgeons. Where was the bullet? Multiple opinions were given including that of Alexander Graham Bell. The correct suggestion turned out to be that of a young, unknown assistant demonstrator of anatomy. What was the proper treatment? Local wound care, removal of the bullet, and laparotomy all were considered. Many have felt that the choice of treatment may have proved to be worse than the injury itself. What did the autopsy show? Even this was controversial, with different observers claiming different results. This historical perspective reviews the case as well the controversies that surrounded it.

Famous Persons↗
PubMed2002

The lateral buttress: an anatomic feature of the lumbar pars interarticularis.

STUDY DESIGN: A morphometric study of the lateral buttress region of the lumbar pars interarticularis from L1-L5 on 10 dried lumbar spines was performed. OBJECTIVE: To qualitatively describe and quantitatively evaluate this portion of the pars and to discuss its clinical and surgical relevance. BACKGROUND: The "lateral buttress" is a bony bridge connecting the superolateral edge of the inferior facet to the pedicle/transverse process junction, offering structural support to the pars interarticularis at upper lumbar levels. To date, no anatomic study has evaluated this structure. METHODS: Direct measurements using vernier calipers were taken at each level, L1-L5, from 10 dried lumbar spines. Surface area of the buttress was calculated and compared statistically for differences between each level, as well as normalized relative to L3. RESULTS: The surface areas of the buttresses at L1-L3 were similar, measuring near 80 +/- 10 mm2. At L4, it measured 50 +/- 10 mm2. And at L5, it measured 15 +/- 5 mm2. These differences were statistically significant. Normalized data showed the buttress at L4 to be 40% smaller and at L5 to be 80% smaller than at upper levels. CONCLUSIONS: This study provides descriptive and anatomic data regarding the lateral buttress portion of lumbar pars interarticularis. The broad buttress of the upper lumbar levels offers support to the pars but can confuse anatomic guidelines for pedicle screw placement and paraspinal approaches. The narrow buttress of lower lumbar levels makes pedicle screw placement and the paraspinal approach easier, but it lessens support to the pars, making spondylolysis and iatrogenic instability more likely.

Humans↗
PubMed2002

Microsurgery in the lumbar intertransverse interval.

The intertransverse interval has long been known as a place to lay bone graft in hope of achieving a solid arthrodesis. Opening it to use the interval to gain access into the foraminal and extraforaminal regions of the spinal canal has only recently been done. The anatomy is simple and embodies a common lumbar spine principle, which is to find a pedicle, because medial to it will be a nerve root. In the intertransverse interval, the lateral border of the pars interarticularis is on the same sagittal plane as the medial border of the pedicle (except for L5). Once through the interlaminar window, the anatomy is very simple--there is only one nerve root to find. The limited ability to manipulate instruments and the increased depth of the exposure make the use of the operating microscope very important. More so than axial MRI cuts and far more so than axial CT cuts, parasagittal MRI cuts reveal a true picture of the openness of the foramen. The type of pathology, whether E/FLDH or foraminal stenosis, can be clearly delineated on parasagittal MRI. It is important, however, that radiologists not overcall foraminal stenosis on axial cuts, either CT or MRI. Foraminal stenosis is easily decompressed by a lateral approach and is very difficult to completely decompress from within the spinal canal. If foraminal stenosis has been left behind from a previous midline SCS decompression, and if the patient has continuing leg pain, then it is easy to avoid the previous midline surgical route and take a paraspinal muscle-splitting approach to complete the foraminal decompression. Other, as yet undiscovered uses for the intertransverse window approach likely exist. The senior author has used this approach to remove a third- or fourth-time recurrent canalicular disk herniation where the fragment is opposite the disk space (the usual situation). By avoiding the previous scarred-in canal and nerve root, it has been possible to remove the ruptured disk. Visualization, however, is not good with this approach.

Decompression, Surgical↗