La cirugía de la columna es tan rentable como la artroplastia total de cadera o de rodilla para la osteoartritis primaria Study: Spine surgery is as cost-effective as total hip or knee arthroplasty for primary osteoarthritis

http://www.healio.com/orthopedics/spine/news/online/%7B0fa46988-15ec-4d8f-8b73-bba9994be709%7D/study-spine-surgery-is-as-cost-effective-as-total-hip-or-knee-arthroplasty-for-primary-osteoarthritis

Study: Spine surgery is as cost-effective as total hip or knee arthroplasty for primary osteoarthritis

Rampersaud YR. Spine J. 2014;doi:10.1016/j.spinee.2013.11.011.

Estudio : Cirugía de la columna es tan rentable como la artroplastia total de cadera o de rodilla para la osteoartritis primaria
Rampersaud YR . Spine J. 2014 ; doi : 10.1016/j.spinee.2013.11.011 .


Los investigadores encontraron por vida similares a los 5 años ratios de coste-utilidad incremental en el manejo quirúrgico de la médula y la artroplastia total de cadera o de rodilla en pacientes con artrosis primaria de la columna vertebral , la cadera o la rodilla.

" A pesar de una tasa de revisión significativamente mayor , el manejo quirúrgico general de focal estenosis espinal lumbar para quienes han fracasado los resultados de gestión médica en la mediana de 5 años y la vida útil de coste-utilidad similar en comparación con los de la artroplastia total de cadera y artroplastia total de rodilla para el tratamiento de la osteoartritis de la perspectiva limitada de un sistema de seguro de salud pública ", escribieron los autores en el resumen.

Los investigadores recolectaron datos sobre el estado de salud a largo plazo de forma prospectiva a los resultados quirúrgicos y retrospectivamente por los costos en los pacientes que se sometieron a primaria de uno a la descompresión de dos niveles , con o sin fusión o total de cadera (ATC ) o la artroplastia total de rodilla ( PTR ) para la osteoartritis primaria en un promedio de 5 años de seguimiento.

La relación costo -utilidad incrementales Cinco años ( ICURs ) fueron $ 21,702 por calidad año de vida ajustado ( AVAC ) para THA , $ 28,595 por QALY para TKA , $ 12,271 por QALY para la descompresión espinal sin fusión y $ 35.897 por AVAC para la descompresión espinal con la fusión. Los ICURs vida eran 5,682 dólares por AVAC de THA , 6.489 dólares por AVAC de TKA , 2994 dólar por AVAC para la descompresión espinal sin fusión y $ 10.806 por AVAC para la descompresión espinal con la fusión. En general, el ICUR para cirugía de columna era 5,617 dólares por AVAC .

" El tratamiento quirúrgico de la artrosis primaria de los resultados de la columna vertebral , de cadera y rodilla en la relación costo -utilidad duraderos que son muy por debajo de los umbrales aceptados de efectividad de costos, " escribieron los autores.

Divulgación: Rampersaud es un consultor para Medtronic.

Researchers found similar 5-year lifetime incremental cost-utility ratios for spinal surgical management and total hip or knee arthroplasty in patients with primary osteoarthritis of the spine, hip or knee.

“Despite a significantly higher revision rate, the overall surgical management of focal lumbar spinal stenosis for those who have failed medical management results in similar median 5-year and lifetime cost-utility compared with those of total hip arthroplasty and total knee arthroplasty for the treatment of osteoarthritis from the limited perspective of a public health insurance system,” the authors wrote in the abstract.

The researchers collected long-term health status data prospectively for surgical outcomes and retrospectively for costs on patients who underwent primary one- to two-level decompression with or without fusion or total hip (THA) or total knee arthroplasty (TKA) for primary osteoarthritis at an average of 5 years follow-up.

Five-year incremental cost-utility ratios (ICURs) were $21,702 per quality adjusted life year (QALY) for THA, $28,595 per QALY for TKA, $12,271 per QALY for spinal decompression without fusion and $35,897 per QALY for spinal decompression with fusion. The lifetime ICURs were $5,682 per QALY for THA, $6,489 per QALY for TKA, $2,994  per QALY for spinal decompression without fusion and $10,806 per QALY for spinal decompression with fusion. Overall, the ICUR for spinal surgery was $5,617 per QALY.

“Surgical management of primary osteoarthritis of the spine, hip and knee results in durable cost-utility ratios that are well below accepted thresholds for cost effectiveness,” the authors wrote.

Disclosure: Rampersaud is a consultant for Medtronic.

http://www.healio.com/orthopedics/foot-ankle/news/online/%7Bafcd907b-09a2-4b69-8a8e-77c714f08c26%7D/larger-posterior-malleolar-fragment-size-in-trimalleolar-fractures-linked-to-poorer-outcomes

Larger posterior malleolar fragment size in trimalleolar fractures linked to poorer outcomes

Hong CC. Foot Ankle Surg. 2014;doi: 10.1016/j.fas.2013.10.001

Researchers in Singapore have determined a connection between the posterior malleolar fragment size in trimalleolar fractures and the likelihood of undesirable postoperative outcome.

“Patients have poorer functional outcome with increasing posterior malleolar fragment size in trimalleolar fractures,” Choon Chiet Hong, MBBS, MRCS, and colleagues wrote in the study.
Hong and colleagues conducted a retrospective review of 31 patients with a mean age of 46 years who underwent trimalleolar fracture repair surgery. Olerud and Moleander (O&M) scores were analyzed as well as the ability to return to sports 1 year after surgery.

Of the 21 patients who completed functional outcome surveys, 11 patients noted residual pain, 13 patients had persistent ankle stiffness and 10 patients had persistent ankle swelling at 1 year postoperatively. Poorer O&M scores were observed as the size of the posterior malleolar fragment increased. Patients with Weber B ankle fractures had higher O&M scores than patients with Weber C fractures.
Prior to injury, 12 patients were involved in sports, of which four patients were able to return to their preoperative level of play at 1-year follow-up. Three patients were unable to return to sports. 
“Residual clinical and functional deficits should be emphasized to patients prior to surgery,” Hong and colleagues concluded. “In terms of sporting activities, at least one quarter of patients will not return to sports.”—by Christian Ingram

Disclosure: Hong has no relevant financial disclosures.

Tratamiento para la hernia de disco, Dr Hector Oviedo, Centro Argentino Cubano de rehabilitacion

http://youtu.be/ZzyqvFZLY-A

Doctor, ¿qué es una hernia discal?

El Doctor Vicente Concejero, jefe clínico del servicio de traumatología de la Clínica CEMTRO, explica en el videoblog de traumatología en qué consiste una hernia discal. Las más frecuentes son las que están situadas en las últimas vértebras lumbares, responsables del 95% de los casos. Fundamentalmente aparece en pacientes jóvenes, entre los 30 y los 50 años. Casi todas las hernias provocan que duela la pierna derecha o la pierna izquierda y lo más importante siempre son los síntomas que presente el paciente, mucha más que la imagen de la resonancia. El tratamiento principal es conservador, no hay que operar más del 4-6% de las hernias.

http://youtu.be/YT54A_FINLo 

http://www.spine-health.com/treatment/spinal-fusion/postoperative-care-spinal-fusion-surgery

Postoperative Care for Spinal Fusion Surgery

The management of activities and needs after a spinal fusion surgery evolve with time. The following is what a typical patient can expect. There are different recommendations based on the spine surgeon's preference, the patient's needs, and the type of spine fusion surgery performed.

• See Spine Fusion Surgery Video

Improvement in preoperative symptoms is achieved in about 80% of patients. The improvement in back pain and function continues up to 2 years after spine fusion surgery. The rate of improvement depends on:

• The ongoing maturation of the fusion mass
• Recovery of the nerve compression
• Conditioning of the muscles after spine surgery
• See Failed Spinal Fusion Surgery

Smoking After Spine Fusion Surgery

Another key factor that impacts recovery after spine fusion surgery is smoking. Nicotine acts like a poison in the bone, inhibiting fusion of the bone. One study of how well the bone mass fuses together in spinal fusion patients show that the nonunion rate is lowest (14%) for nonsmokers, slightly higher (17%) for patients who quit smoking for at least 6 months after surgery, and is highest (26%) for patients who continued to smoke. ("Nonsmokers fare better than smokers in fusion procedures," Orthopedics Today, vol. 20, no. 5, May 2000, p.12.)

As in many other types of treatment for back pain, the more effort put forth by the patient, the better the overall result of spine fusion surgery.

For the estimated 20% of patients who do not improve after spine fusion surgery, further work up and evaluation may be recommended.

http://www.spine-health.com/treatment/spinal-fusion/bone-graft-spine-fusion

Bone Graft for Spine Fusion

In a spinal fusion, a solid bridge is formed between two vertebral segments in the spine to stop the movement in that section of the spine. Bone graft and/or bone graft substitute is needed to create the environment for the solid bridge to form.

The bone graft does not form a fusion at the time of the surgery. Instead, the bone graft provides the foundation and environment to allow the body to grow new bone and fuse a section of the spine together (into one long bone).

At the time of the fusion surgery, instrumentation (e.g. screws and rods) is typically used to provide stability for that section of the spine for the first few months after surgery; over the long term, a solid fusion of bone that has healed together provides stability.

This article reviews the main options available for bone graft. These include using the patient’s own bone (autograft), using cadaver bone (allograft), using a bone graft substitute or bone morphogenetic protein (BMP). Some may be used in combination with each other during the spine surgery.

Article continues below

Bone Graft Considerations

There are a number of considerations to evaluate when deciding which type of bone graft options to use. The main factors to be taken into account include:

• Type of spinal fusion (e.g. ALIF, PLIF, posterolateral gutter)
• The number of levels of the spine involved
• Location of fusion – (neck fusion or lumbar fusion)
• Patient risk factors for non-fusion (e.g. if patient is obese, a smoker, poor bone quality)
• Surgeon experience and preference.

To date, using the patient’s own bone is considered the gold standard. However, this is not the best option for all patients.

In an effort to reduce the surgical risks and possible complications with using the patient’s own bone, and to enhance rates of fusion, the spine medicine community is focusing resources on developing better options.

http://www.spine-health.com/blog/tips-young-mothers-first-day-home-after-spine-surgery-part-4

Tips for a Young Mother's First Day Home after Spine Surgery: Part 4

Parts 1-3 in our blog series introduce you to Sarah,* a mother to two young children who decided to undergo a 360 fusion at L4-S1 with bone graft spine surgery.

We hope to offer some insight on how a mother to young children handles the physical and emotional demands of motherhood and recovering from a major surgery.

• Read more about Lumbar Spinal Fusion Surgery

An MRI revealed Sarah was suffering with severe herniation, bone spurs, stenosis (see above for image), and arthritis.

In part 4 of our series, Sarah offers some tips on how to survive the first day home from the hospital:

1. Time the homecoming just right.
   Sarah stayed in the hospital for four nights and five days. She knew she would need lots of hospital rest in order to have the strength to put on a brave face for her young children once she was home.
   • See Postoperative Care for Spinal Fusion Surgery
   Additionally, Sarah's husband made sure the children were well rested and well fed when Sarah got home, in order to avoid any melt downs. Because Sarah had so much support from her family at home from day one, she feels that coming home on the fifth day was a good decision.
2. Have a plan to deal with the children's joyful rowdiness.
   Sarah's two-year-old daughter was so happy to see her on her first day home from the hospital that she had trouble containing herself. She wanted Sarah to pick her up and play with her, but of course that was out of the question.
   Sarah didn't want to upset her daughter by raining on her parade, so Sarah had her mother distract her two-year-old with special treats and gifts, redirecting her energy and attention to other things.
3. Set up a large recovery area that accommodates little visitors.
   Sarah's recovery area was her king-sized Sleep Number bed with a railing. The large bed allowed Sarah to sit next to her children with the comfort and support of the bed to support her spine.
   She also used her memory foam wedge pillow to add support or to act as a barrier between herself and the children. The railing was essential to help her get in and out of bed, and it served as a tool to help her roll over in the weeks following her surgery.
4. Plan some low-key activities to do with the children in your recovery area.
   Sarah and her children watched TV shows together on Netflix from her bed. This quiet activity allowed the children to take comfort in their mother's presence while not demanding any emotional or physical energy from her.
5. Take your medications on time.
   Stay on top of your pain medication schedule. Sarah noted, "I tried my best in the beginning never to fall behind with my medication, which helped me avoid any pain tears in front of my kids. I didn't want them to see that side of my recovery because I knew they were too young to know that it wasn't their fault, and they might have internalized things in a bad way."
• Read more about Getting Adequate Pain Control After Back Surgery
6. Depend 100% on another adult.
   This probably goes without saying, but there is absolutely no way Sarah could have taken care of herself or her children on her first day home from spine surgery, and for many weeks thereafter. She felt blessed to have her husband, mother, and a reliable day care readily available to take care of the children.

On a final note: Sarah's children weren't the only ones who were happy she was home.

One of Sarah's two cats definitely noticed something was different when Sarah returned home. Sarah notes, "She [the cat] has been my shadow ever since I returned from the hospital. She sleeps at my feet or on my lap, and is constantly checking on me… I always knew she was a protective animal, but the extent to which she appears to be 'concerned' about me has been interesting to witness. My other cat, however, hardly notices me!"

Overall, Sarah feels that her homecoming was a success because of the overwhelming support she received from her family.

Over the next few days after returning home from her surgery, Sarah's physical pain was intense, especially in the mornings. A significant source of her surgical pain came from her iliac crest bone graft. In the next installment, we'll take a closer look at this surprising source of pain.