Thomas J Errico, M.D.

Direct decompression and Coflex interlaminar stabilization compared with laminectomy and posterior spinal fusion with pedicle screw instrumentation for spinal stenosis with back pain or degenerative spondylolisthesis: Two-year results from the prospective, randomized, multicenter FDA IDE trial
Auerbach J.; Davis R.; Errico T.; Bae H.
2011 ;11(10 SUPPL 1):86S-87S, Spine journal
BACKGROUND CONTEXT: Laminectomy and posterior spinal fusion are commonly performed for patients with degenerative spondylolisthesis and spinal stenosis with significant low back pain. Long-term untoward sequelae of lumbar fusion have led to the search for motion-preserving, lessinvasive alternatives. PURPOSE: To evaluate the safety and efficacy of the coflex interlaminar device compared to posterior spinal fusion in the treatment of 1- and 2- level spinal stenosis and degenerative spondylolisthesis. STUDY DESIGN/SETTING: Prospective, randomized, multicenter FDA IDE trial comparing direct decompression and coflex interlaminar stabilization with laminectomy and posterior spinal fusion. PATIENT SAMPLE: 219 patients (146 coflex and 73 fusion controls) were randomized and treated from 21 sites in the United States to receive direct decompression and coflex interlaminar stabilization or laminectomy and posterolateral spinal fusion with spinal instrumentation in a 2:1 ratio. OUTCOME MEASURES: Perioperative data, ODI, VAS Back, VAS (worse) Leg, SF-12, ZCQ, and radiographic outcomes at minimum 2 years. Overall device success was a composite ofO15-point reduction in ODI, no reoperations, no major device-related complications, and no post-operative epidural injections. METHODS: Study inclusion consisted of moderate spinal stenosis with significant low back pain (VAS Back Pain <=50/100) and significant disability (ODI<=40%), with up to Grade I spondylolisthesis, at spinal segments from L1-L5. Data were collected preoperatively, then at 6 week, 3 month, 6 month, 12 month, 18 month, and 24 month time points. RESULTS: Patient follow-up at a minimum of 2 years was 96.6% and 98.6% for coflex and fusion control groups, respectively. There were no group differences at baseline in any demographic, clinical, or radiographic parameter. Coflex patients experienced significantly shorter operative times (p<.0001), estimated blood loss (p<.0001), and length of stay (p<.0001) compared with to fusion controls. At 2 years, mean ODI scores were significantly better in the coflexcohort (p<.021) with a trend towards a greater proportion achieving a 15-point reduction in ODI (p<.06). Both groups demonstrated significant improvement in all VAS Back and Leg parameters. Coflex patients had significantly greater improvement in SF-12 Physical Health outcomes (p<.027) and similar Mental Health outcomes. Coflex subjects had greater improvement in all ZCQ outcomes compared with fusion (Symptom Severity (p<.013); Physical Function (p<.013); Satisfaction (p5025)). Based on the stringent FDA composite for overall success, 66.4% of coflex and 59.7% of fusions succeeded, respectively. The overall complication rate was similar between the groups. At 2 years fusion controls exhibited significantly increased sagittal plane translation (p<.05) and angulation (p<.0001) at the superior adjacent level, while coflexmaintained normal operative and adjacent level motion. CONCLUSIONS: Our results demonstrate safety, efficacy, and noninferiority of decompression followed by coflex interlaminar stabilization compared to fusion in the treatment of spinal stenosis and degenerative spondylolisthesis. Coflex stabilization led to significantly improved perioperative outcomes, multiple clinical outcomes measures, and maintenance of motion at operative and adjacent levels compared with fusion at 2 years. Coflex interlaminar stabilization is a safe and efficacious alternative, and provides several distinct advantages over lumbar spinal fusion with pedicle screw instrumentation
— id: 139766, year: 2011, vol: 11, page: 86S, stat: Journal Article,

Are anti-fibrinolytics effective at reducing peri-operative blood loss in adolescent idiopathic scoliosis?
Hoelscher C.; Verma K.; Errico T.; Dryer J.; Huncke T.; Boenigk K.; Lonner B.
2011 ;11(10 SUPPL 1):67S-67S, Spine journal
BACKGROUND CONTEXT: Anti-fibrinolytics have been proven effective in reducing intra-operative blood loss in several settings. However, their value in Adolescent Idiopathic Scoliosis (AIS) remains unclear. No previous study has compared tranexamic acid (TXA), epsilon aminocaproic acid (EACA), and placebo in regards to their ability to limit operative blood loss, post-operative drain output, and transfusion rate. PURPOSE: To determine the efficacy of intra-operative anti-fibrinolytics at reducing peri-operative blood loss and transfusion rate in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion of at least 5 levels. STUDY DESIGN/SETTING: Prospective, double-blind, randomized clinical trial. PATIENT SAMPLE: Patients between the ages of 10-21 with a diagnosis of adolescent idiopathic scoliosis treated with posterior spinal fusion of at least five levels were prospectively enrolled. OUTCOME MEASURES: Primary outcome measures include estimated blood loss, drain output, total blood loss, and transfusion rate. Secondary outcome measures include pre-, intra-, and post-operative hematocrit, duration of surgery, complications, and length of hospital stay. METHODS: This is a prospective, randomized, double-blind comparison of TXA, EACA and placebo used intra-operatively in patients with AIS. 119 AIS patients were randomly assigned to TXA, EACA, or control. TXA was administered at 10 mg/ kg for a loading dose followed by 1 mg/kg-hr, while EACA was given at a 10 fold higher dose. Parameters recorded included estimated blood loss (EBL), pre, intra and post-operative hematocrit, blood product usage, post-operative drain output, and total blood loss. RESULTS: 119 patients were randomized to TXA (n535), EACA (n538), or placebo (n546). There were 93 females and 26 males, average age 15. Most pre-operative characteristics were similar, however saline patients had significantly greater height, weight, and estimated blood volume vs TXA (p<.05). TXA patients had significantly lower hematocrit at anesthesia start vs saline (33.2 vs 35.7, p<.05). There was no difference in transfusion rate, duration of surgery, levels fused, or anchors placed. When controlling for mean arterial pressure (MAP) during exposure, TXA reduced EBL vs saline (p<.05), and reduced total blood loss, total blood loss per anchor, and total blood loss per degree of curve vs saline (p<.05). Additionally, EACA reduced EBL per anchor vs saline in patients with reduced mean exposure MAP (p<.05). Neither TXA nor EACA reduced EBL or total blood loss in patients with mean exposure MAPO75. While total drain output was not reduced for TXA or EACA vs saline, TXA showed reduced drain output per anchor and degree curve (p<.05) compared to saline. CONCLUSIONS: Our results suggest that anti-fibrinolytics safely reduce blood loss in patients with AIS. However, transfusion rates were not impacted. Further, mean arterial pressure during surgical exposure appears to be a critical factor in the efficacy of anti-fibrinolytic action
— id: 139769, year: 2011, vol: 11, page: 67S, stat: Journal Article,

Adult spinal deformity: A two-year cost-utility analysis and 10-year thought experiment
Hoelscher C.; Warren D.; Lonner B.; Terran J.; Schwab F.; Glassman S.; Bridwell K.; Errico T.; Lafage V.
2011 ;11(10 SUPPL 1):172S-172S, Spine journal
BACKGROUND CONTEXT: Adult spinal deformities (ASD) are disabling conditions. Surgical management of ASD has demonstrated effectiveness in clinical outcome scores. Despite this, the surgical management has come under fire within the landscape of escalating healthcare expenditure due to the cost of acute management. A cost-utility analysis of operative ASD patients comparing pre-operative and post-operative outcome scores has never been performed. PURPOSE: To determine the potential for cost-effectiveness in the surgical correction of ASD. STUDY DESIGN/SETTING: Review of prospectively collected data and application of cost-utility analysis. PATIENT SAMPLE: Adult patients diagnosed with a spinal deformity and treated with anterior, posterior, or combined spinal fusion. OUTCOME MEASURES: Primary outcome measures included patientcentered outcome scores (SRS 23 and Oswestry Disability Index), utility values, and treatment costs. METHODS: 233 patients undergoing primary surgery for ASD including Idiopathic Scoliosis (IS, n5189), Degenerative Scoliosis (DS, n539) and Congenital Scoliosis (CS, n55) were reviewed. We report pre and postoperative outcome scores (SRS, ODI) with 2 year follow-up. Quality Adjusted Life Years (QALYs) were calculated based on reported regression formulas. Medicare DRG hospital and CPT physician (Surgeon, Anesthesia and Neuromonitoring) re-imbursement codes were used to establish an acute care cost (ACC). The ACC and QALY values were used to perform a cost-utility analysis of the operative intervention for ASD. RESULTS: DS patients were significantly older (62.2) vs IS (47.9) but not CS (44.2). Height and weight were similar. DS patients were more likely to have osteoarthritis, leg pain, and leg pain with ambulation (p<.05). IS patients had a significantly lower pre-op ODI and a higher corresponding utility score vs DS patients. Pre-operative SRS scores were similar. At 2 year follow-up, all groups improved on ODI and in each domain of SRS. The only significant difference on SRS was higher mental health scores in DS vs IS. Post-operative utility values were similar. Total QALYs gained at 2 years were significantly greater for DS (0.20) vs IS (0.12), but not vs CS (0.11). Total reimbursements averaged <=35,883, <=37,482, and <=38,787, respectively. At 2 years, the cost/QALY was <=299,025 for IS, <=187,410 for DS, and <=352,609 for CS. Single revision surgery rate within 2 years was 20.6% and multiple revisions was 3.9%. CONCLUSIONS: Our results confirm that surgical correction improves patient outcome in ASD. High ACC of ASD correction has cost-effectiveness ratios above accepted thresholds (O<=50,000) at short-term follow-up. The durability of surgical correction may bring the cost of treatment into an accepted range with long-term follow-up. A thought experiment estimating outpatient expenditure and revision surgery cost over a 10-year followup will be demonstrated. Non-operative patients are unlikely to improve on outcome scores while operative patients likely maintain their improvement despite relatively high revision rates. The possible result is an economic benefit of surgical management when considered over the patient's lifetime
— id: 139760, year: 2011, vol: 11, page: 172S, stat: Journal Article,

Outcomes analysis of anterior-posterior fusion for low grade Isthmic spondylolisthesis
Quirno M.; Kamerlink J.R.; Goldstein J.A.; Spivak J.M.; Bendo J.A.; Errico T.J.
2011 ;69(4):316-319, Bulletin of the NYU Hospital for Joint Diseases
Background. Traditional surgical treatment of isthmic spondylolisthesis is posterior-lateral fusion, but the addition of anterior surgery has been explored. The purpose of this study was to evaluate the surgical and clinical outcomes of anterior-posterior surgical treatment for low-grade isthmic spondylolisthesis. Methods. Retrospectively, we enrolled 23 consecutive patients (mean age of 50) who underwent surgical treatment for low grade isthmic spondylolisthesis. The mean follow-up was 10 months. Basic demographic and radiographic data was collected. Pre- and post-surgical clinical surveys (VAS, ODI, and SF-36) were collected. Results. All 23 patients underwent anterior interbody fusion with a femoral ring allograft or ICBG in combination with posterior lumbar decompression and fusion with instrumentation. The average slip percentage decreased from 23.2% to 19.0% (p = 0.24) while slip angle increased from 9.8degree to 17.9degree (p < 0.001) and average disc height decreased from 1.9 cm to 0.80 cm (p < 0.001). VAS scores decreased from 7.1 to 2.4 (p < 0.001), ODI scores decreased from 52.5 to 28.1 (p < 0.001), and SF-36 scores increased in the Physical Component Scale (PCS) from 29.5 to 42.6 (p < 0.001). Conclusion. In our study, patients demonstrated an improvement in the ODI as well the physical component scores of the SF-36, thus having a good clinical outcome
— id: 148750, year: 2011, vol: 69, page: 316, stat: Journal Article,

Validity of Cobb angle measurements using digitally photographed radiographs
Ricart, Pedro A; Andres, Tate M; Apazidis, Alexios; Errico, Thomas J; Trobisch, Per D
2011 Oct;11(10):942-946, Spine journal
BACKGROUND CONTEXT: Advances in technology are influencing the way that medical information is archived and shared. Considering that an estimated two-thirds of the world has little or no orthopedic care, high demand exists for adequate consultation regarding diagnostic images in orthopedic specialties. PURPOSE: To validate the use of photographed scoliosis films for the accurate interpretation of Cobb angles. STUDY DESIGN: Retrospective review. PATIENT SAMPLE: Thirty scoliosis radiographs. OUTCOME MEASURE: Cobb angle. METHODS: Thirty scoliosis radiographs were photographed using a digital camera from a straight and a 45 degrees angle position. Cobb angles were then measured on the digital images using standard measurement software. Comparison was made between two types of curves: convex and concave, relative to the left side (side for the angled position). RESULTS: There was excellent reproducibility between the measurements of the conventional radiographs and the photographs taken from a straight on position, p value of .97 for convex curves and p value of .98 for concave curves. Photographs taken from a 45 degrees angle significantly increased the magnitude of the curve convex to the angle (p=.001). CONCLUSION: Sharing photographs of scoliosis radiographs can be done with reliability if the image is taken directly in front of the viewbox rather than at an oblique angle; pictures taken at oblique angles are prone to misinterpretation of curve magnitude
— id: 139480, year: 2011, vol: 11, page: 942, stat: Journal Article,

Prospective, randomized study of surgical site infections with the use of perioperative antibiotics for 24 hours versus the duration of a drain after spinal surgery
Ricart-Hoffiz P.; Takemoto R.; Park J.; Andres T.; Hoelscher C.; Goldstein J.; Spivak J.; Bendo J.; Errico T.; Lonner B.
2011 ;11(10 SUPPL 1):23S-23S, Spine journal
BACKGROUND CONTEXT: The use of a postoperative spinal drain for spine surgery patients is widely thought to increase the risk of postoperative infection. While antibiotics are commonly given postoperatively to decrease bacterial seeding of the hematoma, the duration of postoperative antibiotics is more debatable, and protocols may vary. PURPOSE: To determine if the continuation of postoperative antibiotics for the duration of the timea spinal drain is in place reduces the risk of acute surgical site infection, in comparison with postoperative antibiotics given for 24 hours only. STUDY DESIGN/SETTING: Prospective, randomized double-blind study. PATIENT SAMPLE: Patients undergoing multilevel thoracolumbar spine surgery in which a drain is used. OUTCOME MEASURES: Surgical site infections were defined as purulent drainage; organisms obtained from an aseptically obtained culture; pain, swelling and redness; and/or diagnosis of infection by a surgeon. METHODS: 315 patients who underwent multilevel thoracolumbar spine surgery requiring a postoperative drain were enrolled and randomized into two groups: one group receiving 24 hours of perioperative antibiotics and one group receiving antibiotics for the duration that the drain was in place. Data collected included demographics, medical co-morbidities, type of spine surgery and surgical site infection. RESULTS: 13/170 (7.6%) in the 24 hours of antibiotic group developed a surgical site infection while 21/145 (14.5%) in the antibiotic for the duration of the drain were found to have a surgical site infection. The differences between each group were significant (p<.05). There were no significant differences between the groups with respect to demographics, surgical time, type of surgery, drain output or length of stay. CONCLUSIONS: Continuing postoperative antibiotics for the entire duration a drain is in place after spine surgery does not decrease the rate of surgical site infections
— id: 139772, year: 2011, vol: 11, page: 23S, stat: Journal Article,

The Facet Joint Loading Profile of a Cervical Intervertebral Disc Replacement Incorporating a Novel Saddle-shaped Articulation
Stieber, Jonathan R; Quirno, Martin; Kang, Mathew; Valdevit, Anthony; Errico, Thomas J
2011 Oct;24(7):432-436, Journal of spinal disorders & techniques
STUDY DESIGN: Biomechanical study. OBJECTIVE: To evaluate the cervical facet loading profile of an intervertebral cervical disc prosthesis incorporating a unique saddle-shaped articulation and to determine the effect of implantation of the prosthesis on both the loading curve and area distribution of facet loading, when compared with that of an intact specimen. SUMMARY OF BACKGROUND DATA: This is the first study that examines the effect of implantation of a cervical disc replacement on the loading of the facet joints. METHODS: Fresh-frozen ovine cervical spine specimens were used. Specimens were prepared and disarticulated to yield 6 functional spinal units, which were secured and mounted in a custom fixture on a material testing apparatus. A novel pressure sensor was constructed by combining a resistive ink thin film sensor with Fuji pressure-sensitive film. The sensor was calibrated before unilateral insertion into the cervical facet joint via a small arthrotomy. Specimens were tested in both intact condition and after surgical intervention consisting of discectomy and implantation of an intervertebral cervical disc prosthesis (CerviCore, Stryker Spine, Allendale, NJ). Specimens were tested in flexion, extension, and lateral bending to 3 Nm and in torsion to 2.5 Nm. At the termination of each loading profile, the load was maintained for 30 seconds to permit full exposure of the Fuji film. For each configuration, the maximum resultant load, load rate, and contact area pressure at the endpoint of the loading profile were determined. A paired Student t test was used to determine the differences between the intact specimen and the specimen with an implanted intervertebral disc prosthesis. RESULTS: There were no statistically significant differences in mean or maximum pressures between the intact specimen and the specimen with an intervertebral disc in all loading configurations. Similarly, there was no significant difference in the total measured force between the groups in all loading configurations. There was no significant difference in contact areas between the groups in flexion, lateral bending, and torsion. When evaluated in extension, the intact specimen had a mean contact area of 0.8 cm compared with 0.5 cm for the intervertebral disc (P<0.02). CONCLUSIONS: Biomechanical testing in an ovine model demonstrated no significant difference in measured facet pressures and forces between an intact native cervical disc specimen and a cervical intervertebral disc prosthesis using a saddle-shaped articulation. Peak and mean pressures were not demonstrated to be significantly different between the implanted and intact disc conditions. Implantation of the prosthesis resulted in a significant reduction of contact area under extension moments
— id: 137875, year: 2011, vol: 24, page: 432, stat: Journal Article,

The lumbar facet joint: a review of current knowledge: part 1: anatomy, biomechanics, and grading
Varlotta, Gerard P; Lefkowitz, Todd R; Schweitzer, Mark; Errico, Thomas J; Spivak, Jeffrey; Bendo, John A; Rybak, Leon
2011 Jan;40(1):13-23, Skeletal radiology
We present a two-part review article on the current state of knowledge of lumbar facet joint pathology. This first article discusses the functional anatomy, biomechanics, and radiological grading systems currently in use in clinical practice and academic medicine. Facet joint degeneration is presented within the larger context of degenerative disc disease to enable the reader to better understand the anatomical changes underlying facet-mediated lower back pain. Other less-common, but equally important etiologies of lumbar facet joint degeneration are reviewed. The existing grading systems are discussed with specific reference to the reliability of CT and MR imaging in the diagnosis of lumbar facet osteoarthritis. It is hoped that this discussion will stimulate debate on how best to improve the diagnostic reliability of these tests so as to improve both operative and non-operative treatment outcomes
— id: 114816, year: 2011, vol: 40, page: 13, stat: Journal Article,

The lumbar facet joint: a review of current knowledge: Part II: diagnosis and management
Varlotta, Gerard P; Lefkowitz, Todd R; Schweitzer, Mark; Errico, Thomas J; Spivak, Jeffrey; Bendo, John A; Rybak, Leon
2011 Feb;40(2):149-157, Skeletal radiology
This article is the second article in a two-part review on lumbar facet joint pathology. In this review, we discuss the current concepts and controversies regarding the proper diagnosis and management of patients presenting with presumed facet-mediated lower back pain. All efforts were made to include the most relevant literature from the fields of radiology, orthopaedics, physiatry, and pain management. Our focus in this article is on presenting the evidence supporting or refuting the most commonly employed injection-based therapies for facet-mediated lower back pain
— id: 116219, year: 2011, vol: 40, page: 149, stat: Journal Article,

The promethean role of industry in spine surgery research
Errico, Thomas
2010 Dec;23(8):491-492, Journal of spinal disorders & techniques
— id: 115274, year: 2010, vol: 23, page: 491, stat: Journal Article,

The treatment of vertebral and chest wall deformities with expandable thoracoplasty and a prosthetic expandable implant
Kamerlink, Jonathan R; Engel, Itzhak; Patwardhan, Ajit; Valdevit, Antonio; Lowery, Gary; Brayda-Bruno, Marco; Zeller, Reinhard; Errico, Thomas J
2010 Jan-Feb;30(1):90-98, Journal of pediatric orthopedics
BACKGROUND: Expansion thoracoplasty is a temporary solution to allow complete pulomonary development in the setting of vertebral and rib cage deformities. After thoracoplasty, an expandable implant is needed to maintain the correction. The Growing Spine Profiler (GSP) is a new type of readjustable rib distracter. The purpose of this study was to evaluate the experiences of surgeons in Europe with the implantation of the GSP. METHODS: We retrospectively reviewed 44 patients that underwent placement of the GSP at 15 sites throughout Europe. The mean age at the time of surgery was 6.24 years. Basic demographic data and postoperative management were reviewed. All patients received an opening-wedge thoracostomy with device implantation and expansion thoracoplasty. Retrospectively, the original indications for implantation were determined. Digital images of the radiographs were used to measure coronal and sagittal parameters. RESULTS: The most common diagnoses for implantation were hemivertebrae (9), hemivertebrae with chest wall deformity (10), and unilateral bar (8). Outcomes were available for 43 patients with a mean follow-up period of 3.07 years. There were 23 patients that had an adverse event. Rib fractures were the most common adverse event, with 8 incidents in 7 patients. Radiographically, coronal curve magnitudes were maintained, whereas sagittal kyphosis gradually increased. CONCLUSIONS: The GSP was effective in the maintenance of deformity, while providing a moderate complication rate. Further studies need to be performed to determine the safety and efficacy of this implant
— id: 105993, year: 2010, vol: 30, page: 90, stat: Journal Article,

Major intraoperative neurologic monitoring deficits in consecutive pediatric and adult spinal deformity patients at one institution
Kamerlink, Jonathan R; Errico, Thomas; Xavier, Shaun; Patel, Ashish; Patel, Amar; Cohen, Alexa; Reiger, Mark; Dryer, Joseph; Feldman, David; Lonner, Baron; Beric, Aleksandar; Schwab, Frank
2010 Jan 15;35(2):240-245, Spine
STUDY DESIGN: Retrospective review. OBJECTIVE: The purpose of this study was to assess the preoperative neurologic risk in a consecutive series of spinal deformity patients undergoing correction surgery at one institution. SUMMARY OF BACKGROUND DATA: During spinal deformity correction surgery, neurologic monitoring techniques are commonly applied to reduce the risk of neurologic deficits. While previous studies have demonstrated risk factors for neurologic changes in the setting of spinal surgery, these involved long time spans and heterogeneous patient populations. METHODS: Of 301 cases performed over 1 year, 281 cases were monitorable. Patients were grouped according to diagnosis: neuromuscular (NM) scoliosis, Sagittal Plane deformity, and Scoliosis. Demographic and surgical data were collected for neurologically monitorable patients. Coronal and sagittal parameters were measured using digital images of radiographs. Neurologic status was measured with somatosensory-evoked potentials and/or motor-evoked potentials. RESULTS: Primary NM scoliosis cases had the highest incidence of neurologic monitoring changes (NMC) (10%) while revision sagittal plane deformity had the second highest (9.8%). Sensitivity and specificity were both 100%. Overall incidence of neurologic deficit was 1.1%. Of the 13 NMCs patients, 3 patients had persistent neurologic deficit. Majority of NMCs occurred before deformity correction. In patients with NM scoliosis, NMCs increased with hybrid constructs with wires (P < 0.01). In patients with scoliosis, NMCs increased with increased body mass index, estimated blood loss, operative time, and postoperative coronal thoracolumbar curve magnitude (P < 0.04). In patients with primarily sagittal plane deformity, NMCs increased with preoperative proximal curve, postoperative proximal and thoracolumbar curves, and postoperative kyphosis and lordosis (P < 0.04). CONCLUSION: Primary NM scoliosis and revision sagittal plane deformities appear to carry greatest incidence of NMCs during surgical intervention. Most observed NMCs did not result in a permanent neurologic deficit. Neuromonitoring should be assessed throughout the entire surgical procedure. This study may aid surgeons and patients to better assess neurologic risks related to spinal deformity surgery
— id: 106280, year: 2010, vol: 35, page: 240, stat: Journal Article,

Hospital cost analysis of adolescent idiopathic scoliosis correction surgery in 125 consecutive cases
Kamerlink, Jonathan R; Quirno, Martin; Auerbach, Joshua D; Milby, Andrew H; Windsor, Lynne; Dean, Laura; Dryer, Joseph W; Errico, Thomas J; Lonner, Baron S
2010 May;92(5):1097-1104, Journal of bone & joint surgery (American volume)
BACKGROUND: Although achieving clinical success is the main goal in the surgical treatment of adolescent idiopathic scoliosis, it is becoming increasingly important to do so in a cost-effective manner. The goal of the present study was to determine the surgical and hospitalization costs, charges, and reimbursements for adolescent idiopathic scoliosis correction surgery at one institution. METHODS: We performed a retrospective review of 16,536 individual costs and charges, including overall reimbursements, for 125 consecutive patients who were managed surgically for the treatment of adolescent idiopathic scoliosis by three different surgeons between 2006 and 2007. Demographic, surgical, and radiographic data were recorded for each patient. Stepwise multiple linear regression analysis was employed to assess independent correlation with total cost and charge. Nonparametric descriptive statistics were calculated for total cost with use of the Lenke curve-classification system. RESULTS: The mean age of the patients was 15.2 years. The mean main thoracic curve measured 50 degrees, and the thoracolumbar curve measured 41 degrees. The cost varied with Lenke curve type: $29,955 for type 1, $31,414 for type 2, $31,975 for type 3, $60,754 for type 4, $32,652 for type 5, and $33,416 for type 6. Independently significant increases for total cost were found in association with the number of pedicle screws placed, the total number of vertebral levels fused, and the type of surgical approach (R(2) = 0.35, p <or= 0.03). Independently significant increases for reimbursement were found in association with the number of pedicle screws placed and the type of surgical approach (R(2) = 0.12, p <or= 0.02). The hospital was reimbursed 53% of total charges and 120% of total costs. Reimbursement was highly correlated with charge (r = 0.45, p < 0.001). For rehospitalizations, the hospital was reimbursed 65% of charges and 93% of costs. CONCLUSIONS: The largest contributors to overall cost were implants (29%), intensive care unit and inpatient room costs (22%), operating room time (9.9%), and bone grafts (6%). There were three significant independent predictors of increased total cost: the surgical approach used, the number of pedicle screws placed, and the number of vertebral levels fused. This study characterizes the relative contributions of factors that contribute to total costs, charges, and reimbursements that can, in time, identify potential areas for cost reduction or redistribution of resources in the surgical treatment of adolescent idiopathic scoliosis
— id: 109572, year: 2010, vol: 92, page: 1097, stat: Journal Article,

Does Multilevel Lumbar Stenosis Lead to Poorer Outcomes? A Subanalysis of the Spine Patient Outcomes Research Trial (SPORT) Lumbar Stenosis Study
Park, DK; An, HS; Lurie, JD; Zhao, WY; Tosteson, A; Tosteson, TD; Herkowitz, H; Errico, T; Weinstein, JN
2010 FEB 15 ;35(4):439-446, Spine
Study Design. A subanalysis study. Objective. The purpose of this study was to determine the impact of multilevel lumbar stenosis with or without degenerative spondylolisthesis compared to single level disease on patients' baseline symptoms and clinical outcomes over time. Summary of Background Data. Previous studies have demonstrated better clinical outcomes with surgery than nonoperative treatment in patients with spinal stenosis with or without degenerative spondylolisthesis. However, the impact of multilevel stenosis has not been studied in these patients. Methods. The results from a multicenter randomized and observational study, the Spine Patient Outcomes Research Trial (SPORT) comparing surgical versus nonoperative treatment for spinal stenosis with or without spondylolisthesis, were analyzed. The primary outcomes measures were the Bodily Pain and Physical Function scales of the Medical Outcomes Study 36-item Short-Form General Health Survey (SF-36) and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, 1 year, and 2 years. Secondary outcome measures included the stenosis bothersomeness index, leg pain bothersomeness, low back pain bothersomeness, and patient satisfaction. Results. In this subanalysis of SPORT data, multilevel spinal stenosis did not demonstrate worse baseline symptoms or worse treatment outcomes in isolated spinal stenosis; however, if concomitant degenerative spondylolisthesis existed, patients with only single level stenosis tended to improve more than those with multilevel stenosis, particularly after surgery. Conclusion. Patients with spinal stenosis without associated degenerative spondylolisthesis or scoliosis can be managed nonoperatively irrespective of the number of levels involved. If surgery is performed, the number of levels treated does not predict outcome. In contrast, patients with concomitant degenerative spondylolisthesis and single level stenosis do better surgically than those with additional levels of stenosis. This study emphasizes the importance of shared decision-making between the physician and patient when considering treatment for spinal stenosis
— id: 108776, year: 2010, vol: 35, page: 439, stat: Journal Article,

Bone grafting options for lumbar spine surgery: A review examining clinical efficacy and complications
Vaz K.; Verma K.; Protopsaltis T.; Schwab F.; Lonner B.; Errico T.
2010 ;4(3):75-86, SAS Journal
Background: Iliac crest harvest has been considered the 'gold standard' at producing successful arthrodesis of the lumbar spine but is also associated with many donor-site morbidities. Many alternatives have been used to avoid iliac crest harvest, including autologous bone from other donor sites, allogeneic bone, ceramics, and recombinant human bone morphogenetic proteins (rhBMPs). This review will highlight the properties and preparations of these graft types and their potential complications and reported clinical efficacy. Methods: A Medline search was conducted via PubMed by use of the following terms in various combinations: lumbar fusion, freeze-dried allograft, fresh-frozen allograft, autograft, iliac crest, demineralized bone matrix, rhBMP-2, rhBMP-7, scoliosis, bone marrow aspirate, HEALOS, coralline hydroxyapatite, beta tricalcium phosphate, synthetic, ceramics, spinal fusion, PLF, PLIF, ALIF, and TLIF. Only articles written in English were assessed for appropriate material. Related articles were also assessed depending on the content of articles found in the original literature search. Conclusions: Although iliac crest remains the gold standard, reported success with alternative approaches, especially in combination, has shown promise. Stronger evidence with limited sources of potential bias is necessary to provide a clear picture of their clinical efficacy. 2010 Elsevier Inc
— id: 112211, year: 2010, vol: 4, page: 75, stat: Journal Article,

A prospective, randomized, double-blinded single-site control study comparing blood loss prevention of tranexamic acid (TXA) to epsilon aminocaproic acid (EACA) for corrective spinal surgery
Verma, Kushagra; Errico, Thomas J; Vaz, Kenneth M; Lonner, Baron S
2010 ;10:13-13, BMC surgery
BACKGROUND: Multilevel spinal fusion surgery has typically been associated with significant blood loss. To limit both the need for transfusions and co-morbidities associated with blood loss, the use of anti-fibrinolytic agents has been proposed. While there is some literature comparing the effectiveness of tranexamic acid (TXA) to epsilon aminocaproic acid (EACA) in cardiac procedures, there is currently no literature directly comparing TXA to EACA in orthopedic surgery. METHODS/DESIGN: Here we propose a prospective, randomized, double-blinded control study evaluating the effects of TXA, EACA, and placebo for treatment of adolescent idiopathic scoliosis (AIS), neuromuscular scoliosis (NMS), and adult deformity (AD) via corrective spinal surgery. Efficacy will be determined by intraoperative and postoperative blood loss. Other clinical outcomes that will be compared include transfusion rates, preoperative and postoperative hemodynamic values, and length of hospital stay after the procedure. DISCUSSION: The primary goal of the study is to determine perioperative blood loss as a measure of the efficacy of TXA, EACA, and placebo. Based on current literature and the mechanism by which the medications act, we hypothesize that TXA will be more effective at reducing blood loss than EACA or placebo and result in improved patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT00958581
— id: 109216, year: 2010, vol: 10, page: 13, stat: Journal Article,

Long-term clinical outcome of coflex interlaminar-interspinous device
Errico T.; Kamerlink J.; Quirno M.; Samani J.
2009 ;9:62-63, Pain practice
Background: Interlaminar-interspinous implants have gained acceptance as motion preservation devices. There are a limited number of posterior dynamic stabilization implants approved by the FDA. The purpose of this study was to review the long-term clinical outcomes of patients that had placement of an interspinous implant. Methods: This is a retrospective study of 124 patients that underwent placement of a interlaminar-interspinous implant (coflex, Paradigm Spine, New York, NY, U.S.A.) with a mean follow-up of 6.3 years. Patients were treated for spinal stenosis, spinal stenosis and lumbar disc herniation, or lumbar disc herniation. Preoperatively and postoperatively, patients were asked to grade their back and leg pain using the pain severity scale: no pain (0), mild pain (1), moderate pain (2), or severe pain (3). Patient satisfaction was queried concerning their operative procedure. Results: The mean severity of low back pain was decreased at the 2-year follow-up (moderate to mild, P < 0.001) and remained decreased with at least 5 years follow-up (moderate to mild, P < 0.001). The mean severity of leg pain was decreased at the 2-year follow-up (severe to mild, P < 0.001) and with at least 5 years follow-up (severe to mild, P < 0.001). Overall patient satisfaction demonstrated 7% were unsatisfied, 46% were satisfied, and 46% were very satisfied with the clinical outcome. Conclusion: This study has demonstrated that interlaminar-interspinous implant by coflex provides pain relief for patients with low back pain and leg pain. Interlaminar-inter-spinous implant by coflex is an option in the selection for dynamic stabilization
— id: 111409, year: 2009, vol: 9, page: 62, stat: Journal Article,

Long-term device related issues of coflex interlaminar-interspinous device
Errico T.; Kamerlink J.; Quirno M.; Samani J.
2009 ;9:63-63, Pain practice
Objectives: Interlaminar-interspinous implants have gained acceptance as motion preservation devices. Currently, there are a limited number of posterior dynamic stabilization implants approved by the FDA. The purpose of this study was to perform a review of the long-term device related issues of an interlaminar-interspinous implant. Methods: This is a retrospective study of 99 patients who underwent placement of an interlaminar-interspinous implant (coflex, Paradigm Spine, New York, NY, U.S.A.) with a mean follow-up of 7 years. Patients were seen pre-operatively and postoperatively by one orthopaedic spine surgeon. Patients received radiographic analysis at follow-up visits, which was assessed by the operating surgeon for any device related issues. Results: All 99 patients received radiographs at their follow-up with the operating surgeon. The complications were catgorized into the following groups with their respective percentages: no device related issues (92%) and device related issues (8%). The patients with device related issues were categorized into the following groups: Broken U portion of implant (0%); Broken wing of the implant (1%); Displaced U portion of implant less than 5 mm (2%); Displaced U portion of implant more than 5 mm (2%); Displaced U portion of implant with unknown distance (1%); Removed implant (2%); Spinous process fracture (0%); bone-implant interface remodeling (0%). Conclusions: Displacement of the U portion of the implant was the most common complication and could be due to instability at the level of insertion. The data has demonstrated that in the short and long term follow-up, there are very few device related complications
— id: 111410, year: 2009, vol: 9, page: 63, stat: Journal Article,

Survivorship of coflex Interlaminar-Interspinous Implant
Errico T.J.; Kamerlink J.R.; Quirno M.; Samani J.; Chomiak R.J.
2009 ;3(2):59-67, SAS Journal
Background: The purpose of this study was to determine the indications for implantation of the coflex device (Paradigm Spine, LLC, New York, New York), assess long-term complications, and evaluate the long-term clinical outcomes of patients. Methods: A total of 127 patients underwent placement of a coflex implant for various indications by one orthopaedic spine surgeon. The mean follow-up was 6.3 years. The original indications for implantation were determined based upon the data provided in the case report forms. Preoperatively and postoperatively, patients were asked to grade their low-back and leg pain using the visual analog scale (VAS) and the pain severity scale: no pain (0), mild pain (1), moderate pain (2), or severe pain (3). Patients were queried about their satisfaction with the surgical procedure. Follow-up radiographs were taken to determine any device-related issues. Results: The most prevalent diagnoses for implantation were spinal stenosis (19.7%) and spinal stenosis with lumbar disc herniation (35.4%). The mean severity of low-back pain was decreased by 33% (from moderate to mild) at the 2-year follow-up (P < .001) and at the 5-year follow-up (from moderate to mild, P < .001). The mean severity of leg pain was decreased by 66% (from severe to mild) at the 2-year follow-up (P < .001) and at the 5-year follow-up (from severe to mild, P < .001). At the mean follow-up period of 6.3 years, a patient satisfaction query demonstrated that 7% were unsatisfied, 46% were satisfied, and 46% were very satisfied with their clinical outcome. Based on the follow-up radiographs, 92 of patients had no device-related issues and 8% had device-related issues. Conclusion: The data provided have demonstrated that the coflex implant provides pain relief for patients with low-back pain and leg pain. The most common indications for implantation were spinal stenosis and spinal stenosis with lumbar disc herniation. There were very few device-related complications. Clinical Significance: Using coflex is a safe and viable option in the selection of instrumentation for spinal stabilization. copyright 2009 The Spine Arthroplasy Society
— id: 107763, year: 2009, vol: 3, page: 59, stat: Journal Article,

Introduction to spinal deformity
Errico TJ; Petrizzo A
Surgical management of spinal deformities Philadelphia PA : Saunders/Elsevier, 2009,
— id: 5119, year: 2009, vol: , page: ?, stat: Chapter,

Degenerative spondylolisthesis
Errico TJ; Quirno M
Surgical management of spinal deformities Philadelphia PA : Saunders/Elsevier, 2009,
— id: 5126, year: 2009, vol: , page: ?, stat: Chapter,

Surgical management of spinal deformities
Errico, Thomas J; Lonner, Baron S; Moulton, Andrew W
Philadelphia PA : Saunders/Elsevier, 2009,
— id: 1894, year: 2009, vol: , page: , stat: ,

Outcome analysis of anteriorposterior surgical technique for the treatment of low grade lumbar isthmic spondylolisthesis through standardized surveys
Kamerlink J.; Quirno M.; Goldstein J.; Spivak J.; Bendo J.; Errico T.
2009 ;9:67-68, Pain practice
Introduction: The gold standard for the treatment of isthmic spondylolisthesis is posterior-lateral fusion. Few studies have evaluated the clinical outcomes of circumference fusion in the treatment if isthmic spondylolisthesis. The purpose of this study was to evaluate the surgical and clinical outcomes of anterior-posterior surgical treatment for low-grade isthmic spondylolisthesis. Methods: Retrospectively, 23 consecutive patients were enrolled that underwent surgical treatment for Isthmic Spondylolisthesis Grade 1 or 2. Basic demographic data was collected. Radiographic data that was collected included Meyerding Scale, disc height, and slip angle. Pre and post surgical clinical surveys which included VAS, ODI, and SF-36 surveys were collected. Results: There were 23 patients. All patients underwent anterior interbody fusion with a femoral ring allograft or iliac crest bone graft in addition to posterior lumbar decompression and fusion with instrumentation. The average slip percentage decreased from 23.2% to 19.0% (P = 0.24), slip angle increased from 9.8 to 17.9 (P < 0.001), and disc height decreased from 1.9 cm to 0.80 cm (P < .001). VAS scores decreased from 7.1 to 2.4 (P < 0.001). ODI scores decreased from 52.5 to 28.1 (P < 0.001). SF-36 scores demonstrated a significant increase in the Physical Component Scale (PCS) from 29.5 to 42.6 (P < 0.001). Conclusion: This study demonstrates that patients with isthmic spondylolisthesis that undergo circumferential fusion have a good clinical outcome. Patients demonstrated an improvement in the ODI and the physical component scores of the SF-36. These results demonstrate that patients improved in their physical functioning due to the surgery alone
— id: 111411, year: 2009, vol: 9, page: 67, stat: Journal Article,

Adult idiopathic scoliosis and degenerative scoliosis
Kostuik JP; Errico TJ
Surgical management of spinal deformities Philadelphia PA : Saunders/Elsevier, 2009,
— id: 5125, year: 2009, vol: , page: ?, stat: Chapter,

Cerebral palsy and other neuromuscular disorders in children
Nuzzo RM; Errico TJ
Surgical management of spinal deformities Philadelphia PA : Saunders/Elsevier, 2009,
— id: 5123, year: 2009, vol: , page: ?, stat: Chapter,

Biomechanical analysis of a disc prosthesis distal to a scoliosis model
Quirno, Martin; Kamerlink, Jonathan R; Valdevit, Antonio; Kang, Matthew; Yaszay, Burt; Duncan, Naphysah; Boachie-Adjei, Oheneba; Lonner, Baron S; Errico, Thomas J
2009 Jun 15;34(14):1470-1475, Spine
STUDY DESIGN: Biomechanical study of bovine spines. OBJECTIVE: The purpose of this study was to perform a biomechanical test to analyze intervertebral deflections following placement of both 1 and 2 semiconstrained TDRs in the subjacent segments of a long fusion. SUMMARY OF BACKGROUND DATA: Long-term sequela of long lumbar fusion for scoliosis include adjacent segment disease and flatback syndrome. Total disc replacement (TDR) is a viable option for the treatment of these conditions. Little data has been published regarding the placement of a TDR distal to a scoliosis fusion. METHODS: Six thoracolumbar bovine spines (T12-S1) were instrumented from T12 to L5, with bilateral pedicle screw fixation at each level. L5-L6 and L6-S1 served as the test levels. One TDR (FlexiCore, Stryker Spine, Allendale, NJ) was initially performed adjacent to the fusion, followed by a subsequent TDR insertion at the last spinal segment. The applied load, total specimen deflection, and local transducer deflections were recorded before and after a TDR at both levels. The results were expressed as a percentage of the intact specimen. Flexion, extension, lateral bending, and torsional deflections were recorded. RESULTS: There were no significant differences (P > 0.05) in sensor deflection observed at the L5-L6 and L6-S1 levels in the anterior and lateral transducers when compared to intact spines specimens. A similar effect was observed at the L5-L6 and L6-S1 levels in the anterior and lateral transducers when compared to intact or prior L5-L6 and intact L6-S1 constructs. CONCLUSION: This study has shown that using the FlexiCore system at 1 and/or 2 intervertebral disc spaces caudal to a scoliosis fusion model did not significantly change the sensor deflection at the 2 segments adjacent to a scoliosis fusion construct. Future research will continue to define the clinical setting and patients best suited for management by TDR systems
— id: 100194, year: 2009, vol: 34, page: 1470, stat: Journal Article,

Scheuermann's Kyphosis
Sharan AD; Lavelle W; Errico TJ
Surgical management of spinal deformities Philadelphia PA : Saunders/Elsevier, 2009,
— id: 5122, year: 2009, vol: , page: ?, stat: Chapter,

Isthmic and dysplastic spondylolisthesis
Song EW; Lonner BS; Errico TJ
Surgical management of spinal deformities Philadelphia PA : Saunders/Elsevier, 2009,
— id: 5124, year: 2009, vol: , page: ?, stat: Chapter,

The reliability of computed tomography and magnetic resonance imaging grading of lumbar facet arthropathy in total disc replacement patients
Stieber, Jonathan; Quirno, Martin; Cunningham, Mary; Errico, Thomas J; Bendo, John A
2009 Nov 1;34(23):E833-E840, Spine
STUDY DESIGN: Prospective inter-rater and intrarater reliability analysis. OBJECTIVE: To compare the inter-rater and intrarater reliability of magnetic resonance imaging (MRI) and computed tomography (CT) for grading of facet arthropathy as well as determining whether there is a contraindication to total disc replacement (TDR). SUMMARY OF BACKGROUND DATA: Several classifications attempted to evaluate lumbar facet joints and their degree of arthropathy. The Fujiwara-MRI and Pathrea-CT classifications remain the most commonly used. METHODS: A total of 10 fellowship-trained orthopedic spine surgeons and 3 orthopedic spine fellows evaluated 50 levels from L3-L4 through L5-S1 on parallel axial MRI (T1 and T2) and CT images. The degree of osteoarthritis was graded on a 4-point scale (Fujiwara-MRI and Pathrea-CT). Surgeons evaluated whether the degree of facet disease represented a contraindication to TDR. Grading was performed during 2 sessions. Weighted kappa statistics were used to describe inter- and intraobserver agreement. RESULTS: The inter-rater reliability for MRI was 0.21 and 0.07 (fair to slight) among attendings and fellows, respectively. inter-rater reliability for CT was 0.33 and 0.27 (fair), respectively. The mean intrarater reliability for MRI was fair, 0.36 (attendings) and 0.26 (fellows). The mean intrarater reliability for CT was moderate, 0.52 (attendings) and 0.51 (fellows). For possible TDR contraindication, the inter-rater reliability for MRI was 0.22 and 0.01 (fair to slight) among attendings and fellows, respectively. Inter-rater reliability for CT was 0.33 and 0.45 (fair), respectively. The mean intrarater reliability for MRI was fair, 0.36 (attendings) and 0.26 (fellows). The mean intrarater reliability for CT was moderate, 0.52 (attendings) and 0.51 (fellows). CONCLUSION: The current grading system for facet arthropathy has only fair agreement. CT is slightly more reliable for grading. Intrarater reliability was only fair for MRI and moderate for CT. Only limited agreement existed between surgeons as to the extent of facet disease that would pose as a contraindication for TDR
— id: 133299, year: 2009, vol: 34, page: E833, stat: Journal Article,

A comparison of two retroperitoneal surgical approaches for total disc arthroplasty of the lumbar spine
Bendo, John A; Quirno, Martin; Errico, Thomas; Spivak, Jeffrey M; Goldstein, Jeffrey
2008 Jan 15;33(2):205-209, Spine
STUDY DESIGN: Retrospective outcome data analysis. OBJECTIVE: To evaluate if there is a significant difference between the midline rectus (MR) and the paramedian lateral rectus (PLR) approaches with regard to implant position for lumbar disc arthroplasty. To establish that a less than optimal implant position may influence clinical outcome. SUMMARY OF BACKGROUND DATA: Little is known about the impact of varying surgical approaches on lumbar artificial disc implant position and clinical outcome. METHODS: Fifty-seven patients were obtained from one center participating Food and Drug Administration study for the evaluation of the lumbar Prodisc-L. Two different surgical access techniques were compared; the MR and left PLR. Two independent evaluators calculated the postoperative radiographical displacement from the midline in the coronal and sagittal planes for each of the surgical techniques. Pre- and postoperative clinical outcomes were evaluated to determine which surgical access technique was associated with better outcomes and if there was a clinical correlation with technical accuracy. RESULTS: The PLR approach was associated with greater malalignment of the prosthesis in both the coronal and sagittal planes compared with the MR approach. However, the difference was significant only in the sagittal plane (P = 0.021). There was no significant difference in clinical outcome for either approach (P = 0.34). Patients with >or=5 mm prosthetic displacement from the midvertebral point had significantly worse Owestry disability index scores than patients with <3 mm malalignment in both the coronal and sagittal planes regardless of the surgical approach employed. CONCLUSION: The finding of a statistically significant more anteriorly displaced position in the sagittal plane of the total disc arthroplasty using the PLR approach may indicate a need to change to the MR approach. This study also demonstrates that patients with >or=5 mm prosthetic deviation from midline in either the coronal or sagittal planes had diminished clinical outcomes regardless of the approach used
— id: 75855, year: 2008, vol: 33, page: 205, stat: Journal Article,

Looking ahead: what long-term outcomes can we expect from spinal devices for degenerative disc disease
Errico, Thomas J
2008 ;18(4):309-319, Journal of long-term effects of medical implants
Degenerative disc disease is one of the leading causes of pain and disability. Various surgical treatments are available, but the literature does not provide a comparative overview of their long-term outcomes. This article synthesizes the available long-term evidence on the treatment of degenerative disc disease. Fusion for degenerative disc disease has recently shown good long-term clinical outcomes, yet several studies strongly suggest that it may accelerate the degenerative process at adjacent levels. Arthroplasty shows at least equivalent long-term outcomes and is not expected to accelerate adjacent degeneration, but speculative concern remains about its safety, especially in regard to wear debris and facet joint arthrosis. Many other treatment devices are in various stages of development, but long-term studies are not yet available for most of them. When making treatment decisions, physicians and patients must consider the long-term outcomes, because the devices remain implanted indefinitely, and back pain could recur at any time if the degeneration progresses or the device fails. Before making a treatment decision, surgeons and patients should thoroughly discuss the long-term clinical prognosis, the safety of various procedures, the degrees of certainty in our currently available medical knowledge, and the patient's preferences. No one solution will be right for every patient, but we are entering a golden era of choices, where most patients with degenerative disc disease should be able to find a treatment that substantially improves their condition
— id: 109063, year: 2008, vol: 18, page: 309, stat: Journal Article,

Effect of intervertebral disc height on postoperative motion and outcomes after ProDisc-L lumbar disc replacement
Yaszay, Burt; Bendo, John A; Goldstein, Jeffrey A; Quirno, Martin; Spivak, Jeffrey M; Errico, Thomas J
2008 Mar 1;33(5):508-512, Spine
STUDY DESIGN: Retrospective study of patients enrolled in prospective randomized Food and Drug Administration trial. OBJECTIVE: To evaluate the influence of pre- and postoperative disc height on postoperative motion and clinical outcomes. SUMMARY OF BACKGROUND DATA: Our understanding of the factors that influence motion and ultimately patient satisfaction after lumbar disc replacement continues to evolve. METHODS: Forty-two patients with a single level ProDisc-L at either the L4/5 or L5-S1 were selected. Pre- and postoperative disc height and range of motion (ROM) were measured from standing lateral and flexion-extension radiographs. Oswestry Disability Index and visual analog scale were also collected. Student t test and Spearman rho tests were performed to determine if there was any correlation or 'threshold' effect between the disc height and ROM or clinical outcome. RESULTS: The mean anterior and posterior disc height significantly increased from 10.8 mm to 17.6 mm and 4.4 mm to 7.9 mm, respectively (P < 0.01). The mean ROM decreased from 7.0 degrees to 5.7 degrees (P = 0.21). Patients with less than 9 mm of preoperative anterior disc height had an increase in their ROM (2.2 degrees) compared with a loss of ROM (-2.2 degrees) in patients with more than 9 mm of preoperative disc height (P = 0.02). Patients with between 16 mm and 18 mm of postoperative anterior disc height have greater ROM (7.5 degrees) than those above or below this range (3.6 degrees and 3.6 degrees respectively, P < 0.05). There was no correlation or threshold effect between clinical outcomes and disc height. CONCLUSION: Patients with greater disc collapse benefit more in ROM from a total disc replacement. The optimal range to maximize ROM for postoperative anterior disc height is 16 mm to 18 mm. This optimal range did not translate into better clinical outcome at 2 years follow-up
— id: 76470, year: 2008, vol: 33, page: 508, stat: Journal Article,

Comparative charge analysis of one- and two-level lumbar total disc arthroplasty versus circumferential lumbar fusion
Levin, David A; Bendo, John A; Quirno, Martin; Errico, Thomas; Goldstein, Jeffrey; Spivak, Jeffrey
2007 Dec 1;32(25):2905-2909, Spine
STUDY DESIGN: This is a retrospective, independent study comparing 2 groups of patients treated surgically for discogenic low back pain associated with degenerative disc disease (DDD) in the lumbosacral spine. OBJECTIVE: To compare the surgical and hospitalization charges associated with 1- and 2-level lumbar total disc replacement and circumferential lumbar fusion. SUMMARY OF BACKGROUND DATA: Reported series of lumbar total disc replacement have been favorable. However, economic aspects of lumbar total disc replacement (TDR) have not been published or studied. This information is important considering the recent widespread utilization of new technologies. Recent studies have demonstrated comparable short-term clinical results between TDR and lumbar fusion recipients. Relative charges may be another important indicator of the most appropriate procedure. We report a hospital charge-analysis comparing ProDisc lumbar disc replacement with circumferential fusion for discogenic low back pain. METHODS: In a cohort of 53 prospectively selected patients with severe, disabling back pain and lumbar disc degeneration, 36 received Synthes ProDisc TDR and 17 underwent circumferential fusion for 1- and 2-level degenerative disc disease between L3 and S1. Randomization was performed using a 2-to-1 ratio of ProDisc recipients to control spinal fusion recipients. Charge comparisons, including operating room charges, inpatient hospital charges, and implant charges, were made from hospital records using inflation-corrected 2006 U.S. dollars. Operating room times, estimated blood loss, and length of stay were obtained from hospital records as well. Surgeon and anesthesiologist fees were, for the purposes of comparison, based on Medicare reimbursement rates. Statistical analysis was performed using a 2-tailed Student t test. RESULTS: For patients with 1-level disease, significant differences were noted between the TDR and fusion control group. The mean total charge for the TDR group was $35,592 versus $46,280 for the fusion group (P = 0.0018). Operating room charges were $12,000 and $18,950, respectively, for the TDR and fusion groups (P < 0.05). Implant charges averaged $13,990 for the fusion group, which is slightly higher than the $13,800 for the ProDisc (P = 0.9). Estimated blood loss averaged 794 mL in the fusion group versus 412 mL in the TDR group (P = 0.0058). Mean OR minutes averaged 344 minutes for the fusion group and 185 minutes for the TDR (P < 0.05) Mean length of stay was 4.78 days for fusion versus 4.32 days for TDR (P = 0.394). For patients with 2-level disease, charges were similar between the TDR and fusion groups. The mean total charge for the 2-level TDR group was $55,524 versus $56,823 for the fusion group (P = 0.55). Operating room charges were $15,340 and $20,560, respectively, for the TDR and fusion groups (P = 0.0003). Surgeon fees and anesthesiologist charges based on Medicare reimbursement rates were $5857 and $525 for the fusion group, respectively, versus $2826 and $331 for the TDR group (P < 0.05 for each). Implant charges were significantly lower for the fusion group (mean, $18,460) than those for 2-level Synthes ProDisc ($27,600) (P < 0.05). Operative time averaged 387 minutes for fusion versus 242 minutes for TDR (P < 0.0001). EBL and length of stay were similar. CONCLUSION: Patients undergoing 1- and 2-level ProDisc total disc replacement spent significantly less time in the OR and had less EBL than controls. Charges were significantly lower for TDR compared with circumferential fusions in the 1-level patient group, while charges were similar in the 2-level group
— id: 75860, year: 2007, vol: 32, page: 2905, stat: Journal Article,

The Imaging of Spinal Infections
Stieber JR; Schweitzer ME; Errico TJ
2007 ;19(2):106-112, Seminars in Spine Surgery
Spinal infections can arise in a variety of anatomical locations and structures and encompass vertebral osteomyelitis, discitis, disc space infection, epidural abscesses, and infecti= on of the adjacent soft tissue structures. Plain radiography, compute= d tomography, magnetic resonance imaging (MRI), and nuclear imagi= ng all have a role in the diagnosis of spinal infection. MRI conti= nues to be the gold standard for the imaging diagnosis of spinal infections. ⁶⁷Gallium citrate and Tc-99m-methylene diphosphonate scintigraphy have become the standard for nuclear imaging of the spine. Fluorine-18-fluorodeoxyglucose positron emission tomography, strepavidin/¹¹¹In-biotin, and ^99m-ciprofloxacin have shown promise for aiding in t= he diagnosis and evaluation of spinal infection but warrant furthe= r study. copyright 2007 Elsevier Inc. All rights reserved
— id: 72980, year: 2007, vol: 19, page: 106, stat: Journal Article,

Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis
Weinstein, James N; Lurie, Jon D; Tosteson, Tor D; Hanscom, Brett; Tosteson, Anna N A; Blood, Emily A; Birkmeyer, Nancy J O; Hilibrand, Alan S; Herkowitz, Harry; Cammisa, Frank P; Albert, Todd J; Emery, Sanford E; Lenke, Lawrence G; Abdu, William A; Longley, Michael; Errico, Thomas J; Hu, Serena S
2007 May 31;356(22):2257-2270, New England journal of medicine
BACKGROUND: Management of degenerative spondylolisthesis with spinal stenosis is controversial. Surgery is widely used, but its effectiveness in comparison with that of nonsurgical treatment has not been demonstrated in controlled trials. METHODS: Surgical candidates from 13 centers in 11 U.S. states who had at least 12 weeks of symptoms and image-confirmed degenerative spondylolisthesis were offered enrollment in a randomized cohort or an observational cohort. Treatment was standard decompressive laminectomy (with or without fusion) or usual nonsurgical care. The primary outcome measures were the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36) bodily pain and physical function scores (100-point scales, with higher scores indicating less severe symptoms) and the modified Oswestry Disability Index (100-point scale, with lower scores indicating less severe symptoms) at 6 weeks, 3 months, 6 months, 1 year, and 2 years. RESULTS: We enrolled 304 patients in the randomized cohort and 303 in the observational cohort. The baseline characteristics of the two cohorts were similar. The one-year crossover rates were high in the randomized cohort (approximately 40% in each direction) but moderate in the observational cohort (17% crossover to surgery and 3% crossover to nonsurgical care). The intention-to-treat analysis for the randomized cohort showed no statistically significant effects for the primary outcomes. The as-treated analysis for both cohorts combined showed a significant advantage for surgery at 3 months that increased at 1 year and diminished only slightly at 2 years. The treatment effects at 2 years were 18.1 for bodily pain (95% confidence interval [CI], 14.5 to 21.7), 18.3 for physical function (95% CI, 14.6 to 21.9), and -16.7 for the Oswestry Disability Index (95% CI, -19.5 to -13.9). There was little evidence of harm from either treatment. CONCLUSIONS: In nonrandomized as-treated comparisons with careful control for potentially confounding baseline factors, patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and function during a period of 2 years than patients treated nonsurgically. (ClinicalTrials.gov number, NCT00000409 [ClinicalTrials.gov].)
— id: 74083, year: 2007, vol: 356, page: 2257, stat: Journal Article,

Clinical and radiographically/neuroimaging documented outcome in transforaminal lumbar interbody fusion
Houten, John K; Post, Nicholas H; Dryer, Joseph W; Errico, Thomas J
2006 ;20(3):E8-E8, Neurosurgical focus
OBJECT: Although transforaminal lumbar interbody fusion (TLIF) is an increasingly popular surgical technique, there are a limited number of studies in which investigators have stratified outcome data with respect to surgical indications or documented radiographically proven and clinical results with respect to disc space height (DSH). The authors conducted a study to evaluate the long-term outcomes after TLIF with respect to surgical indication and radiographic/neuroimaging results. METHODS: Thirty-three consecutive TLIF-treated patients underwent follow-up investigation for a mean of 37 months. Isthmic spondylolysis was present in eight patients, recurrent disc herniation in 14, and degenerative disc disease (DDD) in 11. The operative technique involved the placement of interbody structural allograft, pedicle screw instrumentation, and morcellized autograft in the anterior interbody space and the contralateral intertransverse gutter. Surgery was performed at L4-5 in 16 patients, L5-S1 in 14, L3-4 in two, and both L4-5 and L5-S1 in one patient. Preoperative symptoms were back pain (in 91% of cases), leg pain (in 94%), sensory loss (in 67%), and motor deficits (in 30%). Postoperatively, back pain was improved in 67% of the patients, unchanged in 27%, and worsened in 7%. Leg pain improved in 80% of patients, was unchanged in 10%, and worsened in 10%. Outcome, as measured using the Prolo Functional and Economic Scales, improved from a score of 4.9 to 7. In patients with spondylolysis and recurrent disc herniation outcomes were better than in those with DDD only. There was no correlation of outcome with symptom duration, patient age, or level of surgery. In an independent review of pre- and late postoperative radiographs no significant differences in lordosis angles, Cobb angles, or DSHs were found. Fusion occurred in all cases. CONCLUSIONS: The TLIF procedure was associated with good clinical outcomes and a high fusion rate but no change in the DSH. Patients who present with spondylolysis and recurrent herniations experience better outcome than those with degenerative disease alone
— id: 74084, year: 2006, vol: 20, page: E8, stat: Journal Article,

Lumbar disc arthroplasty
Errico, Thomas J
2005 Jun;(435):106-117, Clinical orthopaedics & related research
Degenerative disc disease is the leading cause of pain and disability in adults in North America, and spinal fusion is the standard treatment. Despite this, it has been discussed among surgeons that (1) spinal fusion deserves reexamination in terms of its long-term consequences and benefits and (2) modern clinical research and development in disc arthroplasty strongly supports its emergence as an alternative. The ability to relieve pain by maintaining motion may be a critical factor in obtaining not only greater pain relief but in preventing adjacent segment degeneration. Early research in arthroplasty devices was promising but cut short. New knowledge in the functional anatomy and biomechanics of the spine has made possible the development of modern arthroplasty devices (eg, Charite Artificial Disc, ProDisc, Maverick device, FlexiCore device) of different constructions and materials (metal-on-plastic, metal-on-metal) and various ranges of motion/mobility that provide a basis for a classification of spinal mode and an assistance in implant selection. Current research also is confronting the critical obstacles of wear and tear and axial compression. Several devices currently are in clinical trials. A detailed review of their characteristics shows the exciting progress of a new treatment era of total disc replacement in spine-lumbar disc arthroplasty
— id: 56029, year: 2005, vol: , page: 106, stat: Journal Article,

Syntegration: a "more complete" knowledge-based approach to the practice of medicine--North American Spine Society Presidential Address, Chicago, IL
Errico, Thomas J
2005 Jan-Feb;5(1):6-12, Spine journal
— id: 74086, year: 2005, vol: 5, page: 6, stat: Journal Article,

Orthopaedic management of ankylosing spondylitis
Kubiak, Erik N; Moskovich, Ronald; Errico, Thomas J; Di Cesare, Paul E
2005 Jul-Aug;13(4):267-278, Journal of the American Academy of Orthopaedic Surgeons
Ankylosing spondylitis is an inflammatory disease of unknown etiology that affects an estimated 350,000 persons in the United States and 600,000 in Europe, primarily Caucasian males in the second through fourth decades of life. Worldwide, the prevalence is 0.9%. Genetic linkage to HLA-B27 has been established. Ankylosing spondylitis primarily affects the axial skeleton and is characterized by inflammation and fusion of the sacroiliac joints, spine, and hips. The resultant deformity leads to severe functional impairment in approximately 30% of patients. Orthopaedic management primarily involves correction of hip deformity through total hip arthroplasty and, less frequently, correction of spinal deformity with spine osteotomy. Closing wedge osteotomies have the lowest incidence of complications. Whether patients with ankylosing spondylitis are at increased risk for heterotopic ossification remains controversial, but comparison with age- and sex-matched counterparts suggests no dramatically higher risk. Because of the high rate of missed fractures and complications after minor trauma in patients with ankylosing spondylitis, plain radiographs are usually not sufficient for evaluation. Thorough patient assessment should include a comprehensive history, physical examination, and laboratory studies
— id: 74085, year: 2005, vol: 13, page: 267, stat: Journal Article,

Mini-open thoracoscopically assisted thoracotomy versus video-assisted thoracoscopic surgery for anterior release in thoracic scoliosis and kyphosis: a comparison of operative and radiographic results
Levin, Rafael; Matusz, David; Hasharoni, Amir; Scharf, Carrie; Lonner, Baron; Errico, Thomas
2005 Nov-Dec;5(6):632-638, Spine journal
BACKGROUND CONTEXT: Combining anterior release and interbody fusion with posterior instrumented fusion is an accepted treatment for severe rigid spinal deformity. Video-assisted thoracoscopic surgery (VATS) and mini-open thoracoscopically assisted thoracotomy (MOTA) are two minimally invasive approaches to the thoracic spine. Both reduce surgical trauma, improve cosmesis and provide effective exposure for release and fusion. Published data and the authors' surgical experience have demonstrated that both techniques are equivalent in degree of release to traditional open thoracotomy, but no comparison between these two minimally invasive alternatives has been published to our knowledge. PURPOSE: This study compared MOTA and VATS under the hypothesis that both result in similar corrections and comparable operative parameters when used in conjunction with posterior instrumented fusion. STUDY DESIGN/SETTING: Retrospective chart review of consecutive case series by two surgeons. PATIENT SAMPLE: Twenty-one (13 female, 8 male) patients underwent MOTA and 24 patients (17 female, 7 male) underwent VATS for anterior release, discectomy and fusion prior to posterior instrumented fusion. OUTCOME MEASURES: Outcomes were measured at a minimum of 1-year follow-up and included radiographic Cobb measurements and operative parameters. METHODS: The indications for surgery included rigid and severe scoliosis or thoracic kyphosis. Data collection included preoperative demographics, number of levels released, primary curve correction, operative time and blood loss. Data were normalized per number of levels released anteriorly. Statistical analysis of results was done using a two-sample t test assuming equal variances with two-tail p values less than .05. RESULTS: More anterior levels were operated on average in the VATS group (6.33 vs. 4.38 levels). Curve correction per anterior level released was similar in both groups (8.7 and 8.8 degrees/level for MOTA and VATS, respectively). There was a significant difference in operative time with MOTA averaging 131.7 minutes and VATS averaging 162.8 minutes. However, a comparison of the operative time per anterior level operated, approached statistical significance in favor of VATS (33.0 vs. 28.4 minutes, p=.08). There was no significant difference in estimated blood loss during the anterior portion of the surgeries. There was a trend toward decreased blood loss per operated level favoring VATS (68.4 vs. 38.9 cc, p=.09). CONCLUSIONS: Both approaches resulted in corrections that compare favorably with open thoracotomy. We suggest that a factor in choosing between these two minimally invasive techniques is the number of thoracic levels requiring release. For four levels or less, MOTA provides an excellent alternative to standard thoracotomy. For five or more levels, VATS provides for excellent exposure of additional levels with the advantages of less operative time and blood loss per operated level
— id: 62369, year: 2005, vol: 5, page: 632, stat: Journal Article,

The effect of end screw orientation on the stability of anterior instrumentation in cyclic lateral bending
Rodriguez-Olaverri, Juan C; Hasharoni, Amir; DeWal, Hargovind; Nuzzo, Roy M; Kummer, Frederick J; Errico, Thomas J
2005 Sep-Oct;5(5):554-557, Spine journal
BACKGROUND CONTEXT: Screw pullout at the proximal or distal end of multilevel anterior instrumentation can occur clinically. Previous laboratory studies have shown that angulation of vertebral body screws increases screw pullout strength and stability in toggling. PURPOSE: To determine the effect of end screw angulation on instrumentation construct stability after cyclic, lateral bending. STUDY DESIGN: A biomechanical study in calf spines comparing two anterior spinal instrumentation constructs, one with parallel polyaxial screws and the other with angled polyaxial end screws. METHODS: Sixteen instrumented constructs were made from eight thoracic (T8-T12) and eight lumbar calf spines (L1-L5). Eight (four lumbar specimens and four thoracic specimens) had five bicortical screws inserted mid-body and parallel to the end plates. The other eight specimens had two screws angled toward the superior end plates of the top two vertebrae; the middle vertebra had a mid-body screw parallel to the end plate, and the bottom two vertebrae had screws angled towards their inferior end plates. The constructs were then cycled in lateral bending, and the displacements of the two instrumentations with a 10 N-m bending load were compared. RESULTS: After 10,000 cycles, constructs with parallel end screws exhibited twice the average displacement than those with angled screws: 5.4 mm versus 2.9 mm (p=.031). CONCLUSION: The use of angled screws at the ends of anterior constructs demonstrated increased construct stability after cycling compared with traditional transverse screws. Although angled screw insertion is technically more difficult and is possible only with specific screw designs, its use might increase instrumentation longevity
— id: 61842, year: 2005, vol: 5, page: 554, stat: Journal Article,

Anterior posterior fusion and the management of lumbar instability
Stieber JR; Errico TJ
2005 ;17(4):277-284, Seminars in Spine Surgery
Anterior-posterior surgery is indicated for the treatment of lumbar instability in the presence of simultaneous compromise of both the anterior and the posterior spinal elements or to augment the stability and rigidity of a fusion construct. The addition of an anterior interbody fusion to a posterior instrumented fusion serves to more successfully restore sagittal balance, effect indirect neural decompression, and to decrease pedicle screw strain by reconstituting the load-sharing ability of the anterior column. A variety of posterior fixation and minimally invasive techniques has been demonstrated to increase circumferential construct stiffness and rates of fusion. copyright 2005 Elsevier Inc. All rights reserved
— id: 61429, year: 2005, vol: 17, page: 277, stat: Journal Article,

Why a mechanical disc?
Errico, Thomas J
2004 Nov-Dec;4(6 Suppl):151S-157S, Spine journal
Low back pain secondary to degenerative disc disease is an overwhelming and growing problem in the United States and Western countries. Most degenerative disc disease can be treated nonoperatively. There are, however, substantial numbers of patients who have not benefited from exhaustive nonoperative treatments and subsequently seek surgical solutions to their incapacitating back pain. Lumbar fusion for back pain and/or leg pain associated with degenerative disc disease is considered the gold standard by which other treatments are judged. A challenge to spinal fusion for degenerative disc disease is now being offered in the form of the artificial disc. The implantation of an artificial lumbar disc allows for maintenance or restoration of physiologic movement at affected segments. A major long-term complication of spinal fusion is degeneration of a disc adjacent to the fused segments. Theoretically, the maintenance of motion could minimize development of adjacent disc degeneration as seen with spinal fusion. It is interesting to note that fusion of the hip or knee is not considered a primary procedure, but fusion is a primary procedure for the lumbar spine. Four artificial lumbar discs are discussed in this article. Early results are promising in terms of clinical results and movement, but long-term follow-up clinical trials must be done in order to gain an accurate comparison with spinal fusion. Trials are currently ongoing. The clinical results up to now and the potential for maintaining lumbar mobility throughout life warrant continuation of this surgical procedure
— id: 48104, year: 2004, vol: 4, page: 151S, stat: Journal Article,

A fair and balanced view of spine fusion surgery
Errico, Thomas J; Gatchel, Robert J; Schofferman, Jerome; Benzel, Edward C; Faciszewski, Thomas; Eskay-Auerbach, Marjorie; Wang, Jeffrey C
2004 Sep-Oct;4(5 Suppl):S129-S138, Spine journal
— id: 74088, year: 2004, vol: 4, page: S129, stat: Journal Article,

The unique characteristics of "upper" lumbar disc herniations
Sanderson, Scott P; Houten, John; Errico, Thomas; Forshaw, David; Bauman, Joel; Cooper, Paul R
2004 Sep;55(2):385-389, Neurosurgery
OBJECTIVE: To compare the characteristics, presentation, and surgical outcome of patients with microdiscectomies at L1-L2 and L2-L3 with those we treated at L3-L4. We further sought to compare these results with those reported in the literature for discectomies at the L4-L5 and L5-S1 levels. METHODS: We reviewed the clinical data collected from 69 patients who had 72 L1-L2, L2-L3, and L3-L4 microdiscectomies performed from 1989 to 1999 at the New York University Medical Center. Patients who had surgery at L1-L2 or L2-L3 were grouped and compared with those treated at the L3-L4 level. Patients' charts were retrospectively reviewed at a mean of 12.9 months after surgery for presenting signs and symptoms, patient characteristics, and surgical outcome. Long-term follow-up via telephone interview was obtained at an average of 81.3 months after surgery. RESULTS: In the L1-L2 + L2-L3 group, 58% of the patients had previous lumbar disc surgery, compared with only 10% of those in the L3-L4 group, and 20% in the L1-L2 + L2-L3 group required a fusion during the procedure compared with only 10% in the L3-L4 group. These differences are both statistically significant. The short-term chart review demonstrates that only 58% and 53% of patients in the L1-L2 + L2-L3 group were improved with regard to radicular and back pain, respectively, whereas those in the L3-L4 group reported 94 and 87% rates of improvement in the same categories, both highly statistically significant findings. The long-term follow-up confirmed a highly statistically significantly worse outcome in the L1-L2 + L2-L3 group, with only 33% of patients reporting an improvement in their economic or functional status, compared with an 88% rate of improvement in the L3-L4 group. The outcome of our patients with L3-L4 herniations was similar to that reported in the literature for herniations at L4-L5 and L5-S1. CONCLUSION: Herniated discs at the L1-L2 or L2-L3 level are different entities from those at lower levels of the lumbar spine. The surgical outcome in terms of postoperative back and radicular pain is worse for herniated discs at L1-L2 and L2-L3 compared with those treated at L3-L4. Our patients with L1-L2 or L2-L3 surgically treated herniated discs were more likely to have had previous lumbar surgery and required a fusion more often than their counterparts with L3-L4 herniated discs
— id: 46156, year: 2004, vol: 55, page: 385, stat: Journal Article,

Design and evaluation of the FlexiCore metal-on-metal intervertebral disc prosthesis
Valdevit, Antonio; Errico, Thomas J
2004 Nov-Dec;4(6 Suppl):276S-288S, Spine journal
BACKGROUND CONTEXT: The technical difficulties associated with the development of an intervertebral disc prosthesis include endurance demands on the device, lack of consensus concerning the biomechanical principles governing the articulation of the spinal joint and the performance of materials available for implantation. PURPOSE: Although biologically based disc prostheses and augmentations may be the endpoint of spinal disc replacements, these devices and associated technologies will still require decades of work in order to achieve fruition. The more immediate solution will require a durable, biocompatible device capable of restoring range of motion. The evaluation of such a device must include failure testing of critical components as well as a series of fatigue experiments under overloaded conditions. STUDY DESIGN/SETTING: Recent literature citing adjacent level degeneration associated with segmental mobilization and a lack of correlation between successful fusion and clinical success has prompted the need for a dynamic intervertebral disc prosthesis. METHODS: Combined with a better understanding of the biomechanics and the prospect of an increasing percentage of more elderly patients, the future of spinal fusion for pain and instability may need to be reexamined. The authors propose a novel metal-on-metal design for an intervertebral device that features a fixed center of rotation, a mechanical torsional limit, a unique feature to allow for the location of the device in a patient-specific manner, and means by which the device may be implanted directly anterior or anterolaterally. RESULTS: Physiological ranges of motion are retained by the prosthesis. In addition, initial and long-term fixations are achieved through spines and bone ingrowth coating. The device comprises a retained ball and socket positioned between two baseplates. The ball and socket joint permits articulation through the appropriate physiological range of motion and center of rotation as the baseplates provide a stable platform for implantation. CONCLUSIONS: An intervertebral disc prosthesis has been designed and has demonstrated mechanical performance beyond what is required physiologically under preliminary testing
— id: 74087, year: 2004, vol: 4, page: 276S, stat: Journal Article,

Open discectomy as treatment for herniated nucleus pulposus of the lumbar spine
Errico, Thomas J; Fardon, David F; Lowell, Troy D
2003 May-Jun;3(3 Suppl):45S-49S, Spine journal
— id: 74089, year: 2003, vol: 3, page: 45S, stat: Journal Article,

Evaluation of preoperative administration of the cyclooxygenase-2 inhibitor rofecoxib for the treatment of postoperative pain after lumbar disc surgery
Bekker, Alex; Cooper, Paul R; Frempong-Boadu, Anthony; Babu, Ramesh; Errico, Thomas; Lebovits, Allen
2002 May;50(5):1053-1057, Neurosurgery
OBJECTIVE: A combination of analgesics with different mechanisms of action may improve postoperative pain control and reduce the incidence of side effects. This study was designed to assess the efficacy of preoperative administration of rofecoxib (Vioxx; Merck & Co., Inc., Somerset, NJ) in reducing pain and opioid requirements after single-level lumbar microdiscectomy. METHODS: A randomized, double-blind, placebo-controlled clinical trial was performed on 61 consenting patients who were considered American Society of Anesthesiologists Class I or II and who were scheduled for elective single-level lumbar microdiscectomy. Patients received either two doses of rofecoxib 50 mg or a placebo preoperatively. The outcome measures included morphine use in the postanesthesia care unit (PACU), discharge times, and side effect profile. Data were analyzed by use of independent sample t tests for continuous variables or chi(2) tests for categorical variables. A P value of <0.05 was considered significant. RESULTS: The two groups were comparable with respect to patient characteristics, intraoperative opioid and hypnotic consumption, and duration of surgery. Patients in the rofecoxib group required significantly less morphine postoperatively. Significantly more patients in the placebo group reported pain scores greater than 7 at admission to the PACU. Time to first request for analgesia was shorter in the placebo group, but the difference did not reach statistical significance. There were no significant differences between groups in the incidence of nausea, time to discharge from the PACU, or hospital stay. CONCLUSION: Preoperative rofecoxib is effective in reducing postoperative narcotic consumption in patients undergoing lumbar laminectomy. The use of rofecoxib does not shorten PACU length of stay or hospital discharge time. These outcome measures depend on multiple administrative factors
— id: 48718, year: 2002, vol: 50, page: 1053, stat: Journal Article,

Paraplegia after lumbosacral nerve root block: report of three cases
Houten, John K; Errico, Thomas J
2002 Jan-Feb;2(1):70-75, Spine journal
BACKGROUND CONTEXT: Lumbar nerve root blocks and epidural steroid injections are frequently employed in the management of degenerative conditions of the lumbar spine, but relatively few papers have been published that address the complications associated with these interventions. Serious complications include epidural abscess, arachnoiditis, epidural hematoma, cerebrospinal fluid fistula and hypersensitivity reaction to injectate. Although transient paraparesis has been described after inadvertent intrathecal injection, an immediate and lasting deficit has not been previously described as sequelae of a nerve root block. PURPOSE: We present three cases in which either persisting paraplegia or paraparesis occurred immediately after administration of a lumbar nerve root block and propose a mechanism for this devastating but previously unreported complication. STUDY DESIGN/SETTING: Case reports of three patients. PATIENT SAMPLE: Three patients, two women and one man ranging in age from 42 to 64 years, underwent three procedures performed at three different facilities, in the hands of two different injectionists. In each instance, penetration of the dura was not thought to have occurred. In two procedures the needles were placed transforamenally, one at L3-4 on the left and one at L3-4 on the right, and in the third the needle tip was placed immediately lateral to the S1 nerve root. OUTCOME MEASURES: Patient follow-up data from medical office records. METHODS: In each case, needle placement was verified with injection of a contrast media in conjunction with either computerized tomography or biplanar fluoroscopy. No backbleeding or cerebrospinal fluid was encountered upon aspiration in any of the procedures. Magnetic resonance imaging (MRI) was performed within 48 hours of injury in all patients. RESULTS: In each patient, paraplegia suddenly ensued after instillation of the steroid solution and, in each instance, postprocedure MRI revealed increased signal in the low thoracic spinal cord on T2-weighted imaging consistent with edema. The sudden onset of neurological deficit and the imaging changes noted in the spinal cord point to a vascular explanation for these injuries. We postulate that in these patients the spinal needle either penetrated or caused injury to an abnormally low dominant radiculomedullary artery, a recognized anatomical variant. This vessel, also known as the artery of Adamkiewicz, in 85% of individuals arises between T9 and L2, usually from the left, but in a minority of people may arise from the lower lumbar spine and rarely even from as low as S1. The artery of Adamkiewicz travels with the nerve root through the neural foramen and irrigates the anterior spinal artery. Injury of it or injection of particulate matter into it, as what may happen with the commonly used epidural steroid injectates, may result in infarction of the lower thoracic spinal cord, producing the clinical and imaging findings seen in these three patients. CONCLUSIONS: We present the cases of three patients who had lasting paraplegia or paraparesis after the performance of a nerve root block. We propose that the mechanism for this rare but devastating complication is the concurrence of two uncommon circumstances, the presence of an unusually low origin of the artery of Adamkiewicz and an undetected intraarterial penetration of the procedure needle
— id: 39013, year: 2002, vol: 2, page: 70, stat: Journal Article,

Managing lumbar stenosis in the elderly patient: relief during sitting and forward flexion is a strong diagnostic clue
Houten JK; Dryer JW; Errico TJ
2001 Mar;18(3):158-165, Journal of musculoskeletal medicine
Degenerative lumbar spinal stenosis is a problem of increasing importance as the population ages and functional expectations remain high. It usually develops secondary to spondylosis. Classic symptoms of lumbar stenosis are back pain, radiating leg pain, and sciatica exacerbated by walking. This neurogenic claudication usually can be distinguished from other conditions that produce leg pain during the history and physical examination. Plain radiographs suffice for persons with mild to moderate stenosis; more severe symptoms or neurologic involvement calls for other imaging. Management begins conservatively with anti-inflammatory agents and local modalities. Epidural corticosteroids are being used increasingly despite controversy. Surgery may be indicated for patients in whom nonoperative treatment is unrewarding and is safe even for very elderly persons. (33 ref 1 bib) <19>
— id: 26862, year: 2001, vol: 18, page: 158, stat: Journal Article,

Use of epidural steroids after discectomy may predispose to infection
Lowell, TD; Errico, TJ; Eskenazi, MS
2000 FEB 15 ;25(4):516-519, Spine
Study Design. This is a report of three cases of epidural abscess occurring after use of intraoperative epidural methylprednisolone in 31 patients who had undergone lumbar microdiscectomy. The possible role of epidural steroids in the cause of these abscesses is discussed, and a review the literature concerning its value is provided. Objective. To evaluate experiences with the efficacy and safety of perioperative methylprednisolone. Summary of Background Data. No previous study has described a high infection rate with the use of epidural methylprednisolone. The literature supporting epidural steroids is equivocal, and reports supporting their perioperative use are scant. Methods. In an 8-month period, 31 patients received 1 mL (40 mg) epidural methylprednisolone at the conclusion of microdiscectomy. Therapy was discontinued after an increased postoperative deep infection rate was noted. Results in these patients were compared with those in more than 400 others who did not receive intraoperative steroids during a 7-year period. Results. In the steroid group, three epidural abscesses,were encountered. There were no deep infections in the nonsteroid group. Conclusion. The use of perioperative epidural methylprednisolone in the currently reported cases was associated with three incidences of infection. A prospective study is needed to examine its use
— id: 54742, year: 2000, vol: 25, page: 516, stat: Journal Article,

Contemporary management of spinal osteomyelitis
Rezai AR; Woo HH; Errico TJ; Cooper PR
1999 May;44(5):1018-1025, Neurosurgery
OBJECTIVE: We review the results of treatment of a series of patients with spinal osteomyelitis, to formulate a systematic and comprehensive approach to the management of this disease in light of recent technical and conceptual advances in imaging, spinal biomechanics, and internal fixation. METHODS: We retrospectively reviewed the records for 57 consecutive patients with pyogenic spinal osteomyelitis who were treated between June 1987 and June 1995. Pain and weakness were the most common presenting symptoms. The mean duration of symptoms at the time of diagnosis was 10.6 weeks. Surgical indications included the presence or development of motor deficits with epidural compression and/or localized kyphotic deformities or the failure of medical therapy. RESULTS: Thirty-three patients underwent surgery as their initial treatment. Six additional patients experienced medical therapy failure and received subsequent surgical treatment. Seventeen patients were treated using an anterior approach only, 13 were treated using a posterior approach only, and 9 were treated using a combined anterior and posterior approach. After a minimal follow-up period of 24 months, 93% of the surgically treated patients showed neurological improvement or were neurologically intact, with a mean 16-degree decrease in localized kyphotic deformities and with solid bony fusion and resolution of pain for all patients. CONCLUSION: Early surgical decompression results in rapid improvement of neurological deficits, decreases in kyphotic deformities, and stabilization with bony fusion. The presence of active infection does not preclude the use of internal fixation. Nonsurgical management is indicated for patients with minimal or no neurological deficits and the absence of significant localized kyphotic deformities. However, 25% of patients who were initially treated nonsurgically experienced medical therapy failure and underwent surgical treatment
— id: 56434, year: 1999, vol: 44, page: 1018, stat: Journal Article,

Anterior instrumentation of the spine in thoracic and thoracolumbar fractures: The single rod versus the double rod Slot-Zielke device - Point of view
Errico, TJ
1996 MAR 15 ;21(6):739-740, Spine
— id: 53016, year: 1996, vol: 21, page: 739, stat: Journal Article,

Posttraumatic kyphosis of the thoracic and lumbar spine. Editorial review
D'Ariano GD; Errico TJ
1995 ;6(2):95-103, Current opinion in orthopaedics
— id: 8101, year: 1995, vol: 6, page: 95, stat: Journal Article,

Pedicle screws
Dryer JW; Errico TJ
1995 ;6(2):55-60, Current opinion in orthopaedics
— id: 8102, year: 1995, vol: 6, page: 55, stat: Journal Article,

Open discectomy as treatment for herniated nucleus pulposus of the lumbar spine
Errico TJ; Fardon DF; Lowell TD
1995 Aug 15;20(16):1829-1833, Spine
Open discectomy is the 'gold standard' for operative intervention in patients with herniated lumbar discs whose conservative treatment has failed. Over 60 years the indications for surgery and the expected success rates have been clearly elucidated. The specific patient selection and determination of surgical procedures continues to evolve. Recurrent herniations occur at a low rate, and serious complications are rare
— id: 12742, year: 1995, vol: 20, page: 1829, stat: Journal Article,

Microdiskectomy for lumbar disk herniation: a review of 100 cases
Lowell TD; Errico TJ; Fehlings MG; DiBartolo TJ; Ladosi L
1995 Oct;18(10):985-990, Orthopedics (Thorofare NJ)
One hundred patients who underwent microlumbar diskectomy over 5 years were retrospectively reviewed. L4-5 and L5-S1 were compared to determine whether a patient's post-surgical outcome is related to the level where a herniation has occurred. Overall results included 70 excellent, 19 good, 2 fair, and 9 poor. Statistical analysis showed that neither the level involved, length of follow-up, nor degree of manual labor predicted outcome. Older patients and females tended to fare worse, but the trends were not significant. Three recurrent herniations occurred, 1 in the L4-L5 group and 2 in the L5-S1 group. No variable predicted recurrence
— id: 6842, year: 1995, vol: 18, page: 985, stat: Journal Article,

Modern management of spinal tuberculosis
Rezai AR; Lee M; Cooper PR; Errico TJ; Koslow M
1995 Jan;36(1):87-97, Neurosurgery
The resurgence of pulmonary tuberculosis in the United States has been paralleled by a concomitant rise in tuberculosis of the spine (Pott's disease). The appearance of drug-resistant strains of tuberculosis, infection in large numbers of immunocompromised hosts, newer imaging modalities, and the development of more effective spinal reconstruction techniques have raised important issues regarding the management of Pott's disease. In spite of this, there has been little published recently on the modern management of Pott's disease in developed countries. We report our experience with the management of 20 patients with Pott's disease in the past 5 years, 16 of whom were admitted during the last 18 months of this retrospective study. The mean patient age was 49 years. Sixteen (80%) were men. Nineteen (95%) had a positive tuberculin skin test, and 13 (65%) had pulmonary tuberculosis. Symptoms consisted of spinal pain, weakness, sensory complaints, and flank mass in order of decreasing frequency. Ten patients were neurologically intact; the remainder had motor deficits of variable severity. The thoracic spine was involved in 13 patients, the lumbar spine was involved in 4, the cervical spine was involved in 2, and the thoracolumbar spine was involved in 1. Spinal deformity was present in 11 patients, spinal epidural compression was present in 13, and a paraspinal mass was present in 18. Operative indications included motor deficits, spinal deformity, nondiagnostic computer tomographic-guided needle biopsy, and noncompliance with, or lack of, response to medical therapy. Eleven patients underwent operations. Six patients had vertebrectomy and bone grafting with posterior instrumentation when indicated; three had laminectomy, debridement, and abscess drainage; one had laminectomy and posterior instrumentation; and one had paraspinal abscess drainage. Two patients have died; the remainder have been monitored for at least 1 year and are neurologically improved or normal without residual infection. The average angulation decreased from 31 to 24 degrees by the follow-up examination. In selected patients, early operative treatment with instrumentation, when indicated, minimizes neurological deterioration and spinal deformity, allows early ambulation, and results in excellent neurological outcome
— id: 6724, year: 1995, vol: 36, page: 87, stat: Journal Article,

Management of metastatic disease of the spine and vertebral body replacement with silastic cement restrictor
Errico TJ; Cooper PR
Spinal instrumentation Philadelphia : Hanley & Belfus, 1994,
— id: 2894, year: 1994, vol: , page: 483, stat: Chapter,

Posterior plates in the management of cervical instability: long-term results in 44 patients
Fehlings MG; Cooper PR; Errico TJ
1994 Sep;81(3):341-349, Journal of neurosurgery
Although posterior plates are increasingly used to manage cervical spinal instability, long-term follow-up evaluation of patients with a critical analysis of efficacy and complications has not been reported. The authors have retrospectively analyzed the outcome in 44 consecutive patients (37 males and seven females, age range 16 to 80 years) treated with posterior cervical plates. The indications for instrumentation were instability due to trauma in 42 cases, tumor in one, and infection in one. In four patients the follow-up period was limited to 3, 5, 11, and 16 months. Two patients died of chronic medical problems 4 and 9 months after treatment. The remaining 38 patients were followed from 2 to 6 years (mean 46 months). One motion segment was stabilized in 23 patients using two-hole plates; two motion segments were stabilized in the other 21 patients using three-hole plates. In the majority of patients (37 cases), supplemental bone grafting was not used. Patients were immobilized postoperatively in a Philadelphia collar. Solid arthrodesis was achieved in 39 (93%) of 42 patients. Three patients required revision of the cervical plating: in one patient with a C-5 burst fracture, two-hole plates were applied at C5-6 and progressive kyphosis mandated anterior fusion; the second patient required posterior wiring due to screw pull-out resulting from a technical error in screw insertion; the third patient, who refused to wear an orthosis postoperatively, also developed screw pull-out. In two patients who went on to spinal fusion, there was an increase in sagittal kyphosis (6 degrees and 8 degrees) without clinical sequelae. Screw loosening was noted in five patients, involving eight (3.8%) of the 210 lateral mass screws; this complication resulted in instrumentation failure or increased kyphosis in three cases. There were two superficial infections. This analysis indicates that posterior cervical plating is highly effective; at long-term follow-up review the cervical spine was successfully stabilized in 93% of cases. Plate failure was related to faulty screw placement, failure to include sufficient motion segments, and noncompliance with postoperative orthoses. Halo vest immobilization was unnecessary and supplemental bone grafting was generally not required for recent trauma
— id: 12902, year: 1994, vol: 81, page: 341, stat: Journal Article,

A systematic approach to spinal reconstruction after anterior decompression for neoplastic disease of the thoracic and lumbar spine
Cooper PR; Errico TJ; Martin R; Crawford B; DiBartolo T
1993 Jan;32(1):1-8, Neurosurgery
The anterior approach to the thoracic and lumbar spine for neoplastic disease is now a well-accepted procedure, with results, for the most part, superior to those achieved with laminectomy. However, the specific indications for anterior decompression and the selection of reconstruction techniques based on the location and extent of bony destruction have received surprisingly little attention. The authors report their experience with the operative management of 33 patients with benign and malignant tumors of the thoracic and lumbar spine, using the anterior transthoracic or retroperitoneal approach. The role of stabilization and the relative indications for anterior or posterior instrumentation are emphasized. The mean age of patients was 58 years. Twenty-three patients were male. Five patients had benign tumors, and the remainder had a variety of metastatic lesions. Twenty-nine patients had lower extremity motor deficits, although 25 were ambulatory preoperatively. Thirty-seven noncontiguous resections were performed in 33 patients. In 13 patients, the resected vertebral body was replaced with acrylic or bone without instrumentation; in 18, the acrylic was supplemented with anterior instrumentation; and in 6, both anterior and posterior instrumentation were used. Above T11, vertebral reconstruction techniques were used to restore stability after decompression. Between T11 and L4, anterior instrumentation was used to supplement vertebral reconstruction in all patients. Supplemental posterior instrumentation was used for three-column involvement. Motor function was stabilized or improved in 94% of patients, and 88% of patients were ambulatory postoperatively. Of 28 patients with malignant disease, 23 died after a mean survival of 10.2 months (range, 2-51 mo) and 5 are alive a mean of 34.4 months since their operation.(ABSTRACT TRUNCATED AT 250 WORDS)
— id: 56515, year: 1993, vol: 32, page: 1, stat: Journal Article,

A new method of thoracic and lumbar body replacement for spinal tumors: technical note
Errico TJ; Cooper PR
1993 Apr;32(4):678-680, Neurosurgery
Anterior decompressive procedures have gained more widespread usage in the treatment of anterior compressive lesions of the spinal cord due to neoplasms. Alternative methods of vertebral body replacement that use a modified silastic tube placed into adjacent vertebral segments and filled with methyl methacrylate cement are described. The technique is reserved for patients with limited longevity as the result of the malignant nature of their disease process
— id: 13209, year: 1993, vol: 32, page: 678, stat: Journal Article,

Transthoracic and translumber decompression and stabilization for spinal tumors
Errico TJ; Cooper PR
1993 ;15(14):1-5, Contemporary neurosurgery
— id: 33584, year: 1993, vol: 15, page: 1, stat: Journal Article,

Occipitocervical fusion with a five-millimeter malleable rod and segmental fixation
Fehlings MG; Errico T; Cooper P; Benjamin V; DiBartolo T
1993 Feb;32(2):198-207, Neurosurgery
Although occipitocervical fusion is frequently used for instability of the upper cervical spine and the occipitocervical articulation, most currently used techniques have one or more of the following disadvantages: the necessity for sublaminar wires, the use of occipital screws, a fixed angle of instrumentation, or the necessity for routine postoperative halo immobilization. Moreover, many reported techniques are associated with a high rate of nonunion or instrumentation failure. We present our experience with a technically simple method of obtaining rigid occipitocervical arthrodesis using a 5-mm malleable rod that is fixed to the skull by a pair of wires passed through four suboccipital burr holes. Segmental spinal fixation is achieved with Wisconsin interspinous wires and is occasionally supplemented with sublaminar wires. Supplemental autogenous bone graft is used in all cases. A cervical collar is routinely used for postoperative immobilization. The results of treatment were retrospectively reviewed in 16 patients with an average age of 49.4 years (range, 9-69). Mean follow-up was 24 months (range, 12-36 mo). The indication for fusion was instability of the occiput-C1-C2 complex as a result of Chiari malformation, rheumatoid disease, skull base tumor resection, basilar invagination, ankylosing spondylitis, Down's syndrome, cervical laminectomy, and trauma. The average number of levels fused was 5.4 (range, O-C3 to O-T3). Successful occipitocervical arthrodesis was achieved in all but one of the surviving patients. The single patient with a pseudarthrosis was successfully managed with supplemental bone grafting and halo immobilization. There were two deaths from medical complications in chronically ill patients. Other complications included one postoperative instrumentation loosening, one myocardial infarction, and one superficial occipital decubitus. In conclusion, rodding and segmental interspinous wiring is an effective, technically simple method of obtaining rigid occipitocervical fixation, which obviates the need for bulky orthoses
— id: 13259, year: 1993, vol: 32, page: 198, stat: Journal Article,

Pullout strength comparison of two methods of orienting screw insertion in the lateral masses of the bovine cervical spine
Errico T; Uhl R; Cooper P; Casar R; McHenry T
1992 Dec;5(4):459-463, Journal of spinal disorders
We undertook a biomechanical study to compare the pullout strength of 3.5-mm AO screws placed in two different orientations within the bovine cervical spine. The first set of screws were oriented obliquely and passed through the lateral mass, as recommended by the AO group. The orientation of the second set was anterior to posterior through the lateral mass, as recommended by Roy-Camille. All screw holes were drilled and tapped by a spinal surgeon experienced with both techniques. Pullout force was measured on an Instron materials testing machine using a self-centering screw-holding chuck and loading rate of 0.833 mm/sec. Although the bone strength in the Roy-Camille orientation was greater (46.7 N/mm versus 36.1 N/mm, p < 0.05), the overall mean pullout force for the AO orientation was greater (607 N versus 471 N, p < 0.025) due to the longer length of bone available for screw purchase (17.0 mm versus 10.3 mm)
— id: 13342, year: 1992, vol: 5, page: 459, stat: Journal Article,

Spinal trauma
Errico, Thomas J.; Bauer, R. David.; Waugh, Theodore R
Philadelphia : Lippincott, c1991,
— id: 269, year: 1991, vol: , page: , stat: ,

Using tissue expanders in spinal surgery for deficient soft tissue or postirradiation cases
Paonessa KJ; Zide B; Errico T; Engler GL
1991 Aug;16(8 Suppl):S324-S327, Spine
Prior irradiation and scarring can complicate wound closure following spinal surgery. Implanted tissue expanders were used six times in four patients to aid skin closure. Three patients had prior irradiation for cancer, and one had myelomeningocele. The average interval between placement and removal of the expanders was 46 days. Two late failures occurred because of prominent hardware. These expanders may provide adequate myocutaneous covers following spinal surgery in difficult cases
— id: 50613, year: 1991, vol: 16, page: S324, stat: Journal Article,

Cervical spine injuries
Sommer RM; Bauer RD; Errico TJ
Trauma : anesthesia and intensive care Philadelphia : Lippincott, 1990,
— id: 3420, year: 1990, vol: , page: 447, stat: Chapter,

Evaluation and diagnosis of cervical spine injuries: a review of the literature
Bauer RD; Errico TJ; Waugh TR; Cohen W
1987 ;4(2):71-93, Central nervous system trauma
Cervical spine injuries pose devastating potential problems for surgeon and patient alike. This review will stress the early diagnosis of cervical spine injuries, with emphasis on early suspicion of injury. This review will focus on the radiology and types of lesions found with cervical spine injury
— id: 11418, year: 1987, vol: 4, page: 71, stat: Journal Article,

THE ROLE OF DISKOGRAPHY IN THE 1980S
Errico, TJ
1987 Jan;162(1):285-286, Radiology
— id: 31297, year: 1987, vol: 162, page: 285, stat: Journal Article,

Techniques of internal fixation for degenerative conditions of the lumbar spine
Kostuik JP; Errico TJ; Gleason TF
1986 Feb;(203):219-231, Clinical orthopaedics & related research
The indications and techniques for internal fixation of the lumbar spine in degenerative conditions have changed drastically since internal fixation was first applied to the spine almost 100 years ago. Anterior instrumentation and fusion may be used for repair of pseudarthrosis after posterolateral fusion; symptomatic lumbar scoliosis associated with degenerative disc disease; late pain secondary to posttraumatic kyphosis; postlaminectomy instability; and lumbar pain secondary to thoracolumbar kyphosis. Posterior instrumentation and fusion has been performed with Luque instrumentation over 3-4 levels in cases of multilevel instability. Combined anterior and posterior instrumentation and fusion are required for lumbosacral fusion in lumbar scoliosis with degenerative disease, and surgical correction of postsurgical lumbar kyphosis (flat-back syndrome). The techniques are demanding but with attention to detail can be performed with acceptably low-complication rates
— id: 47573, year: 1986, vol: , page: 219, stat: Journal Article,

Heterotopic ossification. Incidence and relation to trochanteric osteotomy in 100 total hip arthroplasties
Errico TJ; Fetto JF; Waugh TR
1984 Nov;(190):138-141, Clinical orthopaedics & related research
Heterotopic ossification can impair the functional results of total hip arthroplasty. The causative role of trochanteric osteotomy in heterotopic ossification is uncertain. Postoperative radiographs of 100 total hip arthroplasties were analyzed for incidence of heterotopic ossification. Forty procedures were performed with trochanteric osteotomy and 60 without. There was a 17% overall incidence of clinically significant heterotopic ossification, 22% with osteotomy and 13% without. High- and low-risk categories revealed clinically significant heterotopic ossification in 25% of the high-risk group and in 8% of the low-risk group. In the high-risk group there was a 32% incidence with trochanteric osteotomy and 22% without osteotomy. In the low-risk group there was a 16% incidence without trochanteric osteotomy and a 3% incidence with trochanteric osteotomy. The increase in clinically significant heterotopic ossification in the high-risk group over that of the low-risk group was statistically significant. The present study showed that trochanteric osteotomy tended to increase the incidence and severity of clinically significant heterotopic ossification. These data suggest that trochanteric osteotomy should be avoided, if possible, during total hip arthroplasty to decrease the risk of heterotopic ossification
— id: 47459, year: 1984, vol: , page: 138, stat: Journal Article,