Browsing by Author "Richardson, William"
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Item Open Access Bipolar tissue sealant device decreases hemoglobin loss in multilevel spine surgery.(Transfusion, 2012-12) Hill, Steven E; Broomer, Bob; Stover, John; White, William; Richardson, WilliamBackground
Traditional techniques for obtaining hemostasis during orthopedic surgery, such as conventional electrocautery and sealants, have limited clinical effectiveness in reducing hemoglobin (Hb) loss and requirement for transfusion. The bipolar tissue sealant device studied in this trial combines radiofrequency energy with saline irrigation to hemostatically seal both cut bone and soft tissue, potentially aiding hemostasis.Study design and methods
Sixty patients undergoing multilevel posterior lumbar instrumentation and fusion were randomly assigned to unipolar cautery alone (control group) or unipolar cautery plus use of the bipolar tissue sealant device (treatment group). Hb loss from the surgical field was measured (rather than estimated) and compared between the two groups. The primary hypothesis was that the treatment group would lose significantly less Hb than the control group.Results
The control group experienced a mean Hb loss of 102.4 g while the treatment group showed a significantly lower mean Hb loss of 66.2 g (p = 0.0004). No significant difference was found between groups with respect to secondary endpoints including length of surgery, number of red blood cell units transfused, number of total blood component units transfused, transfusion avoidance, length of stay, or serious adverse events.Conclusion
Use of a bipolar tissue sealant device in addition to unipolar cautery significantly decreased Hb loss during multilevel, posterior lumbar spinal instrumentation and fusion when compared with unipolar cautery alone.Item Open Access Clustered clinical findings for diagnosis of cervical spine myelopathy.(The Journal of manual & manipulative therapy, 2010-12) Cook, Chad; Brown, Christopher; Isaacs, Robert; Roman, Matthew; Davis, Samuel; Richardson, WilliamCervical spine myelopathy (CSM) is a clinical diagnosis made with imaging confirmation. At present, most clinical tests used to identify CSM are specific and no clusters of tests have proven more beneficial than stand alone tests in guiding treatment decision making. This study endeavored to produce a cluster of predictive clinical findings for a sample of patients using a clinical diagnosis/imaging confirmation as the reference standard for cervical spine myelopathy. Data from 249 patients with various conditions associated with cervical spine dysfunction were analyzed to determine which clinical tests and measures, when clustered together, were most diagnostic for CSM. Using multivariate regression analyses and calculations for sensitivity, specificity, and positive and negative likelihood ratios, a definitive cluster was identified. Thirteen clinical findings were investigated for capacity to diagnosis CSM. Five clinical: (1) gait deviation; (2) +Hoffmann's test; (3) inverted supinator sign; (4) +Babinski test; and (5) age >45 years, were demonstrated the capacity when clustered into one of five positive tests to rule out CSM (negative likelihood ratio = 0.18; 95% CI = 0.12-0.42), and when clustered into three of five positive findings to rule in CSM (positive likelihood ratio = 30.9; 95% CI = 5.5-181.8). This study found clustered combinations of clinical findings that could rule in and rule out CSM. These clusters may be useful in identifying patients with this complex diagnosis in similar patient populations.Item Open Access Comparison of visually estimated blood loss with direct hemoglobin measurement in multilevel spine surgery.(Transfusion, 2013-11) Guinn, Nicole R; Broomer, Bob W; White, William; Richardson, William; Hill, Steven EBackground
Estimates of blood loss in the operating room are typically performed as a visual assessment by providers, despite multiple studies showing this to be inaccurate. Use of a less subjective measurement of blood loss such as direct measurement of the hemoglobin (Hb) mass lost from the surgical field may better quantify surgical bleeding. The objective of this investigation was to compare anesthesiologist estimates of intraoperative blood loss with measured Hb loss.Study design and methods
Sixty patients undergoing posterior spine surgery were enrolled in a prospective, randomized trial comparing intraoperative blood loss using unipolar cautery alone or with use of a bipolar tissue sealant device. Hb concentration and fluid volume were measured from all surgical sponges, suction canisters, and the cell salvage device. Using the volume and concentration of Hb from each solution allowed calculation of Hb mass, which was converted into volume of blood lost and compared with estimates of blood loss documented by the anesthesia team. A single-sample t test of no difference was used to compare estimated with measured blood loss.Results
Mean estimated blood loss exceeded measured blood loss by 246 mL (860 mL vs. 614 mL, p < 0.0001).Conclusion
Estimated blood loss exceeded measured blood loss by 40% on average. The likely etiology of this discrepancy relates to the inability to visually determine Hb concentration of sanguineous solutions in suction canisters and surgical sponges. Ramifications of excessive bleeding estimates include unnecessary transfusion and overadministration of intravenous fluids, both of which may have deleterious effects.Item Open Access Differences in comorbidities on low back pain and low back related leg pain.(Pain practice : the official journal of World Institute of Pain, 2011-01) Goode, Adam; Cook, Chad; Brown, Christopher; Isaacs, Robert; Roman, Matthew; Richardson, WilliamObjective
Investigate the influence of external factors such as depression and BMI among subjects with primary severe low back pain (LBP) and low back related leg pain (LBLP).Background
The report of disability in patients with LBP may be significantly influenced by confounding and moderating variables. No similar studies have examined the influence of these factors on LBLP.Methods
This study included 1,448 consecutive subjects referred to a tertiary spine clinic. Unconditional binary logistic regression was used to determine the influence of comorbidities on the relationship between self-reported back and leg pain. A change in estimate formula was used to quantify this relationship.Results
Among those subjects with primary LBP the unadjusted odds ratio was 8.58 (95% CI 4.87, 15.10) and when adjusting for BMI, depression and smoking was 5.94 (95% CI 3.04, 11.60) resulting in a 36.7% change due to confounding by these comorbidities. Among those with primary LBLP, the unadjusted odds ratio was 4.49 (95% CI 2.78, 7.27) and when adjusting for BMI and depression was 4.60 (95% CI 2.58, 8.19) resulting in a 1.7% change due to confounding by these comorbidities.Conclusion
The disability statuses of the patients with primary LBP in this study were more significantly affected by comorbidities of BMI, depression and smoking than patients with report of LBLP. However, these comorbidities contribute little to the relationship of primary low back related leg pain and Oswestry scores ≥ 40.Item Open Access Gene Therapy and Spinal Fusion: Systematic Review and Meta-Analysis of the Available Data.(World neurosurgery, 2024-06) Cottrill, Ethan; Pennington, Zach; Sattah, Nathan; Jing, Crystal; Salven, Dave; Johnson, Eli; Downey, Max; Varghese, Shyni; Rocos, Brett; Richardson, WilliamObjective
To analyze the extant literature describing the application of gene therapy to spinal fusion.Methods
A systematic review of the English-language literature was performed. The search query was designed to include all published studies examining gene therapy approaches to promote spinal fusion. Approaches were classified as ex vivo (delivery of genetically modified cells) or in vivo (delivery of growth factors via vectors). The primary endpoint was fusion rate. Random effects meta-analyses were performed to calculate the overall odds ratio (OR) of fusion using a gene therapy approach and overall fusion rate. Subgroup analyses of fusion rate were also performed for each gene therapy approach.Results
Of 1179 results, 35 articles met criteria for inclusion (all preclinical), of which 26 utilized ex vivo approaches and 9 utilized in vivo approaches. Twenty-seven articles (431 animals) were included in the meta-analysis. Gene therapy use was associated with significantly higher fusion rates (OR 77; 95% confidence interval {CI}: [31, 192]; P < 0.001); ex vivo strategies had a greater effect (OR 136) relative to in vivo strategies (OR 18) (P = 0.017). The overall fusion rate using a gene therapy approach was 80% (95% CI: [62%, 93%]; P < 0.001); overall fusion rates were significantly higher in subjects treated with ex vivo compared to in vivo strategies (90% vs. 42%; P = 0.011). For both ex vivo and in vivo approaches, the effect of gene therapy on fusion was independent of animal model.Conclusions
Gene therapy may augment spinal fusion; however, future investigation in clinical populations is necessary.Item Open Access Osteoimmunology: Interactions With the Immune System in Spinal FusionBergin, Stephen; Crutcher, Clifford; Keeler, Carolyn; Rocos, Brett; Haglund, Michael; Guo, H; Gottfried, Oren; Richardson, William; Than, KhoiItem Open Access Patient Dose Comparison for Intraoperative Imaging Devices Used in Orthopaedic Lumbar Spinal Surgery.(Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews, 2018-07-24) Foster, NA; Moore, Bria; Womack, Ronald; Nguyen, Giao; Richardson, William; Yoshizumi, TerryBackground:The aim of this study was to determine the amount of radiation exposure from intraoperative imaging during two-level and four-level lumbar fusions. Methods:Five imaging systems were studied: multidetector CT (MDCT) scanner (CT A); two mobile CT units (CT B and CT C); a C-arm (D); and fluoroscopy (E). Metal oxide semiconductor field effect transistor dosimeters measured doses at 25 organ locations using an anthropomorphic phantom. A fat-equivalent phantom was used to simulate an obese body mass index (BMI). Results:The effective dose (ED) for C-arm D was estimated using commercial software. The ED for others was computed from the measured mean organ doses. EDs for a normal BMI patient, receiving a four-level fusion, are as follows: CT A (12.00 ± 0.30 mSv), CT B (5.90 ± 0.25 mSv), CT C (2.35 ± 0.44 mSv), C-arm D (0.44 mSv), and fluoroscopy E (0.30 ± 0.3 mSv). The rankings are consistent across all three BMI values except CT C and fluoroscopy E, which peaked in the overweight size because of system limitations. The other machines' ED trended with patient BMI. Conclusion:The dose reduction protocols were confirmed according to the manufacturer's specifications. The results of this study emphasize the need for the appropriate selection of the imaging system, especially because the type of device could have a substantial effect on patient radiation risk.Item Open Access Psychological Predictors of Outcomes with Lumbar Spinal Fusion: A Systematic Literature Review.(Physiotherapy research international : the journal for researchers and clinicians in physical therapy, 2017-04) Wilhelm, Mark; Reiman, Michael; Goode, Adam; Richardson, William; Brown, Christopher; Vaughn, Daniel; Cook, ChadPurpose
To review the predictive/risk psychological factors at baseline that are associated with a favourable (or non-favourable) outcome following lumbar spinal fusion (LSF).Methods
A computer-assisted literature search of PubMed, CINAHL complete and EMBASE for studies published between January 1, 1990 and October 1, 2014 with controlled vocabulary and key words related to LSF, degenerative lumbar spine diagnoses and appropriate terms for predictive variables. Each study was required to be a retrospective or prospective design that involved LSF (all forms). Quality assessment was conducted with the Quality In Prognosis Studies tool. A study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO# CRD42014008728).Results
The majority of the eight accepted studies were observational, prospective cohorts (n = 6). High levels of baseline depression and lower SF-36 Mental Component Scores (MCS) lower quality of life were associated with non-favourable outcomes. Two studies were rated as high quality, five were moderate and one study had low quality.Conclusions
At present, there are a number of psychological variables that are associated with a poorer outcome with LSF. Higher levels of depression and lower scores on the SF-36 MCS are the most commonly implicated. However, based on the results of the studies using single arm designs there is not enough evidence to determine which psychological variables are influential in predicting outcomes for LSF. Copyright © 2015 John Wiley & Sons, Ltd.Item Open Access Ropivacaine-Epinephrine-Clonidine-Ketorolac Cocktail as a Local Anesthetic for Lumbar Decompression Surgery: A Single Institutional Experience.(World neurosurgery, 2023-08) Bhenderu, Lokeshwar S; Lyon, Kristopher A; Soto, Jose M; Richardson, William; Desai, Ronak; Rahm, Mark; Huang, Jason HObjective
The goal of this study is to discuss our initial experience with a multimodal opioid-sparing cocktail containing ropivacaine, epinephrine, clonidine, and ketorolac (RECK) in the postoperative management of lumbar decompression surgeries.Methods
Patients were either administered no local anesthetic at the incision site or were administered a weight-based amount of RECK into the paraspinal musculature and subdermal space surrounding the operative site once the fascia was closed. We performed a retrospective chart review of all patients 18 years of age or older undergoing lumbar laminectomy and lumbar diskectomy surgeries between December 2019 and April 2021. Outcomes including total opioid use, measured as morphine milligram equivalent, length of stay, and postoperative visual analog scores for pain, were collected. Relationships between variables were analyzed with Student's t-test, chi-square tests, and Fisher exact tests.Results
A total of 121 patients undergoing 52 lumbar laminectomy and 69 lumbar diskectomy surgeries were identified. For lumbar laminectomy, patients who were administered RECK had decreased opioid use in the postoperative period (11.47 ± 12.32 vs. 78.51 ± 106.10 morphine milligram equivalents, P = 0.019). For patients undergoing lumbar diskectomies, RECK administration led to a shorter length of stay (0.17 ± 0.51 vs. 0.79 ± 1.45 days, P = 0.019) and a lower 2-hour postoperative pain score (3.69 ± 2.56 vs. 5.41 ± 2.28, P = 0.006).Conclusions
The RECK cocktail has potential to be an effective therapeutic option for the postoperative management of lumbar decompression surgeries.Item Open Access Surgical Procedure Characteristics and Risk of Sharps-Related Blood and Body Fluid Exposure.(Infect Control Hosp Epidemiol, 2016-01) Myers, Douglas J; Lipscomb, Hester J; Epling, Carol; Hunt, Debra; Richardson, William; Smith-Lovin, Lynn; Dement, John MOBJECTIVE To use a unique multicomponent administrative data set assembled at a large academic teaching hospital to examine the risk of percutaneous blood and body fluid (BBF) exposures occurring in operating rooms. DESIGN A 10-year retrospective cohort design. SETTING A single large academic teaching hospital. PARTICIPANTS All surgical procedures (n=333,073) performed in 2001-2010 as well as 2,113 reported BBF exposures were analyzed. METHODS Crude exposure rates were calculated; Poisson regression was used to analyze risk factors and account for procedure duration. BBF exposures involving suture needles were examined separately from those involving other device types to examine possible differences in risk factors. RESULTS The overall rate of reported BBF exposures was 6.3 per 1,000 surgical procedures (2.9 per 1,000 surgical hours). BBF exposure rates increased with estimated patient blood loss (17.7 exposures per 1,000 procedures with 501-1,000 cc blood loss and 26.4 exposures per 1,000 procedures with >1,000 cc blood loss), number of personnel working in the surgical field during the procedure (34.4 exposures per 1,000 procedures having ≥15 personnel ever in the field), and procedure duration (14.3 exposures per 1,000 procedures lasting 4 to <6 hours, 27.1 exposures per 1,000 procedures lasting ≥6 hours). Regression results showed associations were generally stronger for suture needle-related exposures. CONCLUSIONS Results largely support other studies found in the literature. However, additional research should investigate differences in risk factors for BBF exposures associated with suture needles and those associated with all other device types. Infect. Control Hosp. Epidemiol. 2015;37(1):80-87.Item Open Access Surgical Team Stability and Risk of Sharps-Related Blood and Body Fluid Exposures During Surgical Procedures.(Infection control and hospital epidemiology, 2016-05) Myers, Douglas J; Lipscomb, Hester J; Epling, Carol; Hunt, Debra; Richardson, William; Smith-Lovin, Lynn; Dement, John MObjective
To explore whether surgical teams with greater stability among their members (ie, members have worked together more in the past) experience lower rates of sharps-related percutaneous blood and body fluid exposures (BBFE) during surgical procedures.Design
A 10-year retrospective cohort study.Setting
A single large academic teaching hospital.Participants
Surgical teams participating in surgical procedures (n=333,073) performed during 2001-2010 and 2,113 reported percutaneous BBFE were analyzed.Methods
A social network measure (referred to as the team stability index) was used to quantify the extent to which surgical team members worked together in the previous 6 months. Poisson regression was used to examine the effect of team stability on the risk of BBFE while controlling for procedure characteristics and accounting for procedure duration. Separate regression models were generated for percutaneous BBFE involving suture needles and those involving other surgical devices. RESULTS The team stability index was associated with the risk of percutaneous BBFE (adjusted rate ratio, 0.93 [95% CI, 0.88-0.97]). However, the association was stronger for percutaneous BBFE involving devices other than suture needles (adjusted rate ratio, 0.92 [95% CI, 0.85-0.99]) than for exposures involving suture needles (0.96 [0.88-1.04]).Conclusions
Greater team stability may reduce the risk of percutaneous BBFE during surgical procedures, particularly for exposures involving devices other than suture needles. Additional research should be conducted on the basis of primary data gathered specifically to measure qualities of relationships among surgical team personnel.Item Open Access Systematic review of diagnostic accuracy of patient history, clinical findings, and physical tests in the diagnosis of lumbar spinal stenosis.(European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2020-01) Cook, Christian Jaeger; Cook, Chad E; Reiman, Michael P; Joshi, Anand B; Richardson, William; Garcia, Alessandra NPurpose
To update evidence of diagnostic potential for identification of lumbar spinal stenosis (LSS) based on demographic and patient history, clinical findings, and physical tests, and report posttest probabilities associated with test findings.Methods
An electronic search of PubMed, CINAHL and Embase was conducted combining terms related to low back pain, stenosis and diagnostic accuracy. Prospective or retrospective studies investigating diagnostic accuracy of LSS using patient history, clinical findings and/or physical tests were included. The risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS 2) tool. Diagnostic accuracy including sensitivities (SN), specificities (SP), likelihood ratios (+LR and -LR) and posttest probabilities (+PTP and -PTP) with 95% confidence intervals were summarized.Results
Nine studies were included (pooled n = 36,228 participants) investigating 49 different index tests (30 demographic and patient history and 19 clinical findings/physical tests). Of the nine studies included, only two exhibited a low risk of bias and seven exhibited good applicability according to QUADAS 2. The demographic and patient history measures (self-reported history questionnaire, no pain when seated, numbness of perineal region) and the clinical findings/physical tests (two-stage treadmill test, symptoms after a March test and abnormal Romberg test) highly improved positive posttest probability by > 25% to diagnose LSS.Conclusion
Outside of one study that was able to completely rule out LSS with no functional neurological changes none of the stand-alone findings were strong enough to rule in or rule out LSS. These slides can be retrieved under Electronic Supplementary Material.Item Open Access The clinical value of a cluster of patient history and observational findings as a diagnostic support tool for lumbar spine stenosis.(Physiotherapy research international : the journal for researchers and clinicians in physical therapy, 2011-09) Cook, Chad; Brown, Christopher; Michael, Keith; Isaacs, Robert; Howes, Cameron; Richardson, William; Roman, Matthew; Hegedus, EricObjective
The study aims to create a diagnostic support tool to indicate the likelihood of the presence of lumbar spinal stenosis (LSS) using a cluster of elements from the patient history and observational findings.Design
The study is case based and case controlled.Setting
The study was performed in the tertiary care of a medical center.Subjects
There were a total of 1,448 patients who presented with a primary complaint of back pain with or without leg pain.Methods
All patients underwent a standardized clinical examination. The diagnosis of LSS was made by one of two experienced orthopaedic surgeons based on clinical findings and imaging. Data from the patient history and observational findings were then statistically analysed using bivariate analysis and contingency tables.Results
The most diagnostic combination included a cluster of: 1) bilateral symptoms; 2) leg pain more than back pain; 3) pain during walking/standing; 4) pain relief upon sitting; and 5) age>48 years. Failure to meet the condition of any one of five positive examination findings demonstrated a high sensitivity of 0.96 (95% CI=0.94-0.97) and a low negative likelihood ratio (LR-) of 0.19 (95% CI=0.12-0.29). Meeting the condition of four of five examination findings yielded a LR+ of 4.6 (95% CI=2.4-8.9) and a post-test probability of 76%.Conclusion
The high sensitivity of the diagnostic support tool provides the potential to reduce the incidence of unnecessary imaging when the diagnosis of LSS is statistically unlikely. In patients where the condition of four of the five findings was present, the post-test probability of 76% suggests that imaging and further workup are indicated. This is an inexpensive but powerful tool, with a potential to increase diagnostic efficiency and reduce cost by narrowing the indications for imaging.Item Open Access The risk of risk-adjustment measures for perioperative spine infection after spinal surgery.(Spine, 2011-04) Goode, Adam P; Cook, Chad; Gill, J Brian; Tackett, Sean; Brown, Christopher; Richardson, WilliamStudy design
Cross-sectional data analysis of the Nationwide Inpatient Sample (NIS).Objective
To develop a risk-adjustment index specific for perioperative spine infection and compare this specific index to the Deyo Comorbidity Index. Assess specific mortality and morbidity adjustments between teaching and nonteaching facilities.Summary of background data
Risk-adjustment measures have been developed specifically for mortality and may not be sensitive enough to adjust for morbidity across all diagnosis.Methods
This condition-specific index was developed by using the NIS in a two-step process to determine confounders and weighting. Crude and adjusted point estimates for the Deyo and condition-specific index were compared for routine discharge, death, length of stay, and total hospital charges and then stratified by teaching hospital status.Results
A total of 23,846 perioperative spinal infection events occurred in the NIS database between 1988 and 2007 of 1,212,241 procedures. Twenty-three diagnoses made up this condition-specific index. Significant differences between the Deyo and the condition-specific index were seen among total charges and length of stay at nonteaching hospitals (P < 0.001) and death, length of stay, and total charges (P < 0.001) for teaching hospitals.Conclusion
This study demonstrates several key points. One, condition-specific measures may be useful when morbidity is of question. Two, a condition-specific perioperative spine infection adjustment index appears to be more sensitive at adjusting for comorbidities. Finally, there are inherent differences in hospital disposition characteristics for perioperative spine infection across teaching and nonteaching hospitals even after adjustment.