Purpose

Bone morphogenic protein (BMP-2) is used in spinal arthrodesis to induce bone growth. Studies have demonstrated that it achieves similar fusion rates compared to iliac crest bone graft when used in instrumented fusions. Our study aims at evaluating the requirement for instrumentation in one and two-level spinal arthrodeses when BMP-2 is used in conjunction with local bone to achieve fusion.

The referral time for spine surgery consultation in Halifax is approximately one year. We currently do not understand the significance of delay in surgical consultation, nor do we have documentation of patient-perceived effects of this delay. Identifying patient characteristics associated with spine pathology mandating earlier surgical intervention would have obvious benefit in streamlining this population in our referral pattern. Furthermore, outlining patient characteristics who are unlikely to benefit from orthopaedic surgical assessment for spine surgery may facilitate community management of spinal pathology and accordingly improve wait times for surgical consultation.

The aim of this study was to Identify patient variables that are predictive of need for early surgical evaluation. Also, to assess patient and surgeon satisfaction with wait times for consultation.

Demographic data and questionnaires were prospectively collected on all consenting patients seen by two orthopaedic spine surgeons over a two week period. Patient and surgeon impression of wait was documented, in addition to Oswestry Disability Index (ODI) scores, and the Visual Analogue Scale (VAS) to document pain. Surgeon reasons for scheduling or delaying surgical planning were also documented and correlated to patient scores.

The average wait time for surgical consultation was 9.7 months, with a mode of sixteen months. 62.8% of patients felt that earlier consultation would be more appropriate, while 31.1% felt that they had deteriorated due to the delay. In addition, 26% felt that the delay negatively influenced their prognosis. Treating surgeons felt that the patient should have been seen sooner in 39% of cases, and that delay in consultation negatively affected prognosis in 6.2% of cases. Of two hundred and forty-two patients completing the survey over the two week period, only ten (4.1%) were scheduled for surgery.

Both patients and physicians felt that prolonged referral-consultation wait times were unacceptable, and deleteriously affected prognosis in a significant proportion of cases. The majority of patients seen were not deemed surgical candidates, indicating room for improvement in referral patterns.

Background: It has been demonstrated that a relationship exists between pro-inflammatory cytokine levels and psychological distress. Psychological distress commonly co-exists with back pain and may be detrimental to rehabilitation in such patients undergoing surgery. We aim to establish whether a link exists between psychological distress and increased levels of Interleukin- 6 (IL-6) and it’s soluble receptor (sIL-6r) in patients undergoing surgery for low back pain.

Methods: All individuals selected for spinal fusion or stabilisation surgery, in whom low back pain was the predominant feature, were eligible for inclusion. Participants completed both the Distress and Risk Assessment Method (DRAM) and Hospital Anxiety and Depression Score (HADS) questionnaires pre-operatively. Blood samples for serum IL-6, sIL-6r and high sensitivity C-Reactive Protein (CRP) levels were extracted at recruitment and results were compared with questionnaire findings.

Results: 63 patients were recruited of whom 90.5% had some degree of measurable psychological distress. Patients were divided into two groups based upon the degree of their distress.

Mean IL-6 levels were higher in groups of patients with more distress measured by the DRAM and HADS depression component but were lower in patients with more anxiety. IL-6 receptor levels were higher in patients with raised DRAM and HADS anxiety scores.

No significant correlation between questionnaire responses and cytokine levels was found. A correlation exists between IL-6 and CRP levels even at normal levels of CRP.

Conclusion: There does not appear to be a significant relationship between IL-6 and sIL-6r levels and psychological distress in back pain patients.

Preliminary results suggest that a new rhBMP-2 formulation may provide an alternative for autologous bone graft in two-level posterolateral fusions

The purpose of this study was to compare the success of instrumented two level fusions using a new rhBMP-2 formulation versus iliac crest bone graft (ICBG). In this formulation, rhBMP-2 was at a concentration of 2mg/cc in a Biphasic Calcium Phosphate (60% hydroxyapatite/40% tricalcium phosphate) ceramic granule carrier. Twenty-nine patients were enrolled in this multicentered, prospective, randomized study. Either 30cc of rhBMP-2/BCP or fresh ICBG were used. Clinical evaluations were done preoperatively, at discharge and 1.5, three, six, twelve and twenty-four months including Oswestry Disability Index SF36, back pain and leg pain questionnaires. CT scan and xrays were independently assessed at six, twelve, and twenty-four months. Fusion criteria included bilateral bridging trabecular bone on each level, less than 3mm translation, less than five degrees angulation . Seventeen patients received ICBG and twelve received rhBMP-2/BCP. With the use of rhBMP-2 average OR time was reduced from 3.8 to 2.9 hours. Twenty-nine patients (100%) have reached twenty-four month followup. Clinical improvements were similar in both groups, however, fusion success was much improved with the use of rhBMP-2. At twenty-four months all patients receiving rhBMP-2/BCP were fused versus 58% of ICBG patients. These results suggest that rhBMP-2/BCP may have improved fusion success in challenging two level posterolateral fusions as compared to ICBG.