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
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A critical evaluation of existing scientific evidence of treatment efficacy can be an important part of communicating risk and benefits of treatment options to patients during the course of clinical practice. A checklist of key methodological issues to examine when reading a research study is presented and discussed. Steps in reading a paper include: identifying the research question; identifying the manner in which subjects get enrolled in the study; identifying the treatments and outcomes used; identifying the study design and the comparisons being made; evaluating the study methods for the possibility of bias and uncontrolled confounding; assessing whether the statistical analysis used is appropriate for the study design; assessing whether the study has sufficient statistical power to demonstrate hypotheses being tested. Finally, procedures for grading and evaluating evidence, as used by systematic review groups and international best evidence synthesis consensus groups is briefly described.
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Comparative Study
Efficacy and cost effectiveness of harmonic scalpel compared with electrocautery in posterior instrumentation of the spine.
Different methods to reduce blood loss during spinal surgery have been described already. Although the use of the harmonic scalpel (HS), an ultrasonically activated coagulator, has been described in endoscopic spinal surgery, its efficacy in posterior instrumentation of the spine remains unclear. The aim of this study was to determine if blood loss was lower using the HS than electrocauterization (EC) and to evaluate the cost effectiveness of the HS in reducing the need for transfusion in patients undergoing posterior instrumentation of the spine. ⋯ The following were significantly lower with the HS than with EC: (1) blood loss (1106+/-985 ml vs 2176+/-1764 ml, P < 0.001), (2) frequency of cell saver use (13 vs 28 patients, P = 0.001), (3) average cost of blood products (Euro 72 vs Euro 219, P < 0.001), (4) predonation of autologous fresh frozen plasma (2.58+/-2.78 vs 4.5+/-2.2 U, P = 0.002) and red blood cells (0.38+/-0.75 vs 0.88+/-1.1 U, P = 0.009). The overall costs, including the costs for the HS, remained neutral. The use of the HS in posterior spinal surgery leads to significantly lower blood loss, and less need for and cost of blood products, compared to EC in cases with major anticipated blood loss.
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Two cases of intraoperative, iatrogenic cervical spine fractures in patients with ankylosing spondylitis are reported. ⋯ Iatrogenic fractures of the cervical spine during surgery in ankylosing spondylitis patients are a rare but potentially severe complication. Early diagnosis and therapy are necessary before dislocation, cord compression, and subsequent neurologic impairment occur.
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The choice of instruments for the assessment of outcome in spinal surgery is bewildering. For day-to-day practice, however, consideration of the purpose for which information is required allows construction of simple strategies for data collection. Recommendations are made for short and convenient data sets for use in personal audit, clinical governance, benchmarking, patient selection and business planning. No simple data set can measure in detail every aspect of practice, but use of these recommendations will provide information that will be of great value to the spinal surgeon and ultimately to his patients.
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A literature review of the most widely used condition specific, self administered assessment questionnaires for low back pain had been undertaken. General and historic aspects, reliability, responsiveness and minimum clinically important difference, external validity, floor and ceiling effects, and available languages were analysed. ⋯ Of similar importance are the content, wording of questions and answers in each of the six questionnaires and an analysis of the different score results. The issue of score bias is discussed and suggestions are given in order to increase the construct validity in the practical use of the individual questionnaires.