Biomedical subjects

John R Dimar

Publications and source records attributed to John R Dimar.

16 recordsLinked to original sources

PubMed2006

Posterolateral lumbar spine fusion with INFUSE bone graft.

BACKGROUND CONTEXT: INFUSE has been proven effective in conjunction with threaded cages and bone dowels for single-level anterior lumbar interbody fusion (ALIF). The published experience with posterolateral fusion, although encouraging, utilizes a significantly higher dose and concentration of recombinant human bone morphogenic protein-2 (rhBMP-2) and a different carrier than the commercially available INFUSE. PURPOSE: To present an assessment of fusion rate for posterolateral spine fusion with INFUSE Bone Graft. STUDY DESIGN/SETTING: Retrospective review of patients treated using INFUSE in posterolateral spine fusion in a single institution. PATIENT SAMPLE: 91 patients with minimum 2-year follow-up who underwent posterolateral spine fusion using INFUSE as an iliac crest bone graft (ICBG) substitute. OUTCOME MEASURES: Fusion rate based on fine-cut computed tomographic (CT) scans with sagittal and coronal reconstructions. METHODS: Fusion was performed using one large INFUSE kit (12 mg rhBMP-2, 1.5 mg/mL), which was prepared according to the manufacturer's instructions. The INFUSE sponge was wrapped around the local bone or graft extender and placed over the decorticated surfaces in the lateral gutters. Postoperative CT scans with reconstructions were reviewed by two independent orthopedic spine surgeons. CT scans of a comparison group of 35 patients who underwent primary single-level posterolateral fusion with ICBG were also reviewed. RESULTS: The overall group had a mean 4.38 CT fusion grade and a 6.6% nonunion rate. Primary one-level fusion cases (n=48) had a mean 4.42 fusion grade a 4.2% nonunion rate. Primary multilevel fusions (n=27) had a mean 4.65 CT grade and no nonunions detected. Assessment of the 35 primary one-level ICBG control cases demonstrated a mean CT grade of 4.35 and a nonunion rate of 11.4%. In the 16 cases of revision for prior nonunion, mean CT grade was 3.81 and 4 subjects had nonunions. Additional subgroup analysis showed that smokers (n=14) had a mean 4.32 CT grade with no nonunions. Men had a mean 4.04 CT grade and an 11.1% nonunion rate compared with a mean 4.61 CT grade and 3.6% nonunion rate in women. This difference was statistically significant (p=.036). No significant differences in fusion rate were observed based upon the specific graft extender used (p=.200). CONCLUSIONS: Posterolateral spine fusion involves a more difficult healing environment with a limited surface for healing, a gap between transverse processes and the milieu of distractive forces. Historically, only ICBG has been able to overcome these challenges and reliably generate a successful posterolateral lumbar spine fusion. In contrast to prior studies, clinically available INFUSE delivers only 12 mg rhBMP-2 at a concentration of 1.5 mg/mL. Despite the lower dose and concentration of rhBMP-2, this study suggests that fusion success with INFUSE is equivalent to ICBG for posterolateral spine fusion. As with ICBG, development of solid fusion or nonunion is a multifactorial process. The use of INFUSE is not a substitute for proper surgical technique or optimization of patient-related risk factors. Additional studies are needed to determine the incremental benefit of a greater rhBMP-2 dose or use of alternative carriers for posterolateral fusion. Finally, correlation between radiographic findings and clinical outcomes, and a cost-benefit analysis are needed. Despite these issues, this study presents compelling evidence that commercially available INFUSE is an effective ICBG substitute for one- and two-level posterolateral instrumented spine fusion.

Adult↗

PubMed2006

Clinical outcomes and fusion success at 2 years of single-level instrumented posterolateral fusions with recombinant human bone morphogenetic protein-2/compression resistant matrix versus iliac crest bone graft.

STUDY DESIGN: This is a prospective, randomized study comparing iliac crest bone graft to bone morphogenetic protein (BMP)/compression resistant matrix in instrumented posterolateral fusions for single-level lumbar degenerative disease. A higher recombinant human bone morphogenetic protein (rhBMP)-2 dose and a carrier specific for posterior spine applications were used. OBJECTIVES: As part of a Food and Drug Administration IDE study, clinical outcomes and fusion rates of single-level instrumented posterolateral fusions using iliac crest bone graft or BMP/compression resistant matrix were evaluated. SUMMARY OF BACKGROUND DATA: Although iliac crest graft is the gold standard for lumbar fusion, alternatives to obviate the morbidity of graft harvest have become available. Randomized clinical trials have demonstrated equivalent fusion rates and clinical outcomes with rhBMP-2 and a collagen sponge versus autograft in anterior lumbar fusions. A human pilot study using rhBMP-2 with biphasic calcium phosphate demonstrated similar results for posterolateral fusions. METHODS: Demographic and perioperative data, Short Form 36, Oswestry Low Back Pain Disability Index, and leg and back pain scores were determined before surgery, and 1.5, 3, 6, 12, and 24 months after surgery. Independent neuroradiologists' evaluation of fine-cut computerized tomography scans with reconstructions were obtained at 6, 12, and 24 months. RESULTS: There were 98 subjects, 45 in the iliac crest bone graft group and 53 in the BMP/compression resistant matrix group. There were no significant differences for age, weight, sex, smoking, or previous surgery between the groups. The average operative time (2.9 hours) and blood loss (465 cc) in the iliac crest bone graft group was greater than in the BMP/compression resistant matrix group (2.4 hours and 273 cc). There were no significant differences in any outcome measure at all time intervals. The fusion rate was lower in the iliac crest bone graft group (73%) than in the BMP/compression resistant matrix group (88%) at P = 0.051. CONCLUSION: There was significant improvement of Short Form 36 (physical component score and pain), Oswestry Low Back Pain Disability Index, and leg and back pain scores in both groups over all time intervals. Surgical time and blood loss were significantly less in the BMP/compression resistant matrix group. The fusion rate in the BMP/compression resistant matrix group was significantly higher than the iliac crest bone graft group.

Bone Morphogenetic Protein 2↗

PubMed2006

Nonsurgical resource utilization in adult spinal deformity.

STUDY DESIGN: The enrollment data were retrospectively reviewed for 1,061 patients entered into a prospective multicenter study of adult spinal deformity between January 2002 and June 2004. OBJECTIVE: The purpose of this study is to quantify and analyze the use of nonsurgical resources in patients with adult spinal deformity. SUMMARY OF BACKGROUND DATA: Limited data exist regarding the utilization of nonsurgical treatment methods for adult spinal deformity. METHODS: Demographic data, surgical history, symptom assessment, and nonsurgical treatment regimen were reviewed. Health status measures were the SF-12, SRS-29, and ODI. Nonsurgical patients were divided into low- and high-symptom subgroups based on age adjusted ODI score. Resource utilization was analyzed based on both patient and physician questionnaire responses. RESULTS: High- and low-symptom nonsurgical subgroups differed significantly on all reported health status measures (P < 0.0001). High-symptom patients used greater resources in terms of narcotics, epidural blocks, and physical agent methods (P < 0.001), analgesics (P < 0.01), pain management referral and bed rest (P < 0.02), strength training, nerve root blocks, and stabilization exercises (P < 0.05). CONCLUSIONS: The results of this study demonstrate that, within the population of adult deformity patients, distinct high- and low-symptom groups exist and can be clearly identified. While high-symptom patients used significantly greater resources, most low-symptom patients used nonsurgical resources as well.

Adult↗

PubMed2006

Lumbar degenerative classification study.

The purpose of this study was to develop and validate a classification of indications for fusion in lumbar degenerative disease. Nineteen spine surgeons reviewed a series of 32 case histories and selected the indication for fusion based on an outlined classification system. To determine the degree of interrater variability, K coefficients were calculated (K for all 32 cases, 0.63). Results from this study show the significant difficulty in classifying the indication for fusion in lumbar degenerative disease. The level of the 19 surgeons' agreement regarding surgical indication was only moderate, despite a study design that eliminated controversial issues of patient and procedure selection. To a significant extent, the difficulty in classifying indication for fusion underlines the importance of the process. If we cannot agree on why a specific patient is selected for fusion, it is then impossible to accurately compare outcomes for a given disease process or surgical technique. For this reason, an ongoing effort to refine nomenclature and classification is necessary.

Adult↗

PubMed2005

The impact of positive sagittal balance in adult spinal deformity.

STUDY DESIGN: This study is a retrospective review of 752 patients with adult spinal deformity enrolled in a multicenter prospective database in 2002 and 2003. Patients with positive sagittal balance (N = 352) were further evaluated regarding radiographic parameters and health status measures, including the Scoliosis Research Society patient questionnaire, MOS short form-12, and Oswestry Disability Index. OBJECTIVES: To examine patients with adult deformity with positive sagittal balance to define parameters within that group that might differentially predict clinical impact. SUMMARY OF BACKGROUND DATA: In a multicenter study of 298 adults with spinal deformity, positive sagittal balance was identified as the radiographic parameter most highly correlated with adverse health status outcomes. METHODS: Radiographic evaluation was performed according to a standardized protocol for 36-inch standing radiographs. Magnitude of positive sagittal balance and regional sagittal Cobb angle measures were recorded. Statistical correlation between radiographic parameters and health status measures were performed. Potentially confounding variables were assessed. RESULTS: Positive sagittal balance was identified in 352 patients. The C7 plumb line deviation ranged from 1 to 271 mm. All measures of health status showed significantly poorer scores as C7 plumb line deviation increased. Patients with relative kyphosis in the lumbar region had significantly more disability than patients with normal or lordotic lumbar sagittal Cobb measures. CONCLUSIONS: This study shows that although even mildly positive sagittal balance is somewhat detrimental, severity of symptoms increases in a linear fashion with progressive sagittal imbalance. The results also show that kyphosis is more favorable in the upper thoracic region but very poorly tolerated in the lumbar spine.

Cohort Studies↗

PubMed2005

Initial fusion rates with recombinant human bone morphogenetic protein-2/compression resistant matrix and a hydroxyapatite and tricalcium phosphate/collagen carrier in posterolateral spinal fusion.

STUDY DESIGN: Prospective, randomized, unblinded study of iliac crest bone graft (ICBG) versus recombinant human bone morphogenetic protein-2/compression resistant matrix (rhBMP-2/CRM)in a posterolateral instrumented fusion procedure. OBJECTIVES: Document initial radiographic characteristics, based on computed tomography, with rhBMP-2/CRM for posterolateral fusion at 6 and 12-month intervals. SUMMARY OF BACKGROUND DATA: As the acceptance of INFUSE bone graft as an ICBG replacement becomes more widespread, surgeons have begun to study applications for rhBMP-2 in posterior spinal fusion. Preclinical studies have examined variables including carrier composition, rhBMP-2 concentration, and rhBMP-2 dose. Pilot studies have been performed with encouraging initial results. METHODS: Patients with single level lumbar degenerative disease were enrolled in a randomized study of ICBG versus rhBMP-2/CRM in a posterolateral instrumented fusion procedure. Computed tomography scans at 6 and 12 months were graded as demonstrating no fusion (grade 1), partial or limited unilateral fusion (grade 2), partial or limited bilateral fusion (grade 3), solid unilateral fusion (grade 4), or solid bilateral fusion (grade 5). RESULTS: At our institution, 74 patients (38 rhBMP-2/CRM, 36 ICBG) reached minimum 1-year follow-up and were included in this analysis. Mean fusion grade (scale1-5) at 6 months after surgery was 4.35 in the rhBMP-2/CRM group versus 3.09 in the ICBG group (P < 0.0001). At 1 year after surgery mean fusion grade was 4.62 in the rhBMP-2/CRM group versus 3.77 in the ICBG group (P < 0.0023). CONCLUSIONS: These early results are encouraging and suggest a more rapid incorporation and development of the fusion mass with rhBMP-2/CRM than iliac crest autograft in a single level posterior instrumented fusion.

Adult↗

PubMed2005

Correlation of radiographic parameters and clinical symptoms in adult scoliosis.

STUDY DESIGN: This study is a retrospective review of the initial enrollment data from a prospective multicentered study of adult spinal deformity. OBJECTIVES: The purpose of this study is to correlate radiographic measures of deformity with patient-based outcome measures in adult scoliosis. SUMMARY OF BACKGROUND DATA: Prior studies of adult scoliosis have attempted to correlate radiographic appearance and clinical symptoms, but it has proven difficult to predict health status based on radiographic measures of deformity alone. The ability to correlate radiographic measures of deformity with symptoms would be useful for decision-making and surgical planning. METHODS: The study correlates radiographic measures of deformity with scores on the Short Form-12, Scoliosis Research Society-29, and Oswestry profiles. Radiographic evaluation was performed according to an established positioning protocol for anteroposterior and lateral 36-inch standing radiographs. Radiographic parameters studied were curve type, curve location, curve magnitude, coronal balance, sagittal balance, apical rotation, and rotatory subluxation. RESULTS: The 298 patients studied include 172 with no prior surgery and 126 who had undergone prior spine fusion. Positive sagittal balance was the most reliable predictor of clinical symptoms in both patient groups. Thoracolumbar and lumbar curves generated less favorable scores than thoracic curves in both patient groups. Significant coronal imbalance of greater than 4 cm was associated with deterioration in pain and function scores for unoperated patients but not in patients with previous surgery. CONCLUSIONS: This study suggests that restoration of a more normal sagittal balance is the critical goal for any reconstructive spine surgery. The study suggests that magnitude of coronal deformity and extent of coronal correction are less critical parameters.

Adolescent↗

PubMed2005

A prospective analysis of intraoperative electromyographic monitoring of posterior cervical screw fixation.

OBJECTIVE: This is a prospective study of 26 patients undergoing posterior cervical spine instrumentation with lateral mass or pedicle screws to determine the correlation between intraoperative screw stimulation thresholds and the position of posterior cervical lateral mass and pedicle screws. METHODS: One hundred forty-seven posterior cervical screws (122 lateral mass screws and 25 C7 pedicle screws) in 26 patients were electrically stimulated intraoperatively and stimulation thresholds recorded. Computed tomography (CT) scans were taken postoperatively and were evaluated independently to assess screw position. Electromyographic (EMG) thresholds and CT data were compared to assess the accuracy of the EMG screw stimulation technique in detecting screw malposition. RESULTS: Intraoperative electrical stimulation was accurate in verifying screw position. A stimulation threshold of 15 mA provided a 99% positive predictive value (89% sensitivity, 87% specificity) that the screw was within the lateral mass or pedicle. Stimulation values of 10-15 mA provided a 13% predictive value (66% sensitivity, 90% specificity) that the screw was within the lateral mass or pedicle. A stimulation value of <10 mA provided a 100% predictive value that the screw was malpositioned (70% sensitivity, 100% specificity). CONCLUSIONS: Intraoperative evoked EMG monitoring is a valuable tool in posterior cervical instrumentation using lateral mass and pedicle screws. Stimulation thresholds in this study correlated with screw position. Stimulation values of >15 mA reliably predict acceptable screw position. Values between 10 and 15 mA are generally associated with acceptable screw position, although exploration is recommended. Values below 10 mA are associated with screw malposition and warrant exploration, repositioning, and possible removal.

Bone Screws↗

PubMed2004

Sagittal alignment of the spine and pelvis during growth.

STUDY DESIGN: Prospective study of the sagittal plane alignment of the spine and pelvis in the normal pediatric population. OBJECTIVES: To document the sagittal alignment of the spine and pelvis and its change during growth in the normal pediatric population. SUMMARY OF BACKGROUND DATA: Pelvic morphology as well as sagittal alignment of the spine and pelvis in the pediatric population are poorly defined in the literature. METHODS: Five parameters were evaluated on lateral standing radiographs of 180 normal study participants 4 to 18 years of age: thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and pelvic incidence. Statistical analysis was performed using two-tailed Student t tests and Pearson's coefficients (level of significance = 0.01). RESULTS: The mean thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and pelvic incidence values were 43.0 degrees, 48.5 degrees, 41.2 degrees, 7.2 degrees and 48.4 degrees, respectively. There was no significant difference between males and females. Thoracic kyphosis, lumbar lordosis, pelvic tilt, and pelvic incidence were found to be weakly correlated with age, while sacral slope remained stable with growth. CONCLUSIONS: Pelvic morphology, as measured by the pelvic incidence angle, tends to increase during childhood and adolescence before stabilizing into adulthood, most likely to maintain an adequate sagittal balance in view of the physiologic and morphologic changes occurring during growth. Pelvic tilt and lumbar lordosis, two position-dependent parameters, also react by increasing with age, most likely to avoid inadequate anterior displacement of the body center of gravity. Sacral slope is achieved with the standing posture and is not further significantly influenced by age. These results are important to establish baseline values for these measurements in the pediatric population, in view of the reported association between pelvic morphology and the development of various spinal disorders such as spondylolisthesis and scoliosis.

Adolescent↗

PubMed2004

Treatment of pyogenic vertebral osteomyelitis with anterior debridement and fusion followed by delayed posterior spinal fusion.

STUDY DESIGN: Case series. OBJECTIVES: The results of surgical treatment of osteomyelitis with anterior debridement and fusion followed by delayed posterior stabilization and fusion are presented. METHODS: Forty-two patients with vertebral osteomyelitis are presented. There were 5 cervical, 12 thoracic, 1 thoracolumbar, 19 lumbar, and 5 lumbosacral lesions. The most frequently identified organism was Staphylococcus aureus. Most patients had significant comorbidities, including diabetes, or were immunocompromised. Ninety percent had elevated erythrocyte sedimentation rates and C-reactive proteins, while white blood cell counts were less reliably elevated. Imaging studies included radiographs, CT scans, and MRIs. All patients were treated with anterior debridement and strut grafting followed by 14.4 days of intravenous antibiotics and delayed instrumented posterior fusions and received 6 weeks of intravenous antibiotics after surgery. RESULTS: All patients had resolution of their infections with no recurrence. There were two deaths. Neurologic deficits resolved in all patients. The diagnosis of pyogenic vertebral osteomyelitis is frequently delayed and presents a significant surgical challenge. The indications for surgical debridement were neurologic compromise, failed medical treatment, soft tissue extension, extensive vertebral body and disc space destruction, and progressive deformity. Many of these patients were severely ill at presentation and required urgent treatment. Anterior debridement and fusion followed by intravenous antibiotics allows for restoration of anterior column support and control of the infection before posterior instrumentation and fusion. CONCLUSION: This study demonstrates that anterior surgical debridement with fusion, followed by a period of intravenous antibiotics and delayed instrumented posterior fusion, is highly effective in the treatment of pyogenic osteomyelitis that has failed medical management.

Adult↗

PubMed2003

Perioperative complications of posterior lumbar decompression and arthrodesis in older adults.

BACKGROUND: Lumbar arthrodesis is commonly done in elderly patients to treat degenerative spine problems. These patients may be at increased risk for complications because of their age and associated medical conditions. In this study, we examined the rates of perioperative complications associated with posterior lumbar decompression and arthrodesis in patients sixty-five years of age or older. METHODS: We reviewed the hospital records of ninety-eight patients who were sixty-five years of age or older when they had a posterior decompression and lumbar arthrodesis with instrumentation, between 1993 and 1995, to treat degenerative disease of the spine. The average age was seventy-two years (range, sixty-five to eighty-four years). RESULTS: Perioperative complications occurred in seventy-eight patients. Twenty-one patients had at least one major complication, and sixty-nine had at least one minor complication. Forty-nine patients had more than one complication. The most common major complication was wound infection (prevalence, 10%), and the most common minor complication was urinary tract infection (prevalence, 34%). The complication rate increased with older age, increased blood loss, longer operative time, and the number of levels of the arthrodesis. CONCLUSIONS: Surgeons should be vigilant about perioperative complications in elderly patients treated with multi-level lumbar decompression and arthrodesis with instrumentation. Elderly patients should be made aware that they are at increased risk for surgical complications because of their age. Attention should be paid to controlling blood loss and limiting operative time.

Aged↗

PubMed2002

Vertebral osteonecrosis associated with the use of intradiscal electrothermal therapy: a case report.

STUDY DESIGN: This report describes a case of vertebral body osteonecrosis associated with the use of intradiscal electrothermal therapy. OBJECTIVES: To alert clinicians to a previously unreported complication, vertebral body osteonecrosis, after an intradiscal electrothermal therapy procedure. SUMMARY OF BACKGROUND DATA: The intradiscal electrothermal therapy procedure is a new treatment that has been advocated in the management of chronic low back pain of discogenic origin. The intradiscal electrothermal therapy procedure uses a fluoroscopically guided thermal catheter to heat the intervertebral disc. A review of the literature regarding this procedure has not revealed osteonecrosis as a complication. METHODS: The patient's work-up and postoperative course are documented, and all medical records were reviewed retrospectively. RESULTS: The patient's pain had improved only minimally at initial follow-up after L5-S1 combined anterior and posterior spinal fusion, undertaken after intradiscal electrothermal therapy failure. CONCLUSIONS: Intradiscal electrothermal therapy has gained increasing popularity in the treatment of discogenic low back pain, in large part because of its minimally invasive nature and perceived low risk for major complications. Previous reports in the literature have not noted any major complications associated with the proper use of this device. Clinicians should be advised that intradiscal electrothermal therapy can be associated with complications, which in the current case, led to osteonecrosis of the vertebral body.

Adult↗

PubMed2002

Evaluation of the fixation and strength of a "rescue" revision pedicle screw.

One potential complication of pedicle screw instrumentation is long-term nerve root irritation, most commonly resulting from medial or inferior screw malpositioning. This study evaluated the pullout strength and fatigue strength properties of a novel "rescue" revision screw designed to reduce the sequelae of medial screw malpositioning by eliminating threads along the section of the screw corresponding to the pedicular region. The results of this study revealed that a rescue screw with threads eliminated from one half of its circumference provided comparable pullout strength to fully threaded pedicle screws in cadaveric specimens. In addition, mechanical testing of the rescue screw did not show a decrease in fatigue strength characteristics compared with controls. These results suggest that the rescue screw may offer a way to decrease nerve root irritation caused by canal impingement without jeopardizing the overall strength of the spinal construct.

Aged↗

PubMed2002

Surgical management of adjacent level degeneration following lumbar spine fusion.

Thirty-eight patients who underwent extension of a prior lumbar fusion for treatment of adjacent level degeneration were retrospectively evaluated. Patient age, pain relief with the initial surgical procedure, and distal level of fusion significantly affected outcome. Overall, this study suggests that adjacent level fusion yields results that are not optimal but provides sigificant clinical improvement for patients with symptomatic adjacent level degeneration.

Adult↗

PubMed2002

Acute calcific discitis in adults.

Acute calcific discitis in the pediatric population is a well-described entity and may rarely involve the adult population. Acute calcific discitis does occur in adults, presenting clinically with the abrupt onset of severe back pain with a classic radiographic calcification of the disc similar to that of a discogram; it resolves with nonsurgical symptomatic treatment. To our knowledge, no cases of "idiopathic" adult calcific discitis have been reported in the orthopedic literature. We report 2 adult patients with symptomatic thoracic disc calcifications that closely resemble those observed in children and briefly discuss the relevant clinical and radiographic features, along with a review of the literature.

Adult↗

PubMedDate not supplied

Perioperative complications of lumbar instrumentation and fusion in patients with diabetes mellitus.

BACKGROUND CONTEXT: Prior studies have documented an increased complication rate in diabetics treated by lumbar decompression. Despite the assumption that this risk would be exacerbated in larger fusion procedures, a recent study found no such increased risk. PURPOSE: To clarify the perioperative risk for patients with diabetes mellitus undergoing instrumented lumbar fusion as compared with controls. To identify differences, if any exist, between patients with insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes (NIDDM). STUDY DESIGN/SETTING: This is a retrospective case-control study designed to examine the risk of perioperative complications in patients with diabetes mellitus treated by lumbar instrumentation and fusion. This study analyzed 94 diabetic patients and 43 controls treated by posterior lumbar instrumentation and fusion. Outcome was assessed based on the occurrence of perioperative complications. Complications were classified as major or minor. METHODS: Hospital and office records were reviewed for 94 diabetics (51 NIDDM, 43 IDDM) and 43 controls matched for age, sex and procedure with the IDDM group. The groups were compared for demographic characteristics, surgical data, perioperative complications and fusion rate. RESULTS: The NIDDM, IDDM and control groups were equivalent with regard to age, gender, nicotine use, fusion levels, operative time and estimated blood loss. There was a significant difference in complication rate between the NIDDM (53%) and IDDM (56%) groups versus controls (21%). There was a significant increase in complications with multilevel fusion in all groups and with increased operative time in the IDDM group. There was a significantly greater nonunion rate in the NIDDM (22%) and IDDM (26%) groups as compared with controls (5%). CONCLUSIONS: Patients with both IDDM and NIDDM have a significantly increased risk of perioperative complications as compared with controls when treated by lumbar instrumentation and fusion.

Adolescent↗