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Objective: Bone morphogenetic protein (BMP) was first approved in 2002 for use in single-level anterior lumbar fusions as an alternative to iliac crest grafts. Subsequent studies have concluded that BMP provides superior fusions rates and therefore reduces reoperations for nonunions. The purpose of this study was to determine the reoperation rates for symptomatic nonunions in posterior cervical (subaxial) spinal fusions with and without the use of BMP and to determine if the nonunion rates are statistically significantly different between the two groups., Methods: Between January 2009 and September 2013, the authors identified 1158 posterior cervical spinal fusion cases in the subaxial spine (C2-7) from a large spine registry (Kaiser Permanente). Patient characteristics, diagnoses, operative times, lengths of stay, and reoperations were extracted from the registry. Reoperations for symptomatic nonunions were adjudicated via chart review. Logistic regression was conducted to produce estimates of odds ratios (OR) and 95% confidence intervals (CIs). Kaplan-Meier curves for the non-BMP and BMP groups were generated and compared using the log-rank test., Results: In this cohort there were 1158 patients (19.3% with BMP) with a median follow up of 1.7 years (interquartile range [IQR] 0.7-2.9 years) and median duration to operative nonunion of 0.63 years (IQR 0.44-1.57 years). Kaplan-Meier curves showed no significant difference in reoperation rates for nonunions using the log-rank test (p = 0.179). In a subset of patients with more than 1 year of follow-up, 788 patients were identified (22.5% with BMP) with a median follow-up duration of 2.5 years (IQR 1.7-3.4 years) and a median time to operative nonunion of 0.73 years (IQR 0.44-1.57 years). There was no statistically significant difference in the symptomatic operative nonunion rates for posterior cervical (subaxial) fusions with BMP compared with non-BMP (1.1% vs. 0.7%; crude OR 1.73, 95% CI 0.32-9.55, p = 0.527) for more than 1 year of follow-up., Conclusions: This study presents the largest series of patients using BMP in posterior cervical (subaxial) spinal fusions. Reoperation rates for symptomatic nonunions with more than 1 year of follow-up were found to be 1.1% with BMP and 0.7% without BMP. There was no significant difference in the reoperation rates for symptomatic nonunions with or without BMP.

Study Design: A retrospective review of instrumented spine registry from an integrated US healthcare system., Objective: Investigate the 30-day readmission rate and risk factors after instrumented spine surgery., Summary of Background Data: Published readmission rates range from 2% to over 20%. We were interested in learning which patients were at greatest risk, when did readmissions occur, and why., Method: 30-day readmission rates were determined for 14,939 patients after an index spine procedure between 1/2009 and 3/2013. Data were analyzed with descriptive statistics, univariate, and multivariate logistic regression analysis., Result: The average age of the cohort was 59 (SD = 13.4) and 52% were female. The 30-day readmission rate was 5.5% (821/14,939). The temporal pattern for readmission was: 17% (140) at week 1, 48% (394) at week 2, 72% (591) at week 3, and 100% (821) at week 4. The leading causes were wound complications (infection, hematoma, dehiscence, seroma), sepsis, pain management, pneumonia, and pulmonary emboli/deep venous thrombosis. In a multivariate model, readmission risk factors were: malignancy (OR 2.99, 95% CI: 1.56, 5.73), operative time more than 400 minutes (OR 2.59, 95% CI: 1.66, 4.02), operative time 300-399 minutes (OR 2.33, 95% CI: 1.54-3.52), hospital stay 6-10 days (OR 2.03, 95% CI: 1.31-3.14), hospital stay more than 10 days (OR 1.85, 95% CI: 1.1, -3.08), surgical complications (OR 1.67, 95% CI: 1.18, 2.36), operative time 200-299 (OR 1.52, 95% CI: 1.04, 2.22), depression (OR 1.48, 95% CI: 1.14, 1.93), rheumatoid arthritis (OR 1.45, 95% CI: 1.05, 2.01), deficiency anemia (OR 1.30, 95% CI: 1.05, 1.61), and hypothyroidism (OR 1.29, 95% CI: 1.01, 1.64)., Conclusion: Surgical complications (dural tear, deep infections, superficial infections, epidural hematoma), malignancy, lengthy operative times, and lengthy initial hospitalizations are all risk factors for 30-day readmission. These findings should be considered during preoperative assessment and surgical planning., Level of Evidence: 3.

Study Design: A retrospective cohort study with medical record review., Objective: To determine if there is difference in the operative nonunion rates with and without the use of bone morphogenetic protein (BMP) after spinal fusions by analyzing data from an integrated health care system's spine registry., Summary of Background Data: BMP was first approved in 2002 for use in single-level anterior lumbar fusions. Follow-up studies have advocated its use in reducing the need for reoperations for nonunions. Recent studies, however, have questioned these conclusions and the usefulness of BMP in spinal fusions has been highly debated., Methods: We identified 9425 spinal fusion cases between 2009 and 2011 from a spine registry in a large integrated health care organization. Patient characteristics, diagnosis, operative times, length of stay, and reoperations were extracted from the registry. Reoperations for nonunions were adjudicated via medical record review. Cox regression models were used to evaluate the risk of reoperation while adjusting for confounders., Results: In our cohort, there were 5456 BMP cases and 3969 non-BMP cases. The mean age was 60.4 years (standard deviation: 12.9 yr), with the majority being females (53%). The median follow-up time was 1.2 years (interquartile range: 0.6-2.0 yr). Reoperation rates for BMP versus non-BMP nonunions for all fusion cases with follow-up of 1 year or more (1.9% vs. 2.2%) and follow-up of 2 years or more (2.3% vs. 2.6%) were not statistically significantly different. Operative nonunion rates did not reach statistical significance for different spine regions and for different fused columns (anterior only, posterior only, or combined). After controlling for differences in patient characteristics, operative times, levels fused, and spinal regions, the risk of reoperation in the BMP versus non-BMP groups was 0.67 (95% CI: 0.42-1.06)., Conclusion: In this large cohort of spinal fusions at all spine regions involving all fused columns with and without BMP, we found no statistically significant difference in operative nonunion rates., Level of Evidence: 3.

Objectives: To assess if hydroxyapatite (HA)-coated titanium pedicle screws exhibit the same electroconductive characteristics as non-HA-coated screws., Methods: Resistance measurements were obtained from a random sampling of 10 HA-coated pedicle screws and 10 non-HA-coated screws, and surgical conditions simulated. Surface resistivity measurements were taken for each screw to determine voltage drop over its entire length., Results: The non-HA-coated screws tested showed low resistive properties and proved to be an ideal conductor of electrical current. The resistive properties associated with the HA-coated pedicle screws were found to be similar to those of commonly used insulators removing the effectiveness of triggered electromyographic responses., Conclusions: Based on test results, these data suggest that the resistance value of the HA-coated screw is large enough to prevent modern Intra-Operative Monitoring (IOM) equipment from delivering the necessary current through the shank of the screw to create a diagnostic electromyographic response. Any response that would be produced would be because of shunting of electric current from the non-coated head of the screw into adjacent tissue and not through the shank of the screw. These study results suggest that HA-coated screws cannot be stimulated to assist in determining the accuracy of pedicle screw placement.

The effects of functional load and muscle force application on isometry of the posterior cruciate ligament were determined. Eight fresh-frozen cadaver knees were mounted in a custom-designed rig. A full range of motion and muscle forces were applied through the quadriceps, hamstring, and gastrocnemius tendons during a simulated static squat maneuver. The low-load isometric posterior cruciate ligament point was located 5.63 mm proximal and 0.18 mm anterior to the anatomic center of the posterior cruciate ligament origin on the femur. The high-load state, with no gastrocnemius and hamstring muscle forces applied, shifted the isometric point 6.32 mm proximal and 6.72 mm anterior (P < 0.05). Loading the hamstring and gastrocnemius muscles also shifted the isometric point (P < 0.05). This study indicated that the most isometric region of the posterior cruciate ligament femoral attachment changed significantly when functional loads and muscle forces were applied to the knee. This finding may have implications for both surgical reconstruction and rehabilitation of the posterior cruciate ligament-injured knee.

If nonoperative management fails to relieve a clearly identifiable and surgically treatable cause of lumbar pain, then surgery may be beneficial. Certain "red flags" indicate the need for urgent or emergent surgical intervention. Low back pain is associated with several degenerative conditions in the lumbar spine, including degenerative disc disease, spinal stenosis, spondylolisthesis, degenerative scoliosis, facet joint syndrome, and disc herniation.