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While ordering the two-view cervical spine X-rays is a routine in evaluating patients with nontraumatic cervical spinal disorders, the anteroposterior (AP) view seems to provide relatively less information than the lateral view. Considering the radiation and cost of the examination, and given that most surgical patients would already have CT and/or MRI available, it is reasonable to examine the utility of the AP view in cervical spine radiography in nontraumatic conditions. This study aims to (a) examine how often the radiological reports of the cervical spine describe findings from an AP view and (b) survey senior spine surgeons nationwide regarding their utilization of the AP view in actual practice. Review of radiological reports using the technique of text-mining, followed by a survey of surgeons. A total of 210 patients diagnosed with nontraumatic cervical spinal disorders at our hospital, and 24 senior spine surgeons nationwide. Percentages of the radiological aspects of the cervical spine that are described in the radiological reports by view (AP vs lateral vs both views), percentages of the surgeons' responses. This study included two parts: a review of radiological reports and a survey of surgeons. In Part 1, radiological reports of the two-view cervical spine radiographs for patients diagnosed with nontraumatic cervical spinal disorders at a tertiary spine center were collected, excluding those with tumor or previous cervical spinal surgery. After the hospital's medical informatics service used programming algorithms to locate the first such radiography of each patient, the radiological reports were reviewed in two steps. Step 1 used the technique of text-mining to obtain 50 most frequently used words in the radiological reports so as to summarize the main radiological aspects of a cervical spine (eg, alignment, disc space, uncovertebral joint, etc.) Then, step 2 identified the source of each radiological aspect's description in the radiological report: Was it from the AP view, the lateral view, or both? For example, a sentence in the radiological report read, "Frontal view demonstrates no significant uncovertebral hypertrophy," and this indicates that this radiological aspect -the uncovertebral joint- was evaluated using the AP view. As another example, a report noted "disc space narrowing at C5-6 with prominent osteophyte." As disc space narrowing is inherently a lateral-view sign, this indicates that both the disc space and the osteophyte here in this report were described using the lateral view. In this way, each radiological aspect of the cervical spine was examined, recorded, and tallied in all of the radiological reports. Then in Part 2, a two-question survey asking surgeons whether they think the AP view is practically useful and why was distributed among a group of 37 senior spine surgeons nationwide, who were from a published survey study on a different topic. A total of 210 radiological reports from 2006 and 2020 were eligible for inclusion. Together, they described 18 radiological aspects of the cervical spine. Of these 18 radiological aspects, 28% (5/18, eg, uncovertebral joint, transverse process) were described exclusively on the AP view, 50% (9/18, eg, lordosis, disc space) were exclusively on the lateral view, and 22% (4/18, eg, fracture, degenerative changes in general) could be from both views. These 18 radiological aspects varied in their frequency of presence in the radiological reports, ranging from disc degeneration (82%, 172/210) to cervical scoliosis (0.5%, 1/210). The AP view was used to describe uncovertebral joint (24%, 51/210), transverse process (3%, 6/210), lung apices (1%, 2/210), and some other signs. Three radiological aspects could be from both the AP and lateral views: alignment in general (81%, 171/210), fracture (53%, 112/210) and degenerative changes in general (26%, 54/210). The survey of surgeons obtained a response rate of 65% (24/37). Among the respondents, 63% (15/24) thought that the AP view is useful, and the reasons included showing deformity or alignment (47%, 7/15), showing facet osteoarthritis (27%, 4/15), showing clavicle or rib for spinal level localization (20%, 3/15) and showing the uncovertebral joints (20%, 3/15), among others. For nontraumatic degenerative cervical spinal disorders, the AP view of the cervical spine radiography provides relatively less information than the lateral view. However, the radiological reports and surgeons' feedback suggest that the AP view is sometimes useful in actual practice. As such, the value of the AP view should be patient-specific and dependent upon whether the AP view is essential for the care of the specific patient. A granular practice guideline regarding when to and when not to order the AP view is needed, and warrants future research. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Traumatic fractures of the spine are most common at the thoracolumbar junction and can be a source of great disability. Purpose: To review the most current information regarding the pathophysiology, injury pattern, treatment options, and outcomes. Study design: Literature review. Methods: Relevant articles, textbook chapters, and abstracts covering thoracolumbar spine fractures with and without neurologic deficit from 1960 to the present were reviewed. Results: The thoracolumbar spine represents a unique system from a skeletal as well as neurological standpoint. The rigid rib-bearing thoracic spine articulates with the more mobile lumbar spine at the thoracolumbar junction (T10 - L2), the site of most fractures. A complete examination includes a careful neurologic examination of both motor and sensory systems. CT scans best describe bony detail while MRI is most efficient at describing soft tissues and neurological structures. The most recent classification system is that of the new Thoracolumbar Injury Classification and Severity Score. The different fracture types include compression fractures, burst fractures - both stable and unstable -, flexion-distraction injuries and fracture dislocations. Their treatment, both operative and non-operative depends on the degree of bony compromise, neurological involvement, and the integrity of the posterior ligamentous complex. Minimally invasive approaches to the care of thoracolumbar injuries have become more popular, thus, the evidence regarding their efficacy is presented. Finally, the treatment of osteoporotic fractures of the thoracolumbar spine is reviewed, including vertebroplasty and kyphoplasty, their risks and controversies, and senile burst fractures, as well. Conclusions: Thoracolumbar spine fractures remain a significant source of potential morbidity. Advances in treatment have minimized the invasiveness of our surgery and in certain stable situations, eliminated it all together. [Copyright &y& Elsevier]

With the aging of society, patients with concurrent degenerative lumbar disorders and hip osteoarthritis, also referred to as the "hip-spine syndrome," are frequently evaluated by both spine and arthroplasty surgeons. The decision-making can be straightforward in many but in others, the optimal treatment order—spine surgery or total hip arthroplasty (THA) first—remains unclear and complicated, especially when neurological deficits are involved. To compare, in spine and arthroplasty surgeons respectively, the treatment order preference among four typical scenarios of hip-spine syndrome with different neurological symptoms. Prospective survey at a professional society level. Eighty-eight experienced spine (37) and total hip arthroplasty (51) surgeons from the Scoliosis Research Society (SRS) and The Hip Society, respectively. Percentage of surgeons, in each specialty, choosing "spine first" in each scenario. Four fictional patients were devised to have concurrent degenerative lumbar disorders and painful hip osteoarthritis, with the primary neurological symptom in each scenario being (a) radicular leg pain, (b) neurogenic claudication, (c) leg weakness, and (d) myelopathy, respectively. A survey with history, physical examination, and radiographs was formulated and sent to clinical members of SRS and The Hip Society soliciting their treatment order preference—spine surgery or THA first—and their rationale. Surgeons' choices, as measured by the percentage choosing "spine surgery first," were compared among the four scenarios and between the two specialties. Text-mining was used to summarize the rationale for decision-making by identifying the most frequently used words in surgeons' comments. Responses were received from 37 (37/100, 37%) spine surgeons and 51 (51/101, 50%) arthroplasty surgeons across North America. In both specialties, the percentage choosing "spine first" varied in the same fashion among the four scenarios. Myelopathy, leg weakness, neurogenic claudication, and radicular pain, in that order, drove the decision-making toward "spine first" (97%, 73%, 46% and 8% of the spine surgeons and 86%, 45%, 33%, and 18% of the arthroplasty surgeons chose "spine first"). Only in the scenario of leg weakness did a significant disparity noted between the two specialties: spine surgeons were more sensitive to weakness than arthroplasty surgeons (73% vs 45% choosing "spine first," P=0.017). In both specialties, text-mining showed that the words that describe the symptoms or pathologies of the neurological deficits, such as "stenosis," "weakness," and "myelopathy," were most frequently used in surgeons' comments in most scenarios except for that of radicular pain. The nature of neurological deficits influences the treatment order preference for hip-spine syndrome in both spine and arthroplasty surgeons, with myelopathy, weakness, neurogenic claudication, and radicular pain, in this order, driving the decision-making toward performing spine surgery first. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Lumbar lateral listhesis has been found to be associated with radicular leg pain in adult scoliosis. This relationship, however, has yet to be specified by making a simple grading/classification system of lateral listhesis that stratifies the risk of leg pain. Such a classification could better alert surgeons of potential involvement of nerve impingement early in the evaluation, especially in such emerging settings as "telehealth" wherein history inquiry and image review may take place separately. To develop and validate a radiographic classification system of lumbar lateral listhesis that stratifies the probability of having radicular leg pain in adult scoliosis. Derivation and validation of a risk-based classification system, at a tertiary university hospital. A total of 294 consecutive adult scoliosis patients enrolled in a retrospective derivation cohort (189 patients) and a prospective validation cohort (105 patients). Odds ratio of the radiological parameters of lumbar lateral listhesis in predicting leg pain, and the percentage of patients with leg pain in each type of lateral listhesis. A radiographic classification of lumbar lateral listhesis was developed using a derivation (retrospective) cohort of consecutive adult scoliosis patients diagnosed at our clinic in 2011-2015. Four radiographic factors of lateral listhesis were put into multivariable logistic regression to identify two most influential predictors of radicular leg pain:(1) L4 lateral listhesis, (2) Nash-and-Moe grade of vertebral rotation at the lowest slipped segment, (3) the number of slipped segments, and (4) the presence of another listhesis superiorly at the thoracolumbar junction contralateral to the main listhesis below.. These four factors were selected based on research evidence and clinical experience, and odds ratio was used to assess their strength of association with the presence of radicular leg pain. The classification was thus made based on the two most influential factors of the four and, then, validated in a prospective cohort of consecutive patients diagnosed in 2016-2018. In the derivation cohort of 189 patients, vertebral rotation ≥ grade 2 (OR=9.5, 95% CI: 3.8-24.6) and the presence of L4 lateral listhesis (OR=4.5, 95% CI: 1.8-12.1) were found to be most strongly associated with the presence of radicular leg pain. The classification of lumbar lateral listhesis was thereby made based on the presence of these two factors: Type 1 (neither of the two factors present), Type 2 (one of two factors present), and Type 3 (both factors present). Additionally, Type 0 was used to describe scoliosis without any lateral listhesis. The prevalence of leg pain varied significantly among the four types: 0% (0/49), 6% (3/47), 34% (25/74), and 68% (13/19) in Type 0, 1, 2, and 3, respectively (P<0.001). Patients with Type 2 or 3 lateral listhesis were more likely than expected to have leg pain. A similar pattern was noted (P=0.64) when validating this classification system in a prospective cohort of 105 consecutive patients: the prevalence of leg pain was 0% (0/21), 17% (4/24), 47% (23/49), and 73% (8/11) in Type 0, 1, 2, and 3, respectively (P<0.001). Still, patients with Type 2 or 3 listhesis were more likely to have leg pain. This classification system of lumbar lateral listhesis can effectively stratify the probability of radicular leg pain in adult scoliosis. Type 2 and Type 3 lateral listhesis should alert physicians of potential nerve impingement early in the evaluation. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Patients undergoing lumbar spine surgery have high rates of preoperative opioid use, which is associated with inferior outcomes and higher risks for opioid dependency postoperatively. Determine whether there are identifiable subgroups of patients that follow distinct patterns in pre- and postoperative opioid dosing. Examine how preoperative patterns in opioid dosing relate to postoperative opioid patterns, opioid cessation, and the risk for adverse events. Retrospective analysis of an administrative claims database (MeritiveTM Marketscan® Research Databases 2007–2015). The 9,768 patients undergoing primary single level lumbar fusion. Primary: daily morphine milligram equivalent (MME) opioid dosing calculated from prescriptions dispensed for 1 year before and after surgery; secondary: 90-day all-cause readmission and complications, 90-day acute postoperative pain, 90-day and 1-year reoperation, surgical costs, length of stay, and discharge disposition. Distinct patient subgroups defined by patterns of daily MME pre- and postoperatively were identified via group-based trajectory modeling. Associations between these groups and outcomes were assessed with multivariable logistic regression with risk adjustment for patient and surgical factors. Among primary single level lumbar fusion patients, 59.5% filled an opioid prescription in the 3 months preceding surgery, whereas 40.5% were opioid naïve (Naïve). Five distinct subgroups of daily MME were identified among those filling opioids preoperatively: (1) Naïve to 3m (21.2% of patients): no opioids until 3 months preoperatively, escalating to 15 MME/day; (2) Low to 3m (11.4%): very low or as needed dose until 3 months preoperatively, escalating to 15 MME/day; (3) 6m Rise (6.9%): no opioids until 6 months preoperatively, escalating to >30 MME/day; (4) Medium (9.8%): increased linearly from 10 to 25 MME/day across the year before surgery; (5) High (10.0%): increased linearly from 60 to >80 MME/day across the year before surgery. These five preoperative opioid groups were related to postoperative opioids filled in a dose-response manner. The two preoperative patient groups with chronic Medium to High -dose opioid dosing were associated with increased adverse events, including all-cause readmission, reoperation, and pneumonia, whereas a low baseline group with a large, earlier preoperative rise in opioid dosing (6m Rise) had increased encounters for acute postoperative pain. Postoperatively, only 9.5% of patients did not fill an opioid prescription. Five distinct postoperative subgroups were identified based on their patterns in daily MME: Two groups ceased filling opioids within the year following surgery (33.6% of patients), and three groups declined in opioid dosage following surgery but plateaued at low (0–5 MME/day, 29.1%), medium (10–15 MME/day, 12.0%), or high (70–75 MME/day), 13.1%) doses by 1 year. Patients within the higher preoperative opioid groups were more likely to belong to the postoperative groups that were unable to cease filling opioids. Identification of a patient's preoperative time trend in daily opioid use may provide significant prognostic value and help guide pain management and risk reduction efforts. III. [ABSTRACT FROM AUTHOR]

Background Context: Exposure to surgical smoke remains a potential occupational health concern to spine operating room personnel. Using a smoke evacuator (local exhaust ventilation) is currently regarded as a primary means of protection, yet few studies have evaluated its utility in actual surgeries.Objective: To examine the utility of two common types of local smoke evacuators, a para incisional evacuator and a smoke evacuation pencil, in reducing surgical smoke exposure in spine surgery.Study Design: A prospective self-controlled study.Patient Sample: After the pre-estimation of sample size, 51 consecutive spine surgeries (25 and 26 patients using the para incisional smoke evacuator and the smoke evacuation pencil, respectively) were enrolled between February 2018 and March 2019.Outcome Measures: Two outcome measures were used to evaluate the level of surgical smoke exposure, which was defined as the concentration of ultrafine smoke particles in the air (number of particles per cm3, ppc) around the operating table: (a) the average smoke level was the arithmetic mean of all measurements recorded during the surgery; and (b) the peak smoke level was the highest measurement recorded.Methods: Consecutive surgeries that involved bilateral symmetrical surgical exposure of the spine via a posterior midline incision were evaluated. Cauterized smoke was evacuated by two smoke evacuators: a "para incisional evacuator," which used a flat broad suction pad positioned immediately adjacent to the incision (25 patients), and a "surgical smoke evacuation pencil" which is an incorporated part of the electrocautery (26 patients). The level of smoke exposure was measured separately when surgically exposing the two sides of the spine: starting with one side (determined randomly) with the smoke evacuator being turned on and, then, the other side with the smoke evacuator off. The results were compared between the two sides.Results: The para incisional smoke evacuator significantly reduced the average smoke level by an average of 59.7% (287 [interquartile range {IQR}: 126, 526] vs. 1,177 [IQR: 395, 2,702], p<.001). The surgical smoke evacuation pencil also reduced the average smoke level by an average of 44.1% (917 [IQR: 448, 1936] vs. 1,605 [IQR: 775, 4,280], p<.001). Both evacuators significantly reduced peak smoke levels as well.Conclusions: This study provides evidence supporting the utility of local smoke evacuation in reducing surgical smoke exposure in spine surgery. Such technology may help to improve the occupational health protection for spine operating room workers. [ABSTRACT FROM AUTHOR]

Background: Understanding patient-specific trends in costs and healthcare resource utilization (HCRU) surrounding lumbar spine surgery is critically needed to better inform surgical decision making and the development of targeted interventions.Purpose: 1) Identify subgroups of patients following distinct patterns in direct healthcare payments pre- and postoperatively, 2) determine whether these patterns are associated with patient and surgical factors, and 3) examine whether preoperative payment patterns are related to postoperative payments, healthcare resource utilization (HCRU), and adverse events.Study Design/setting: Retrospective analysis of an administrative claims database (IBM Marketscan Research Databases 2007-2015).Patient Sample: Adults undergoing primary single-level decompression surgery for lumbar stenosis (n=12,394).Outcome Measures: Direct healthcare payments, HCRU payments (15 categories), 90-day complications and all-cause readmission, 2-year reoperation METHODS: Group-based trajectory modeling is an application of finite mixture modeling that is able to identify meaningful subgroups within a population that follow distinct developmental trajectories over time. We used this technique to identify subgroups of patients following distinct profiles in preoperative direct healthcare payments. A separate analysis was performed to identify distinct profiles in payments postoperatively. Patient and surgical factors associated with these payment profiles were assessed with multinomial logistic regression, and associations with adverse events were assessed with risk-adjusted multivariable logistic regression.Results: We identified 4 preoperative patient payment subgroups following distinct profiles in payments: Pre-Low (5.8% of patients), Pre-Early-Rising (4.8%), Pre-Medium (26.1%), and Pre-High (63.3%). Postoperatively, 3 patient subgroups were identified: Post-Low (8.9%), Post-Medium (29.6%), and Post-High (61.4%). Patients following the higher-cost pre- and postoperative payment profiles were older, more likely female, and had a greater physical and mental comorbidity burden. With each successively higher preoperative payment profile, patients were increasingly likely to have high postoperative payments, use more HCRU (particularly high-cost services such as inpatient admissions, ER, and SNF/IRF care), and experience postoperative adverse events. Following risk adjustment for patient and surgical factors, patients following the Pre-High payment profile had 209.5 (95% CI: 144.2, 309.7; p<.001) fold greater odds for following the Post-High payment profile, 1.8 (1.3, 2.5; p=.003) fold greater odds for 90-day complications, and 1.7 (1.2, 2.6; p=.035) fold greater odds for 2-year reoperation relative to patients following the Pre-Low payment profile.Conclusions: There are identifiable subgroups of patients who follow distinct profiles in direct healthcare payments surrounding lumbar decompression surgery. These payment profiles are related to patient age, sex, and physical and mental comorbidities. Notably, preoperative payment profiles may provide prognostic value, as they are associated with postoperative costs, HCRU, and adverse events.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Background context Allogeneic blood transfusions have an immunomodulating effect, and the previous studies in other fields of medicine demonstrated an increased risk of infections after administration of allogeneic blood transfusions. Purpose Our primary null hypothesis is that exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery is not associated with postoperative infections after controlling for patient and treatment characteristics. Second, we assessed if there was a dose-response relationship per unit of blood transfused. Study design/Setting This is a retrospective cohort study from a tertiary care spine referral center. Patient Sample A total of 3,721 patients underwent laminectomy and/or arthrodesis of the lumbar spine. Outcomes measures Postoperative infections, pneumonia, endocarditis, meningitis, urinary tract infection, central venous line infection, surgical site infection, and sepsis, within 90 days after lumbar spine surgery were included. Methods Multivariable logistic regression analyses were used to assess the relationship of perioperative allogeneic blood transfusion with specific and overall postoperative infections accounting for age, duration of surgery, duration of hospital stay, comorbidity status, preoperative hemoglobin, sex, type of operation, multilevel treatment, operative approach, and year of surgery. Results The adjusted odds ratio for exposure to allogeneic blood transfusion from multivariable logistic regression analysis was 2.6 for any postoperative infection (95% confidence interval [CI]: 1.7–3.9, p<.001); 2.2 for urinary tract infections (95% CI: 1.3–3.9, p=.004); 2.3 for pneumonia (95% CI: 0.96–5.3, p=.062); and 2.6 for surgical site infection requiring incision and drainage (95% CI: 1.3–5.3, p=.007). Secondary analyses demonstrated no dose-response relationship between the number of blood units transfused and any of the postoperative infections. Because of the low number of endocarditis (1 case, 0.031%), meningitis (1 case, 0.031%), central venous line infection (1 case, 0.031%), and sepsis (14 cases, 0.43%), we abstained from multivariable analysis. Conclusions Conscious of the limitations of this retrospective study, our data suggest an increased risk of surgical site infection, urinary tract infection, and overall postoperative infections, but not pneumonia, after exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery. These findings should be taken into account when considering blood transfusion and developing transfusion policies for patients undergoing lumbar spine procedures. [ABSTRACT FROM AUTHOR]

Background Context: Improved understanding of the pre- and postoperative trends in costs and healthcare resource utilization (HCRU) is needed to better inform patient expectations and aid in the development of strategies to minimize the significant healthcare burden associated with lumbar spine surgery.Purpose: Examine the time course of costs and HCRU in the 2 years preceding and following elective lumbar spine surgery for stenosis in a large national claims cohort.Study Design/setting: Retrospective analysis of an administrative claims database (IBM® Marketscan® Research Databases 2007-2015).Patient Sample: Adult patients undergoing elective primary single-level lumbar surgery for stenosis with at least 2 years of continuous health plan enrollment pre- and postoperatively.Outcome Measures: Functional measures, including monthly rates of HCRU (15 categories), monthly gross covered payments (including payments made by the health plan and deductibles and coinsurance paid by the patient) overall, by HCRU category, and by spine versus non-spine-related.Methods: All available patients were utilized for analysis of HCRU. For analysis of payments, only patients on noncapitated health plans providing accurate financial information were analyzed. Payments were converted to 2015 United States dollars using the medical care component of the consumer price index. Trends in payments and HCRU were plotted on a monthly basis pre- and post-surgery and assessed with regression models. Relationships with demographics, surgical factors, and comorbidities were assessed with multivariable repeated measures generalized estimating equations.Results: Median monthly healthcare payments 2 years prior to surgery were $275 ($22, $868). Baseline HCRU at 2 years preoperatively was stable or only gradually rising (office visits, prescription drug use), but began an increasingly steep rise in many categories 6 to 12 months prior to surgery. Monthly payments began an increasingly steep rise 6 months prior to surgery, reaching a peak of $1,402 ($634, $2,827) in the month prior to surgery. This was driven by an increase in radiology, office visits, PT, injections, prescription medications, ER encounters, and inpatient admissions. Payments dropped dramatically immediately following surgery. Over the remainder of the 2 years, the median total payments declined only slightly, as a continued decline in spine-related payments was offset by gradually increased non-spine related payments as patients aged. By 2 years postoperatively, the percentage of patients using PT and injections returned to within 1% of the baseline levels observed 2 years preoperatively; however, spine-related prescription medication use remained elevated, as did other categories of HCRU (radiology, office visits, lab/diagnostic services, and also rare events such as inpatient admissions, ER encounters, and SNF/IRF). Patients with a fusion component to their surgeries had higher payments and HCRU preoperatively, and this did not resolve postoperatively. Variations in payments and HCRU were also evident among plan types, with patients on comprehensive medical plans-predominantly employer-sponsored supplemental Medicare coverage-utilizing more inpatient, ER, and inpatient rehabilitation & skilled nursing facilities. Patients on high-deductible plans had fewer payments and HCRU across all categories; however, we are unable to distinguish whether this is because they used fewer of these services or if they were paying for these services out of pocket without submitting to the payer. By 2 years postoperatively, 51% of patients had no spine-related monthly payments, while 33% had higher and 16% had lower monthly payments relative to 2 years preoperatively.Conclusions: This is the first study to characterize time trends in direct healthcare payments and HCRU over an extended period preceding and following spine surgery. Differences among plan types potentially highlight disparities in access to care and plan-related financial mediators of patients' healthcare resource utilization. [ABSTRACT FROM AUTHOR]

Background Context: Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain.Purpose: This study sought to determine: (1) the proportion of patients having surgery following CESI, and (2) the timing of and factors associated with subsequent surgery.Study Design: Retrospective analysis of a large, national administrative claims database.Patient Sample: The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof.Outcome Measures: The primary outcome was the time from index CESI to surgery.Methods: Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year before CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models.Results: Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35 to 54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery.Conclusions: Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making. [ABSTRACT FROM AUTHOR]

Background Context: It is recognized that radiological parameters of type 2 dens fractures, including displacement and angulation, are predictive of treatment outcomes and are used to guide surgical decision-making. The reproducibility of such measurements, therefore, is of critical importance. Past literature has shown poor interobserver reliability for both displacement and angulation measurements of type 2 dens fractures. Since such studies however, various advancements of radiological review systems and measurement tools have evolved to potentially improve such measurements.Purpose: To re-examine the inter-rater reliability of measuring displacement and angulation of type 2 dens fractures using modern radiological review systems. Besides quantitative measurements, the reliability of raters in identifying diagnostic classifications based on translational and angulational displacement was also examined.Study Design: Radiographic measurement reliability and agreement study.Patient Sample: Thirty-seven patients seen at a single institution between 2002 and 2017 with primary diagnosis of acute type 2 dens fracture with complete computed tomography (CT) imaging.Outcome Measures: Radiological measurements included displacement and angulation. Diagnostic classifications based on consensus-based clinical cutoff points were also recorded.Methods: Measurements were performed by five surgeons with varying years of experience in spine surgery using the hospital's electronic medical record radiological measuring tools. The radiological measurements included displacement and angulation. Diagnostic classifications based on consensus-based clinical cutoff points were also recorded. Each rater received a graphic demonstration of the measurement methods, but had the autonomy to select a best cut from the sagittal CT to measure. All raters were blinded to patient information.Results: Measurements for displacement and angulation among the five raters demonstrated "excellent" reliability. Intra-rater reliability was also "excellent" in measuring displacement and angulation. The reliability of diagnostic classification of displacement (above vs. below 5 mm), was found to be "very good" among the raters. The reliability of diagnostic classification of angulation (above vs. below 11°) demonstrated "good" reliability.Conclusions: Advancement of radiological review systems, including review tools and embedded image processing software, has facilitated more reliable measurements for type 2 odontoid fractures. [ABSTRACT FROM AUTHOR]

Background Context: Lumbosacral epidural steroid injections (ESIs) have increased dramatically despite a narrowing of the clinical indications for use. One potential indication is to avoid or delay surgery, yet little information exists regarding surgery rates after ESI.Purpose: The purpose of this research was to determine the proportion of patients having surgery after lumbar ESI for disc herniation or stenosis and to identify the timing and factors associated with this progression.Study Design/setting: This study was a retrospective review of nationally representative administrative claims data from the Truven Health MarketScan databases from 2007 to 2014.Patient Sample: The study cohort was comprised of 179,025 patients (54±15 years, 48% women) having lumbar ESIs for diagnoses of stenosis and/or herniation.Outcome Measures: The primary outcome measure was the time from ESI to surgery.Methods: Inclusion criteria were ESI for stenosis and/or herniation, age ≥18 years, and health plan enrollment for 1 year before ESI to screen for exclusions. Patients were followed longitudinally until they progressed to surgery or had a lapse in enrollment, at which time they were censored. Rates of surgery were assessed with the Kaplan-Meier survival curves. Demographic and treatment factors associated with surgery were assessed with multivariable Cox proportional hazard models. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work.Results: Within 6 months, 12.5% of ESI patients underwent lumbar surgery. By 1 year, 16.9% had surgery, and by 5 years, 26.1% had surgery. Patients with herniation had surgery at rates of up to five-fold to seven-fold higher, with the highest rates of surgery in younger patients and those with both herniation and stenosis. Other concomitant spine diagnoses, male sex, previous tobacco use, and residence a rural areas or regions other than the Northeastern United States were associated with higher surgery rates. Medical comorbidities (previous treatment for drug use, congestive heart failure, obesity, chronic obstructive pulmonary disease, hypercholesterolemia, and other cardiac complications) were associated with lower surgery rates.Conclusions: In the long term, more than one out of every four patients undergoing ESI for lumbar herniation or stenosis subsequently had surgery, and nearly one of six had surgery within the first year. After adjusting for other patient demographics and comorbidities, patients with herniation were more likely have surgery than those with stenosis. The improved understanding of the progression from lumbar ESI to surgery will help to better inform discussions regarding the value of ESI and aid in the shared decision-making process. [ABSTRACT FROM AUTHOR]

Background Context: Neuroforaminal stenosis is one of the key factors causing clinical symptoms in patients with cervical radiculopathy. Previous quantitative studies on the neuroforaminal dimensions have focused on measurements in a static position. Little is known about dimensional changes of the neuroforamina in the cervical spine during functional dynamic neck motion under physiological loading conditions.Purpose: This study aimed to investigate the in vivo dimensional changes of the neuroforamina in human cervical spine (C3-C7) during dynamic flexion-extension neck motion.Study Design: A case-control study was carried out.Methods: Ten asymptomatic subjects were recruited for this study. The cervical spine of each subject underwent magnetic resonance image scanning for construction of three-dimensional (3-D) vertebrae models from C3 to C7. The cervical spine was then imaged using a dual fluoroscopic system while the subject performed a dynamic flexion-extension neck motion in a sitting position. The 3-D vertebral models and the fluoroscopic images were used to reproduce the in vivo vertebral motion. The dimensions (area, height, and width) were measured for each cervical neuroforamen (C3/C4, C4/C5, C5/C6, and C6/C7) in the following functional positions: neutral position, maximal flexion, and maximal extension. Repeated measures analysis of variance and post hoc analysis were used to examine the differences between levels and positions.Results: Compared with the neutral position, almost all dimensional parameters (area, height, and width) of the subaxial cervical neuroforamina decreased in extension and increased in flexion, except the neuroforaminal area at C5/C6 (p=.07), and the neuroforaminal height at C6/C7 (p=.05) remained relatively constant from neutral to extension. When comparisons of the overall change fromextension to flexion were made between segments, the overall changes of the neuroforaminal area and height revealed no significant differences between segments, and the width overall change of the upper levels (C3/C4 and C4/C5) was significantly greater than the lower levels (C5/C6 and C6/C7) (p<.01).Conclusions: The dimensional changes of the cervical neuroforamina showed segment-dependent characteristics during the dynamic flexion-extension. These data may have implications for diagnosis and treatment of patients with cervical radiculopathy. [ABSTRACT FROM AUTHOR]

Background context Previous studies have reported position-dependent changes of the lumbar intervertebral foramen (LIVF) dimensions at different static flexion-extension postures. However, the changes of the LIVF dimensions during dynamic body motion have not been reported. Purpose The objective of this study was to investigate the in vivo dimensions of the LIVF during a dynamic weight-lifting activity. Study design/Setting This was a retrospective study. Methods Ten asymptomatic subjects were recruited for this study. Three-dimensional (3D) vertebral models of the lumbar segments from L2 to S1 were constructed for each subject using magnetic resonance images. The lumbar spine was then imaged using a dual fluoroscopic imaging system as the subject performed a dynamic weight-lifting activity from an upper body position of 45° to a maximal extension position. The in vivo positions of the vertebrae along the motion path were reproduced using the 3D vertebral models and the fluoroscopic images. The minimal area, height, and width of each LIVF during the dynamic body motion were analyzed. Results The LIVF area and width monotonically decreased with lumbar extension at all levels except L5–S1 (p<.05). On average, the LIVF area decreased by 7.4±6.7%, 10.8±7.7%, and 10.0±8.0% at the L2–L3, L3–L4, and L4–L5 levels, respectively, from the flexion to the upright standing position, and by 6.4±5.0%, 7.7±7.4%, and 5.1±5.1%, respectively, from the upright standing to the extension position. The LIVF height remained relatively constant at all segments during the dynamic activity. The foramen area, height, and width of the L5–S1 remained relatively constant throughout the activity. Conclusions Human lumbar foramen dimensions show segment-dependent characteristics during the dynamic weight-lifting activity. [ABSTRACT FROM AUTHOR]

Background context The notion that all patients with spinal epidural abscess (SEA) require surgical decompression has been recently challenged by reports of successful medical management of select patients with SEA. Purpose The purpose of this study was to identify the independent variables that determine success or failure of medical management of SEA. Study design/setting This was a retrospective, case-control study. Patient sample Patients 18 years or older with diagnosis of SEA admitted to our institution during the study period were included in the sample. Outcome measures The outcome measure was successful management of SEA by eradication of the infection without worsening of neurologic deficits. Methods All patients admitted to our health-care system with a diagnosis of SEA from 1993 to 2011 were identified and the data were retrospectively collected. Patients 18 years or older diagnosed with SEA were included. Excluded were those with postsurgical SEA or phlegmon without an abscess and those with a complete spinal cord injury from SEA for longer than 48 hours. Results A total of 355 patients with average age of 60 years met our inclusion criteria. Of the patients who initially underwent nonoperative treatment, 54 patients failed medical management and 73 patients were successfully treated without surgery. Univariate and multivariate analysis identified incomplete or complete spinal cord deficits as the most significant risk factor for failure of medical management. Age older than 65 years, diabetes, and methicillin-resistant Staphylococcus aureus (MRSA) were also independent risk factors for failure. An algorithm for probability of failed antibiotic management of spinal epidural abscess predicted 99% probability of failure for patients with all four of these risk factors. Conclusions SEA treated with medical management alone has a very high risk for failure if the patient is older than 65 years with diabetes, MRSA infection, or neurologic compromise. In the absence of these risk factors, nonoperative management of spinal epidural abscess may be considered as the initial line of treatment with close monitoring. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Lumbar degenerative spondylolisthesis (DS), typically characterized by the forward slippage of the superior vertebra of a lumbar motion segment, is a common spinal pathological condition in elderly individuals. Significant deformation and volume changes of the spinal canal can occur because of the vertebral slippage, but few data have been reported on these anatomic variations in DS patients. Whether to restore normal anatomy, such as reduction of the slippage and restoration of disc height, is still not clear in surgery. Purpose: This study was designed to determine the volume change of the spinal canal and detect specific anatomic factors affecting the spinal canal volume in DS patients. Study design/setting: A case-control study. Methods: Nine asymptomatic volunteers (mean age 54.4) and 9 patients with L4/L5 DS (mean age 73.4) were recruited. All patients had intermittent claudication and different extent low back pain, and two patients also had leg pain. L4/L5 vertebral motion segment unit of each subject was reconstructed using three-dimensional computed tomography or magnetic resonance images in a solid modeling software. In vivo lumbar vertebral motion during functional postures (supine, standing upright, flexion, and extension) was determined using a dual fluoroscopic imaging technique. The volume of the spinal canal was measured at each functional posture. Various anatomic parameters (disc height, cross-sectional area of the canal, left-right diameter of the canal, anterior-posterior diameter of the canal, slippage, posture, intervertebral disc angle [DA], etc.) that may potentially affect the canal volume were also measured, and their correlations with the volume change of spinal canal were analyzed. This study was funded by a 2-year, $275,000 grant from the National Institutes of Health. Results: On average, spinal canal volume was larger at supine and flexion postures than at stand and extension postures in both the DS and the asymptomatic groups. Spinal canal volume of the DS patients were significantly lower than that of the asymptomatic subjects under all the four postures (p<.05). Correlation analysis showed that spinal canal volume was strongly affected by the posterior disc height (Pearson correlation coefficient γb=0.822) and the slippage percentage (γb=−0.593) and moderately affected by the anterior disc height (γb=0.300) and the DA (γb=−0.237). Conclusions: The volume of spinal canal is affected by multiple factors. Increased spinal canal volume at supine and flexion positions may explain the clinical observations of relief of symptoms at these postures in DS patients. The data also suggest that reduction of slipped vertebral body, decrease of DA, intervertebral distraction, and decompression could all be effective to increase the canal volume of DS patients thus to relieve clinical symptoms. [Copyright &y& Elsevier]

Abstract: Background context: Increased fusion rates have been reported with the addition of an anterior cervical plate (ACP) to anterior cervical discectomy and fusion (ACDF). Bioabsorbable implants have become increasingly used in orthopedic and spine surgical procedures. There are limited data regarding the outcomes of bioabsorbable ACP (bACP) with ACDF. Purpose: To compare the clinical and radiographic outcomes of patients undergoing ACDF for single-level degenerative disorders with a bACP versus a conventional metal ACP (mACP). Study design: Retrospective comparative cohort study. Patient sample: Thirty-one patients undergoing ACDF for a single-level degenerative disorder (ie, disc herniation or spondylotic neural compression). Outcome measures: Incidence of early (within 2 weeks) complications, postoperative sagittal alignment, Odom’s criteria, and pseudarthrosis rate. Methods: The authors retrospectively reviewed the results of a consecutive series of patients undergoing ACDF for symptomatic single-level disc herniation or spondylotic neural compression with either a bACP or an mACP over a 3-year period. Operative notes, clinical charts, and radiographs were analyzed. Radiographic outcomes were assessed for intersegmental alignment, graft subsidence, fusion rate, prevertebral soft-tissue shadow, and graft containment. Clinical outcome was evaluated by Odom’s criteria. Results: Fourteen patients underwent ACDF with a bACP and 15 with an mACP. Radiographic outcomes at the most recent follow-up demonstrated pseudarthrosis in 4 of 14 patients (29%) in the bACP group and 0 of 15 patients in the mACP group. Graft extrusion and anterior displacement was present in three of four pseudarthroses (75%). Comparing preoperative and final radiographs, cervical lordosis was maintained at the operative segment in only 3 of 14 bACP patients (21%) compared with 8 of 15 patients (53%) in the mACP group. The mean Cobb angle was 2.4°±1.9° lordosis in the mACP group and −2.7°±2.5° kyphosis in the bACP group (p=.12). In the mACP group, 14 of 15 patients had good or excellent results. In the bACP group, only 7 of 14 patients had good or excellent results. Conclusions: Bioabsorbable ACP fixation was associated with a high rate of graft extrusion and early loss of intersegmental cervical alignment. Inferior clinical outcomes were observed in patients in the bACP group compared with the mACP group. Based on these findings, continued use of the bACP used in this study cannot be recommended. [Copyright &y& Elsevier]

Abstract: Background context: Several reports indicate that patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) have increased mortality after cervical spine fractures. However, outcomes of the fractured hyperostotic cervical spine are incompletely described, and there are limited data regarding the covariable effects of patient age and medical comorbidities on mortality. Purpose: To determine mortality associated with cervical fractures in patients with hyperostotic disease. Study design: Retrospective case-control study. Patient sample: Forty-three patients identified through a registry as having fractures of the cervical spine in the setting of hyperostotic disease. These patients were matched to 43 controls who did not carry the diagnosis of hyperostotic disease. Outcome measures: Mortality at 3 months and 1, 2, and 3 years after fracture. Methods: An institutional database was used to identify all cervical fractures sustained by patients aged 65 years and older from 1991 to 2006. Demographic information, date of injury, associated injuries, treatment type, presence of AS or DISH, and comorbidities were abstracted from medical records and radiographs. Mortality was ascertained using the National Death Index. Patients with AS or DISH were matched to controls who did not carry the diagnosis of hyperostotic disease. Risks of mortality were calculated at 3 months, 1 year, 2 years, and 3 years. Kaplan–Meier methods, logistic regression analysis, the two independent sample t test, and the Fisher exact test were used to compare mortalities between the two groups. Statistical significance was determined as p values <.05. Results: Forty-three patients were identified as having fractures in the setting of hyperostotic disease of the cervical spine. Twenty-seven individuals had DISH, and 16 had AS. The average age of both the study group and controls was 80 years, with an age range of 68 to 94. There was no significantly increased risk of mortality between the overall study group and control group at 3 months (p=.20), 1 (p=.22), 2 (p=.15), or 3 years (p=.50) after injury. Compared with controls, subgroup analysis of patients with AS showed a statistically increased risk of mortality at 3 months (p<.01) and at 1 and 2 years (p<.01 at both time points). When compared with individuals with DISH, those with AS had an increased risk of mortality at time points up to 2 years after fracture. Patients with DISH did not have an increased mortality risk at any time point when compared with controls. Conclusions: The effect of fracture on mortality appears to be greatest in those with AS. Patients with DISH did not demonstrate an increased risk of mortality compared with age- and sex-matched controls. Future studies of patients with hyperostotic disease should analyze patients with DISH and AS separately instead of as a single homogenous group. Level of evidence: Level IV. [Copyright &y& Elsevier]

There are few prior reports of acute failures of pelvic instrumentation. To report the incidence and risk factors for an under-reported cause of early revision surgery in adult spinal deformity. Multicenter retrospective cohort. Thirteen academic medical centers performed a retrospective review of 18 months of consecutive adult spinal fusions extending 3 or more levels which included new pelvic screws placed at the time of surgery. Acute pelvic fixation failure was defined as occurring within 6 months of the index surgery and requiring surgical revision. A univariate analysis was conducted to compare those patients with and without failure. In an attempt to control for confounders, a subsequent multivariate analysis was conducted which included all variables from the univariate results with a p>0.1. Failure occurred in 38 of 779 cases (5%), and consisted of either slippage of the rods or displacement of the set screws from the screw tulip head, screw shaft fracture, screw loosening, and/or resultant kyphotic fracture of the sacrum. Reported revision strategies utilized placing new pelvic fixation, and/or multiple rod constructs spanning to the pelvis. Two patients revised with <4 rods to the pelvis sustained a second acute failure, but no secondary failures occurred when at least 4 rods were used. In the univariate analysis, the magnitude of surgical correction was higher in the failure cohort (change in lumbar lordosis, and presence of a 3-column osteotomy, each <0.05). A 3-column osteotomy located at the lower lumbar segments between L4-S1, as opposed to correction at higher levels, particularly increased the risk (OR of 2.7, P=0.03). Use of pelvic screws <8.5mm in diameter increased the likelihood of failure (p<0.05). In the multivariate analysis, male gender, increasing BMI, increasing number of levels fused, and increasing preop pelvic incidence were each associated with increased risk of failure (p<0.05 for each). In addition, either a previously solid L5-S1 fusion or the use of an interbody device at L5-S1 at the index surgery significantly decreased the risk of acute pelvic fixation failure (OR of 0.33, p=0.017). Acute catastrophic failures involved large magnitude surgical corrections, particularly those with 3-column osteotomies located from L4-S1, and likely resulted from high mechanical strain on the pelvic instrumentation, with resultant associated rod/screw failure and/or kyphotic sacral fractures. Patients with large magnitude surgical corrections should have anterior structural support placed at the most caudal motion segment, and may benefit from multiple rods connecting to more than 2 pelvic fixation points. If failure occurs, salvage with a minimum of 4 rods and 4 pelvic fixation points can be successful. S2AI Screws (Approved for this indication), thoracolumbosacral pedicle screw system (Approved for this indication) [ABSTRACT FROM AUTHOR]

In the treatment of patients with adult spinal deformity, analysis of spinopelvic balance is essential in determining treatment options. This includes pelvic tilt (PT) and incidence (PI), lumbar lordosis (LL), and the sagittal vertical axis (SVA). Historically, the measurement of radiographs was done by hand with poor to moderate inter-observer reliability. More recently digital PACS tools provided improved accuracy and reliability, with the latest software semi-automating this process with a promise of increased efficiency. To our knowledge, no studies have examined the inter-observer reliability of semi-automated PACS software. This study aims to compare the reliability of this software versus PACS to determine if the improved efficiency occurs at the cost of reliability. Full spine X-rays were retrospectively reviewed from 25 patients older than 18 years seen at a tertiary medical center between 2014 and 2017. Patients were included if they had greater than 5cm of sagittal imbalance, without prior surgical spinal fusion and/or instrumentation. Spinopelvic parameters were measured in two radiographic programs: one with basic, non-spine specific measurement tools (eUnity, Client Outlook, Waterloo, Canada); and a second with spine-specific measurement tools that semi-automate the measurement of these parameters (Sectra, Sectra AB, Linköping, Sweden). Balance parameters included SVA, PI, PT, and LL. Two authors re-measured radiographs after a 6-month interval and results were compared to original measurements. Data were compared by examining inter-rater and inter-program reliability using interclass correlation coefficient (ICC). We hypothesized that modern semi-automated software, with its promise of increased measurement efficiency, would maintain reliable results. The subjects' mean age was 67.9 +/- 13.8 years old, and 32% were male. The inter-program reliability was strong, with ICC values greater than 0.91 for each parameter. Similarly, there was strong inter-observer reliability with ICC values greater than 0.88. Delayed re-measurement also showed strong reliability with ICC values greater than 0.90 (p < 0.001 for all measurements). There is excellent inter-observer and inter-program reliability between the basic PACS and semi-automated programs. These data demonstrate that the purported efficiency of semi-automated measurement programs does not come at the cost of measurement reliability. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]