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Background: Cannabidiol (CBD) is a cannabis derivative that has been popularized as a medicinal product with analgesic and anti-inflammatory effects. Given the anecdotal observations that several patients have reported use of CBD for spine-related pain, this study was designed to characterize CBD consumption patterns and perceived effects in patients with spine-related complaints. Methods: The study design was a cross-sectional survey. Over a 4-week period, an anonymous paper survey was administered to all patients presenting for evaluation by 1 of 9 spine surgeons at a single institution. Surveys were given upon registration for the office visit and collected by the office manager or nurse before evaluation by the surgeon. Patients were included regardless of surgical status (ie, preoperative, postoperative, or nonoperative) or region of pathology (lumbar, thoracic, or cervical). The survey consisted of multiple-choice questions on patient patterns of CBD use. Results: Out of 300 surveys, 214 (71%) were completed. CBD use for spine-related pain was reported by 54 (25.2%) patients. CBD was initially used for potential relief of back pain (66.7%), neck pain (37.0%), leg pain (35.2%), and/or arm pain (9.3%). Users also sought improvements in insomnia (25.9%) and mood (18.5%). Oil was the most popular formulation (64.8%). CBD was most often consumed 2–5 times (40.7%) or 6–10 times (31.5%) per week. The most common source of initial recommendation for CBD was friends or family (75.9%). Reported benefits were pain relief (46.3%), improved sleep (33.3%), and reduced anxiety (20.4%); however, 24.1% of patients reported no benefit from CBD use. The most reported side effect was fatigue (7.4%). Most users (63.0%) would recommend CBD to a friend for pain relief. Conclusion: CBD is already used by many patients, and further high-quality research on this supplement is essential. Level of Evidence: 4. Clinical Relevance: CBD is a commonly used by spine patients as an off label treatment.

Thrombosis and infections are two grave, interrelated problems associated with the use of central venous catheters (CVL). Currently used antibiotic coated CVL has limited clinical success in resisting blood stream infection and may increase the risk of emerging antibiotic resistant strains. We report an antibiotic-free, fluoropolymer-immobilized, liquid perfluorocarbon-coated peripherally inserted central catheter (PICC) line and its effectiveness in reducing catheter associated thrombosis and pathogen colonization, as an alternative to antibiotic coated CVL. Commercially available polyurethane PICC catheter was modified by a three-step lamination process, with thin fluoropolymer layers to yield fluoropolymer–polyurethane–fluoropolymer composite structure before applying the liquid perfluorocarbon (LP). This high throughput process of modifying commercial PICC catheters with fluoropolymer is quicker, safer and shows higher thromboresistance than fluorinated, omniphobic catheter surfaces, produced by previously reported self-assembled monolayer deposition techniques. The LP immobilized on the fluoropolymer is highly durable in physiological flow conditions for over 60 days and continue to resist Staphylococcus colonization.

The biologic steps involved in creating a bony fusion between adjacent segments of the spine are a complex and highly coordinated series of events. There have been significant advancements in bone grafts and bone graft substitutes in order to augment spinal fusion. While autologous bone grafting remains the gold standard, allograft bone grafting, synthetic bone graft substitutes, and bone graft enhancers are appropriate in certain clinical situations. This article provides an overview of the basic biology of spinal fusion and strategies for enhancing fusion through innovations in bone graft material. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-020-09749-5) contains supplementary material, which is available to authorized users.

This study aims to investigate lumbar spine (LS) volumetric bone density (vBMD) as a risk factor for complications (pseudoarthrosis, instrumentation failure, adjacent fractures), re-operation, and time to complication after fusion. Lumbar spine (LS) fusion surgery is increasingly performed worldwide. Complications after fusion result in significant morbidity and healthcare costs. Multiple factors, including osteoporosis, have been suggested to contribute to risk of complications and re-operation. However, most studies have used DXA, which is subject to artifact in patients with spine pathology, and none have investigated the relationship between BMD and timing of post-operative complications. This study aims to investigate LS volumetric bone density (vBMD) as a risk factor for complications (pseudoarthrosis, instrumentation failure, adjacent fractures), re-operation, and time to complication after fusion. We evaluated a cohort of 359 patients who had initial LS fusion surgery at our institution, had pre-operative LS CTs and post-operative imaging available for review. Demographic factors, smoking status, vBMD, and details of surgical procedure were related to likelihood and timing of post-operative complications. Mean age was 60 ± 14 years, vBMD 122 ± 37 g/cm3. Median follow-up was 11 months. Skeletal complications occurred in 47 patients (13%); 34 patients (10%) required re-operation. Low vBMD (directly measured and estimated using HU) and smoking were associated with increased risk of skeletal complications. Each increase in baseline vBMD of 10 g/cm3 decreased the complication hazard and increased the complication-free duration in time-to-event analysis (hazard ratio 0.91, 95% CI 0.83–0.98, p

Vertebral column resection is a powerful tool in the management of complex spinal deformity. Indications for VCR include rigid or focal, angular kyphosis or coronal deformity, hemivertebrae, and post-tuberculous spinal deformity. We review the approach to the patient with complex spinal deformity, VCR surgical technique, intraoperative considerations and outcomes reported in the literature.

Study Design: Retrospective study. Objective: To compare 2 methods of selecting the lowest instrumented vertebra (LIV) on the rates of revision surgery for distal junctional kyphosis (DJK) following treatment for Scheuermann’s kyphosis (SK). Methods: A retrospective review of patients who have undergone surgical treatment for SK was performed. Forty-four patients were divided into 2 groups based on intervention: Group 1 (n = 26) included patients who had an LIV distal to or at the sagittal stable vertebrae (SSV), and Group 2 (n = 18) included patients who had an LIV proximal to the SSV. For each group, demographic, radiographic, and revision surgery data was analyzed. Results: The average follow-up was 3.1 years. There were no differences among demographic variables between the groups. Preoperative and postoperative thoracic kyphosis, lumbar lordosis, and sagittal balance were not different between groups. Postoperatively, Group 1 demonstrated a significantly greater average lordotic disc angle below the LIV compared with Group 2 (Group 1, −6.2 ± 4.3° vs Group 2, −2.9 ± 5.8°; P = .02). In a subgroup analysis, extending fusions to the sagittal stable vertebra rather than the first lordotic disc resulted in fewer distal LIV complications necessitating revision surgery compared with fusing short of the SSV (5% vs 36.3%, P = .04). Conclusion: The SSV method may reduce complications secondary to distal junctional failure, but at the expense of incorporating additional motion segments in a typically young population.

BACKGROUND CONTEXT Since 2000, the annual death toll from opioid associated overdose has increased by over 300%. To reduce the opioid consumption, physicians have used alternative approaches, which have proven to not only be effective, but also reduce the side effects such as nausea, constipation, and addiction. IV acetaminophen has been shown to successfully accomplish the reduction in opioid use, however, it is an expensive alternative. Testing the efficacy of IV acetaminophen vs its oral formulation will likely modify future postoperative pain management regimens while also addressing cost-effectiveness. PURPOSE To prospectively evaluate clinical outcomes and determine the cost effectiveness of IV vs oral (PO) acetaminophen following lumbar circumferential spine surgery. We hypothesize that IV acetaminophen will perform better than PO in terms of length of stay, morphine equivalence, and change in VAS scores from baseline. STUDY DESIGN/SETTING A prospective, single-center, randomized control trial. PATIENT SAMPLE Patients between the ages of 18-85 who underwent circumferential lumbar fusion surgery, while failing conservative treatment for more than 6 months were included in the study. Patients were excluded if they had already undergone lumbar surgery at the index level(s), were diagnosed with osteoporosis, had dysphagia prohibiting oral administration, or had a history of substance abuse. OUTCOME MEASURES Outcome measures included opioid equivalence, length of hospital stay, VAS measurements, and Oswestry Disability Index (ODI) scores. METHODS Once enrolled, patients were randomized to either the IV or PO acetaminophen treatment groups. Preoperatively, patients completed a baseline analgesic regimen questionnaire, surveys including VAS, SF-12, and ODI, and were administered their first acetaminophen dose within three hours of first incision. Postoperatively, patients received seven subsequent doses of their assigned acetaminophen, with access to supplemental analgesics if needed. Analgesic usage and VAS scores were monitored until discharge. Surveys were completed at six weeks and six months follow-up. RESULTS Average daily opioid consumption for the IV group was significantly lower than the PO group during the immediate postoperative period. Average length of stay was similar between groups, 3.3 days for PO and 3.7 days for IV. VAS back and leg scores were not statistically different between groups, however, both groups experienced a decrease by more than the minimally clinically important difference (MCID) of 12 points from baseline. ODI also decreased by the MCID at the 6-month follow-up, which was defined as 12.8% for ODI. CONCLUSIONS Along with an overall reduction in opioid usage, patient-reported outcomes depict successful improvement of pain management with the use of IV acetaminophen following circumferential spinal fusion surgery. Furthermore, despite the large discrepancy between the two formulations in cost-to-perceived-benefit ratio, the significant reduction of opioid usage and, therefore, its associated costs, provides a far less dramatic divergence. The continued testing of the efficacy of IV acetaminophen vs its oral formulation will likely modify future postoperative pain management regimens while also addressing the opioid epidemic plaguing communities across the US. FDA DEVICE/DRUG STATUS OFIRMEV (Approved for this indication).

STUDY DESIGN Basic Science. OBJECTIVE To determine if locally delivered simvastatin can enhance bone formation in a rat spinal fusion model. SUMMARY OF BACKGROUND DATA The bone-anabolic properties of statins in fracture healing are well established, however, few studies have evaluated the impact of locally delivered statins in spinal fusion. METHODS We formulated poly(lactic-co-glycolic acid) (PLGA) nanoparticles by adapting previously published techniques. Two types of nanoparticles were created: simvastatin nanoparticles (SimNP) and nanoparticles without simvastatin (BlankNP). Drug elution from SimNP was characterized. Osteoblastic differentiation was analyzed using MC3T3-E1 cells cultured in differentiation medium containing SimNP or BlankNP. Forty male 12 week old outbred Wistar rats underwent uninstrumented posterolateral fusion using iliac crest bone graft and BlankNP, SimNP or simvastatin drug. X-rays to assess bone formation were obtained at 4 weeks and 9 weeks post-operatively. Spines were explanted at 9 weeks for micro-CT analysis, and a blinded manual assessment of fusion (MAF). RESULTS SimNP achieved a release efficiency of 74.1% with ∼50% release occurring in the first day. Simvastatin and SimNP treated cells showed significantly greater expression of osteopontin (OPN) and osteocalcin (OCN). On micro-CT analysis, SimNP animals had higher bone volume and percent bone volume (bone volume/total volume) than control animals. SimNP rats had higher X-ray scores at 4 weeks (p=0.010) and 9 weeks (p

Spine fusion is one of the most common orthopedic surgeries, with more than 400,000 cases performed annually. While these procedures correct debilitating pain and deformities, complications occur in up to 45%. As successful fusion rests upon early stability of hardware in bone, patients with structural skeletal deficits may be at particular risk for complications. Few studies have investigated this relationship, and none have used higher order imaging to evaluate microstructural mechanisms for complications. Standard DXA measurements are subject to artifact in patients with spinal disease and therefore provide limited information. The goal of this prospective study was to investigate pre-operative bone quality as a risk factor for early post-operative complications using high resolution peripheral QCT (HR-pQCT) measurements of volumetric BMD (vBMD) and microarchitecture. We hypothesized that patients with low vBMD and abnormal microarchitecture at baseline would have more skeletal complications post-operatively. Conversely, we hypothesized that pre-operative DXA measurements would not be predictive of complications. Fifty-four subjects (mean age 63 years, BMI 27 kg/m2) were enrolled pre-operatively and followed for 6 months after multi-level lumbar spine fusion. Skeletal complications occurred in 14 patients. Patients who developed complications were of similar age and BMI to those who did not. Baseline areal BMD and Trabecular Bone Score by DXA did not differ. In contrast, HR-pQCT revealed that patients who developed complications had lower trabecular vBMD, fewer and thinner trabeculae at both the radius and tibia, and thinner tibial cortices. In summary, abnormalities of both trabecular and cortical microarchitecture were associated the development of complications within the first six months following spine fusion surgery. Our results suggest a mechanism for early skeletal complications after fusion. Given the burgeoning number of fusion surgeries, further studies are necessary to investigate strategies that may improve bone quality and lower the risk of post-operative complications.

The purpose of this study was to test a hypothesis that overweight patients with adolescent idiopathic scoliosis present with larger curves and achieve less surgical correction than do healthy weight counterparts. A total of 251 individuals were grouped by BMI into overweight (BMI% ≥85) and healthy weight (BMI%

The resection point of a lumbar three-column osteotomy (3CO) creates separation of the spino-pelvic complex. This study investigates the impact of patients' baseline deformity and level of 3CO resection on the distribution of correction between the trunk and the pelvis following osteotomy closure.Patients who underwent single lumbar 3CO, upper instrumented vertebra (UIV) T1-T10, and 6 month follow-up were included. The truncal and pelvic closures were calculated based on the vertebrae adjacent to the osteotomy level and the impact of radiographic parameters and level of 3CO on the closures were analyzed.113 patients were included. Patients who experienced more pelvic correction had significantly higher Pelvic Tilt and lower Sagittal Vertical Axis at baseline. Patients who underwent more caudal osteotomies with higher pelvic compensation with modest SVA sustained more pelvic correction.The osteotomy closure is driven by patient's specific deformity. More caudal osteotomy level leads to greater pelvic tilt improvement.III.

BACKGROUND CONTEXT More than 400,000 spinal fusion surgeries are performed annually in the US, with related health care costs exceeding $287 billion. As spinal fusion involves extensive instrumentation of the vertebrae, patients with skeletal abnormalities may be at increased risk for complications. However, preoperative identification of high-risk patients remains a challenge. Due to skeletal effects of aging and estrogen deficiency, postmenopausal (PM) women may be at particular risk. Dual energy x-ray absorptiometry (DXA) measurements of areal BMD are subject to artifact in patients with spinal pathology, and may be limited as screening tests. PURPOSE This prospective study investigated skeletal health in postmenopausal women having lumbar spine fusion and matched controls using DXA and high resolution peripheral QCT (HRpQCT) measurements of volumetric BMD (vBMD) and microarchitecture. We aimed to determine if HRpQCT would reveal additional abnormalities in vBMD and microarchitecture in fusion patients compared to DXA. STUDY DESIGN/SETTING Prospective, single center study. PATIENT SAMPLE A total of 60 patients were included in this study. PM women undergoing lumbar fusion were prospectively enrolled and compared to PM controls. OUTCOME MEASURES HRpQCT measurements of cortical and trabecular vBMD and microarchitecture, DXA, age and BMI. METHODS PM women undergoing lumbar fusion (n=20) were matched 1:2 by age with PM controls (n=40) who had no history of spine surgery or secondary osteoporosis. Subjects had assessments by standard DXA and high resolution peripheral QCT (HRpQCT) to measure cortical (Ct) and trabecular (Tb) vBMD and microarchitecture of the distal radius and tibia. RESULTS Mean age of subjects was 66+/-6 years, BMI (28+/-6 kg/m2) without any significant differences between groups. By DXA, T-scores in fusion patients were normal at the lumbar spine (mean 0.0) and osteopenic at the total hip (-1.2), femoral neck (-1.5) and 1/3 radius (-1.5). T- Scores did not differ significantly from controls at any site. In contrast, HRpQCT revealed low vBMD (total, Ct, Tb) in fusion patients compared to controls at both radius and tibia, with total vBMD 21-30% lower, Ct density ∼7% and Tb density ∼25% lower. Fusion patients had microarchitectural abnormalities, significantly fewer, thinner and more widely spaced trabeculae. Specifically, Tb number was 9% lower, Tb thickness 6% lower, and Tb separation 23% greater at the radius with similar differences at the tibia. CONCLUSIONS In summary, PM women presenting for spine fusion surgery had low volumetric BMD and abnormal trabecular microarchitecture, despite DXA values that were normal or slightly low. Our results suggest that additional techniques may be necessary for detection of bone quality deficits in patients presenting for spinal fusion. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Shoulder balance for adolescent idiopathic scoliosis (AIS) patients is associated with patient satisfaction and self-image. However, few validated systems exist for selecting the upper instrumented vertebra (UIV) post-surgical shoulder balance.The purpose is to examine the existing UIV selection criteria and correlate with post-surgical shoulder balance in AIS patients.Patients who underwent spinal fusion at age 10-18 years for AIS over a 6-year period were reviewed. All patients with a minimum of 1-year radiographic follow-up were included. Imbalance was determined to be radiographic shoulder height |RSH| ≥ 15 mm at latest follow-up. Three UIV selection methods were considered: Lenke, Ilharreborde, and Trobisch. A recommended UIV was determined using each method from pre-surgical radiographs. The recommended UIV for each method was compared to the actual UIV instrumented for all three methods; concordance between these levels was defined as "Correct" UIV selection, and discordance was defined as "Incorrect" selection.One hundred seventy-one patients were included with 2.3 ± 1.1 year follow-up. For all methods, "Correct" UIV selection resulted in more shoulder imbalance than "Incorrect" UIV selection. Overall shoulder imbalance incidence was improved from 31.0% (53/171) to 15.2% (26/171). New shoulder imbalance incidence for patients with previously level shoulders was 8.8%.We could not identify a set of UIV selection criteria that accurately predicted post-surgical shoulder balance. Further validated measures are needed in this area. The complexity of proximal thoracic curve correction is underscored in a case example, where shoulder imbalance occurred despite "Correct" UIV selection by all methods.

Background context Hyperkyphosis confers a significant risk for neurologic deterioration as well as compromised cardiopulmonary function. Posterior vertebral column resection (PVCR) is a challenging but effective technique for spinal cord decompression and deformity correction that even under the setting of limited resources can be performed to reduce the technical difficulties, the operating time, and possibly the complications of the traditional two-staged vertebral column resection (VCR). Purpose To report on the results of VCR performed through a single posterior approach (PVCR) in the treatment of severe rigid kyphosis in a series of patients treated and followed at a Scoliosis Research Society Global Outreach Program site in West Africa. Study design Retrospective case series. Patient sample Forty-five consecutive patients treated with PVCR for correction of severe rigid kyphosis. Outcome measures Clinical and radiographic outcomes and complications; Scoliosis Research Society outcome instrument (SRS-22). Methods From 2002 to 2009, 45 patients (20 male and 25 female) underwent PVCR for kyphosis from congenital deformity (nine) or secondary to tuberculosis of the spine (36). Preoperative demographics, preop and postop neurologic status, SRS-22 scores and complications were recorded; upright full spine X-rays were available in all patients. Mean age was 14 years (6–47 years); mean follow-up 27 months (2–79 months). Mean preoperative kyphosis measured 108°. The deformity apex was resected via a costotransverse (thoracic) or posterolateral (lumbar) approach; neurosurveillance with sensory (somatosensory-evoked potentials) and motor (motor-evoked potentials) potential was used in all cases. Posterior instrumentation was used in all patients, and anterior structural cage was used in 32 patients. Results Intraoperative monitoring changes occurred in 10 patients (22%), and one patient progressed to complete spinal cord injury. Average preoperative local kyphosis was 108° and corrected to 600 postoperatively. Postoperatively, no additional patient showed neurologic deterioration; of the 11 patients with preoperative gait disturbances, 4 improved to normal gait, 5 remained the same, and 2 showed deterioration of their walking ability to nonambulating level. Total SRS-22 scores improved from 3.18 to 3.54 (p=.01), primarily self-image domain. Conclusions Posterior vertebral column resection was successfully undertaken for the management of thoracic and thoracolumbar hyperkyphosis, demonstrating improvements in overall kyphosis and clinical outcome. Neuromonitoring provided the required safety to perform these challenging complex spine deformity procedures.

Study Design Retrospective analysis of a prospectively collected single-center database. Objectives To report the incidence of and identify risk factors for perioperative complications in surgically treated pediatric and adult patients with complex spine deformities in an underserved region and Scoliosis Research Society Global Outreach Program site. Summary of Background Data Surgical treatment for complex spinal deformity is challenging and requires a multidisciplinary approach for optimal management. The incidence and risk factors for major perioperative complications in outreach sites with limited resources are unknown. Methods A total of 427 consecutive patients who underwent instrumented spinal fusion for complex spinal deformities were reviewed. Clinical, radiographic, and demographic data were reviewed at preoperative and postoperative time points, and potential risk factors for perioperative complications were assessed. The authors performed multivariate logistic regression analysis (LRA) to determine independent risk factors for postoperative complications and neurological deficits. Results Major complications were seen in 85 cases, which consisted of neurologic deficits (n = 27; 17 transient and 10 permanent), wound infections (n = 17), implant-related problems (n = 35), progressive deformity (n = 13), and death (n = 6). Among the possible risk factors, univariate LRA indicated 3-column osteotomies as a risk factor for postoperative major complications and multivariate LRA indicated 3-column osteotomies as an independent risk factor for neurological deficit. Curves 100° and above were at higher risk for complications. Conclusions Postoperative complications were seen in 20% of surgically treated patients with complex spine deformities at a Scoliosis Research Society SRS Global Outreach Program site. Three-column osteotomies were identified as an independent risk factor of both postoperative complications and neurological deficits. The significant observed correlation of 3-column osteotomies and postoperative neurological deficits should serve as a guide for surgeons in the preoperative planning and management of severe spinal deformities, especially in locations with limited resources. Patients undergoing correction of large curves may also have a higher complication rate.

Current guidelines for the optimal treatment degenerative spondylolisthesis are weak and based on limited high-quality evidence. There is some moderate evidence that decompression alone may be a feasible treatment with lower surgical morbidity and similar outcomes to fusion when performed in a select population with a low-grade slip. Similarly, addition of interbody fusion may be best suited to a subset of patients with high-grade degenerative spondylolisthesis, although this remains controversial. Minimally invasive techniques are increasingly being utilized for both decompression and fusion surgeries with more and more studies showing similar outcomes and lower postoperative morbidity for patients. This will likely be an area of continued intense research. Finally, the role of spondylolisthesis reduction will likely be determined as further investigation into optimal sagittal balance and spinopelvic parameters is conducted. Future identification of ideal thresholds for sagittal vertical axis and slip angle that will prevent progression and reoperation will play an important role in surgical treatment planning. Current evidence supports surgical treatment of degenerative spondylolisthesis. While posterolateral spinal fusion remains the treatment of choice, the use of interbodies and decompressions without fusion may be efficacious in certain populations. However, additional high-quality evidence is needed, especially in newer areas of practice such as minimally invasive techniques and sagittal balance correction.

Study Design Consensus-building using the Delphi and nominal group technique. Objective To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery. Summary of Background Data Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed. Methods The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting. Results Participants had a mean of 13.4 years of practice (range: 2–32 years) and 103.1 (range: 50–250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants. Conclusion We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery. Level of Evidence Level V.

Study Design: A prospective study of a new technique. Objective: The aims of this study were to report a manual technique for measuring vertebral curves on digital spine radiographs, and to assess the agreement of this technique with that of digital software for measuring vertebral curves. Summary of Background Data: Modern picture archiving and communication systems (PACS) typically include software for evaluating radiographic measurements. However, in the outpatient spine setting, patients may present with radiographs stored on a physical disc, which may not include software for measuring vertebral curves. Certain smartphone applications may be used to determine curve magnitude; however, the need exists for an accurate manual technique to measure vertebral curves on digital radiographs in the absence of available analytic software or smartphone technology. Methods: We prospectively reviewed anteroposterior and lateral spine radiographs of 24 spinal deformity patients. Two independent observers measured Cobb angles for: (1) the major coronal curve; (2) the thoracic kyphosis (T2–T12); and (3) the lumbar lordosis (T12–S1). Measurements were made: (1) digitally using our institution’s PACS; and (2) by a manual technique, which involves placement of an adhesive Post-It note directly on the computer screen, transcribing the angle onto the Post-It note with a pencil, and measuring the angle with a handheld goniometer. Intraclass correlation coefficients (ICCs) were calculated to determine the agreement between the 2 methods. Results: For both observers, the agreement between the digital PACS and manual Post-It techniques was graded as excellent for both coronal and sagittal plane curves (all ICCs>0.9). Interobserver reliability between the 2 observers was also graded as excellent for both the PACS and Post-It techniques (all ICCs>0.9). Conclusions: The Post-It technique for measuring Cobb angles demonstrated excellent agreement with the PACS system in our series of spinal deformity patients. Curves on digital radiographs can be accurately measured using a convenient manual technique.

Study design Retrospective review. Objective The purpose of this study is to review the postoperative complications in pediatric patients undergoing spine surgery and to establish a preoperative classification that stratifies surgical risk and case difficulty. Summary of Background Data Pediatric spinal deformity (PSD) surgery can be challenging technically as well as economically. Often, a multidisciplinary approach to managing these patients is necessary. In an environment where resources are limited, such as in global outreach efforts, a method for stratifying PSD surgical cases can be useful for allocating appropriate resources and assigning appropriate skill sets in order to optimize patient outcomes and to streamline efforts. Materials and Methods A total of 145 consecutive PSD patients who underwent instrumented spinal fusion were reviewed. Radiographic measurements and demographic data were reviewed. A classification was established based on the curve magnitude, etiology, ASA grade, number of levels fused, the preoperative neurologic status, body mass index and type of osteotomies. Multiple regression analysis (MRA) and logistic regression analysis (LRA) were applied to indicate risk factors for complications. Results The average age was 14.3 years (10–20 years). The etiology was idiopathic scoliosis (n = 71), congenital scoliosis (n = 38), infectious (n = 11), and others. 23 patients had neurologic deficits preoperatively. Twenty-three patients had a posterior vertebral column resection. Patients were classified as Level 1 (n = 5), Level 2 (n = 19), Level 3 (n = 24), Level 4 (n = 58), and Level 5 (n = 39). Intraoperative neuro-monitoring changes were observed in 46 cases. Major complications were seen in 45 cases. A major complication consisted of implant related (n = 13), deep wound infection (n = 8), neurologic deficit (n = 7), death (n = 2), and others (n = 9). MRA demonstrated a significant correlation between classified level and %EBL/TBV, operative time, and complication rate. The risk level predicted the occurrence of general (odds ratio [OR] = 1.54; 95% confidence interval [CI] = 1.08–2.21; p = .019) and neurologic (OR = 3.34; 95% CI = 1.06–17.70; p = .036) complications. Osteotomy and resection procedures were independent predictors for postoperative neurologic complications (OR = 1.7, 95% CI = 1.11–2.85; p = .015). Conclusion Corrective spine surgery for complex pediatric deformity is challenging and carries a substantial risk. No single parameter appears to independently predict postoperative complications. However, when all risk factors are considered, there is a trend toward increased intraoperative electromonitoring change and postoperative neurologic risk with the higher level score in our classification. The newly established surgical risk stratification based on patient-specific clinical and radiographic factors can guide surgeons in their preoperative planning and surgical management of severe spine deformity in order to achieve optimal outcomes.

BACKGROUND CONTEXT While historically the main focus in AIS was the coronal Cobb, there has been a growing interest in also integrating consideration for sagittal plane alignment. The effect of surgical thoracic kyphosis (TK) correction on adjacent curvatures remains unclear. PURPOSE This study aims to elucidate the reciprocal changes associated with TK correction in Lenke one-two AIS patients. STUDY DESIGN/SETTING Multicenter retrospective study. PATIENT SAMPLE A total of 155 AIS patients with Lenke one-two curves operated on with either surgical bands or pedicle screws were included. OUTCOME MEASURES Classic spino-pelvic parameters at baseline and 2years (2Y). METHODS Reciprocal changes associated to TK correction were analyzed, alignment predictive formulas were defined using 75% of the cohort and 25% for validation. RESULTS A total of 155 patients were included (15yo, 86% female), the majority of patients (92.9%) had T4-T12 completely fused. From pre to post, there was a significant decrease (all p CONCLUSIONS It is already known that the correction of one sagittal curve leads to changes in surrounding curves and it is well observed in this study that the correction of TK leads to changes in CL and LL. These changes are directly correlated to the magnitude of TK change, and are thus predictable. It is interesting to note that an inadequate restoration of TK from hypokyphosis will result in a greater PI-LL mismatch.In the setting of surgical planning; these formulas would be invaluable for the surgeons and could lead to better postop courses.

BACKGROUND CONTEXT Lumbar spine fusions are rated amongst the most painful surgical procedures. Adequately controlling post-operative pain while minimizing opioid use is an important public health objective PURPOSE The purpose of this study was to examine the effect of intravenous ketorolac (IV-K) on hospital opioid use compared to IV placebo (IV-P) and IV Acetaminophen (IV-A). STUDY DESIGN/SETTING Prospective, randomized, double-blind trial. PATIENT SAMPLE Patients aged 18-75 undergoing 1-2 level posterior lumbar fusion without history of long-term opioid use. Smokers and those with contraindications to IV-A or IV-K were excluded OUTCOME MEASURES The primary outcome was in-hospital opioid use up to post-operative day 3 (POD3). The secondary outcomes were opioid related adverse events (ORAE) and length of stay (LOS). METHODS Patients (Pts) were randomized to receive IV-K, IV-P or IV-A. IV-K pts received 15mg (age > 65) or 30mg (age RESULTS A total of 115 patients met the inclusion criteria (39 IV-K, 39 IV-A, 37 IV-P). There was no difference between patients with regards to demographic or surgical variables. The IV-K group had substantially lower opioid use at 72h (181±156mg) compared to IV-A (268± 176mg) and IV-P (315±183mg) (p=0.003). IV-K was superior to IV-A (p=0.030) and IV-P (0.001). IV-A was not superior to IV-P (p=0.234). Similar trends were observed for opioid use per hour (IV-K: 3.0±2.4mg/hr; IV-A: 4.1±2.3mg/hr; IV-P: 4.7±2.5mg/hr, p=0.009). IV-K pts reported improved pain control on POD1 (p=0.050). IV-K pts trended toward shorter LOS (IV-K: 75±44hr; IV-A: 93±60hr; IV-P:88±35hr, p=0.231). There were no differences in ORAE, drain output, hematocrit levels, serum creatinine and transfusion rates. CONCLUSIONS IV-K results in a substantial reduction in opioid use (>40% vs IV-P, >30% vs IV-A) and improved pain control on POD1. There is a trend toward decreased LOS; there appears to be no increase in in-hospital complications. Longer term follow-up is planned to assess the impact of IV-K on pseudarthrosis. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.

BACKGROUND CONTEXT Lumbar spine fusions are rated among the most painful surgical procedures. Adequately controlling postoperative pain while minimizing opioid use is an important public health objective. SUMMARY Early results of this double-blind, randomized, placebo-controlled trial show that intravenous ketorolac (IV-K) results in a substantial reduction in opioid use and improved pain control compared to placebo (IV-P) and IV acetaminophen (IV-A). IV-K did not increase rates of hematoma, drain output, transfusions or serum creatinine. There was a trend toward decreased length of stay (LOS) with IV-K. HYPOTHESIS IV-K would decrease in hospital opioid use compared to IV Placebo (IV-P) and Intravenous Acetaminophen (IV-A). DESIGN Randomized, double-blind trial. METHODS Patients (Pts) were randomized to receive IV-K, IV-P or IV-A. The inclusion criteria were: age 18-75, 1-2 level lumbar fusion and no history of long-term opioid use. Smokers and pts with contraindications to IV-A or IV-K were excluded. IV-K pts received 15mg (age >65) or 30mg (age RESULTS A total of 115 pts met inclusion criteria (39 IV-K, 39 IV-A, 37 IV-P). There was no difference between pts with regard to demographic or surgical variables. IV-K group had substantially lower opioid use at 72h (181±156mg) compared to IV-A (268±176mg) and IV-P (315±183mg) (p=0.003). IV-K was superior to IV-A (p=0.030) and IV-P (0.001). IV-A was not superior to IV-P (p=0.234). Similar trends were observed for opioid use per-hour (IV-K: 3.0±2.4mg/h; IV-A: 4.1±2.3mg/h; IV-P: 4.7±2.5mg/h, p=0.009). IV-K pts reported improved pain control on POD1 (p=0.050). IV-K pts trended toward shorter LOS (IV-K: 75±44h; IV-A: 93±60h; IV-P:88±35h, p=0.231). There were no differences in ORAE, drain output, hematocrit levels, serum creatinine and transfusion rates. CONCLUSION IV-K results in a substantial reduction in opioid use (>40% vs IV-P, >30% vs IV-A) and improved pain control on POD1. There is a trend toward decreased LOS; there appears to be no increase in in-hospital complications. Longer term follow-up will assess impact of IV-K on pseudarthrosis. IV-K reduces opioid use after spinal fusion by >40% compared to placebo and >30% compared to IV acetaminophen. There is a trend toward decreased LOS with IV-K. FDA DEVICE/DRUG STATUS Intravenous ketorolac and intravenous acetaminophen are FDA app

The corresponding author regret that co-author name was incorrectly published as "Elias C. Papadopoulus" in the article. The correct name of the author should be displayed as "Elias C. Papadopoulos".

The corresponding author regret that co-author name was incorrectly published as “Elias C. Papadopoulus” in the article. The correct name of the author should be displayed as “Elias C. Papadopoulos”.

STUDY DESIGN Survey based on complication scenarios. OBJECTIVE To assess and compare perceived potential impacts of various perioperative adverse events by both surgeons and patients. SUMMARY OF BACKGROUND DATA Incidence of adverse events after adult spinal deformity surgery remains substantial. Patient-centered outcomes tools measuring the impact of these events have not been developed. An important first step is to assess the perceptions of surgeons and patients regarding the impact of these events on surgical outcome and quality of life. METHODS Descriptions of 22 potential adverse events of surgery (heart attack, stroke, spinal cord injury, nerve root injury, cauda equina injury, blindness, dural tear, blood transfusion, deep vein thrombosis, pulmonary embolism, superficial infection, deep infection, lung failure, urinary tract infection, nonunion, adjacent segment disease, persistent deformity, implant failure, death, renal failure, gastrointestinal complications, and sexual dysfunction) were presented to 14 spinal surgeons and 16 adult patients with spinal deformity. Impact scores were assigned to each complication on the basis of perceptions of overall severity, satisfaction with surgery, and effect on quality of life. Impact scores were compared between surgeons and patients with a Wilcoxon/Kruskal-Wallis test. RESULTS Mean impact scores varied from 0.9 (blood transfusion) to 10.0 (death) among surgeons and 2.3 (urinary tract infection) to 9.2 (stroke) among patients. Patients' scores were consistently higher (P < 0.05) than surgeons in all 3 categories for 6 potential adverse events: stroke, lung failure, heart attack, pulmonary embolism, dural tear, and blood transfusion. Three additional complications (renal failure, non-union, and deep vein thrombosis) were rated higher in 1 or 2 categories by patients. CONCLUSION There was substantial variation in how both surgeons and patients perceived impacts of various adverse events after spine surgery. Patients generally perceived the impact of adverse events to be greater than surgeons. Patient-centered descriptions of adverse events would provide a more complete description of surgical outcomes.

Retrospective case series of surgically treated adult patients with fixed sagittal imbalance.To assess clinical and radiographic changes after pedicle subtraction osteotomy (PSO) to treat adult fixed sagittal imbalance.Although recent reports have shown favorable clinical outcomes for PSO, few reports have published long-term follow-up outcomes. It is also unknown whether long-term outcomes are correlated with the level of proximal fusion and the radiographic changes that are observed after PSO.We reviewed the charts, X-rays, and postoperative SRS-22 and Oswestry Disability Index (ODI) scores of 32 adult patients who presented with fixed sagittal imbalance and were treated with lumbar PSO. Long fusions were defined as those proximal to T6, and short fusions were defined as those below T8. Measured radiographic parameters included thoracic kyphosis, lumbar lordosis (LL), sacral slope, pelvic incidence, and sagittal balance (SVA). Statistical analysis included Student t test and chi-square test. A p value of.05 and a confidence interval of 95% were considered statistically significant.Among the reviewed cases were 23 women and 9 men, with a mean age of 50.9 years (range, 33-76 years) and a mean follow-up 8.6 years (range, 5-16 years). The LL increased from -16.0° preoperatively to -52.1° postoperatively. This metric decreased to -51.0° at final follow-up. The SVA decreased from 10.4 cm preoperatively to 3.6 cm postoperatively. The SVA increased to 5.4 cm at the final follow-up visit. There were 17 long fusions and 15 short fusions. The SRS scores at the final follow-up time point were: total, 3.63; function, 3.59; pain, 3.68; self-image, 3.46; mental health, 3.56; satisfaction, 4.26. A total of 16 patients exhibited minimal disability, 11 exhibited moderate disability, and 2 exhibited severe disability in ODI scores at the final follow-up visit (average, 28.2%). The SRS and ODI scores were not significantly different between groups (p = .64 for SRS; p = .59 for ODI). We observed no significant differences between groups with respect to the LL, sacral slope, or pelvic incidence. The observed increase in SVA at the final follow-up visit was significantly larger in the short fusion group compared with the increase we observed in the long fusion group (p = .03). The thoracic kyphosis (T5-T12) and proximal junctional angle at the final follow-up visit also significantly increased in patients who underwent a short fusion (p.001). A total of 14 major complications occurred in 12 patients (8 in the short fusion group and 6 in the long fusion group) (p = .43). Eight patients required additional surgery to treat these complications.In a group of adults presenting with fixed sagittal imbalance, PSO provided good sagittal balance and maintained favorable clinical outcomes in both the short and long fusion groups despite a slight decrease in the SVA and a high complication rate. The data suggest that the loss of sagittal balance may be attributed to increase global and junctional kyphosis in short fusion groups, and should be monitored for long-term outcomes. Particular attention should be paid to the long-term deterioration of the SVA in adults who present with fixed sagittal imbalance after PSO.

Background context Fusion of the spine requires de novo bone formation and remodeling, processes that rely heavily on the action of the osteoblast and osteoclast. Bisphosphonate drugs and intermittent parathyroid hormone (PTH) therapy are widely prescribed to treat osteoporosis and act on the osteoblast/osteoclast complex. The impact of these medications on spine fusion is not known. Purpose To evaluate the available evidence on the potential impact of bisphosphonates and PTH on fusion rate and fusion quality in spinal arthrodesis. Study design A systematic review of the literature. Patient Sample All available literature regarding the impact of bisphosphonates and PTH on spinal fusion. Outcome measures Fusion rate and histologic, microstructural, or biomechanical measures of fusion quality. Methods A systematic review of the literature published between 1980 and 2011 was conducted using major electronic databases. The results of studies meeting criteria for inclusion were then aggregated and examined for consensus on the effect of these medications on spine fusion. Results The literature contained 18 animal studies and one clinical trial investigating the impact of these medications on spine fusion. Most animal studies evaluating the impact of bisphosphonates on fusion rate have not found statistically significant changes with treatment, although this fact may be attributable to low statistical power. The animal literature does suggest that bisphosphonate therapy results in a less histologically mature fusion mass; however, the impact of these changes on fusion mass biomechanics is unclear. The only available human study suggests that these bisphosphonates may increase the radiographically defined fusion rate but did not demonstrate an impact on clinical outcome. In animals, PTH improves the fusion rate and fusion mass microstructure, but data on its effect on fusion mass biomechanics are lacking. No studies have evaluated the impact of PTH on spine fusion in humans. Conclusions In animals, bisphosphonate therapy appears to impede maturation of the fusion mass, with an unclear effect on mechanical strength. This effect was not seen in the lone human study, which suggested that these medications improved the radiographically defined fusion rate. The available animal studies on intermittent PTH treatment suggest that it may improve fusion rate and fusion mass microstructure. Given the widespread use of these agents, further investigation into their impact on human spine fusion is necessary to inform the care of patients with osteoporosis who are undergoing spine surgery.

Study Design Retrospective chart and radiographic review. Objective The purpose of this study was to identify any additional risk factors adding-on after selective thoracic fusion in adolescent idiopathic scoliosis (AIS). Summary of Background Data Previous studies have shown that the proper selection of lowest instrumented vertebra (LIV) is critical in preventing adding-on (AD) phenomenon after selective thoracic fusion (STF). However, even after selecting the correct LIV, AD can still occur. Methods This is a retrospective review of 380 consecutive AIS patients who underwent corrective surgery by a single surgeon. LIV was chosen as stable vertebra (SV) or SV–1 if intersected by the center sacral vertical line (CSVL). One hundred thirty-five patients were identified who had complete radiographic images stored in PACS. After Lenke 5, anterior or combined surgeries, TL fusion, and hybrid construct were excluded, two groups were identified out of 78 patients who received STF with all pedicle screw construct: Adding-on (AD) and Control. AD was defined as >5° angle of the superior endplate of LIV–1 to the inferior endplate of LIV+1 between postoperation and the final follow-up. We analyzed the values for the AD group and compared them with those for the control group to identify risk factors not previously defined. Results Patients with other complication and follow-up less than 2 years were excluded, and there remained 11 patients in AD (14%), and 8 in the control group. There was no significant difference between the 2 groups in terms of demographic data, LIV selection, and curve types. In AD, there was significant curve progression within fused segments. Even though lumbosacral takeoff (LSTO) was not significantly different, (LIV-H)+LSTO and LIV-H (LIV horizontal) showed significant difference. Conclusion After excluding the effect of known risk factors for AD, LIV-H angle, and LIV-H mismatch with LSTO were found to be the additional risk factors for AD. In addition to consideration of other risk factors such as LIV selection or Risser stage, these risk factors should be considered.

STUDY DESIGN Cross-Sectional Cohort Study OBJECTIVE.: To describe age-stratified normative values of novel occipitocervical, cervical, and cervicothoracic alignment parameters. SUMMARY OF BACKGROUND DATA Full-body radiographic images obtained without stitching or vertical distortion represent an ideal method to evaluate occipitocervical alignment and horizontal gaze. METHODS One hundred twenty adults with no back or neck symptoms were recruited. Age, sex, body mass index, Neck Disability Index (NDI), and Oswestry Disability Index scores were recorded. Radiographic parameters measured included: center sacral vertebral line, chin brow vertical angle (CBVA), orbital tilt (OrT), orbital slope, occipital slope (OS), occipital incidence, occiput-C2 (O-C2) lordosis, cervical lordosis (C2-C7, CL), T1 slope (TS), neck tilt, thoracic inlet angle (TIA), cervicothoracic kyphosis (C6-T4), and C2-C7 sagittal vertical axis (C2-7 SVA). Interobserver reliability was calculated for all measurements (intraclass correlation coefficient, ICC). A Pearson correlation was used to determine relationships between variables. RESULTS A total of 115 patients were analyzed; average age as 50.1 years (range 22-78). All measured variables had an ICC >0.6. CL (r = -0.33, P

STUDY DESIGN Cross-sectional cohort study. OBJECTIVE Describe age-stratified normative values of traditional and novel sagittal alignment parameters. SUMMARY OF BACKGROUND DATA Full-body radiographic techniques can capture coronal and sagittal standing images from the occiput to the foot without stitching or vertical distortion. This provides an ideal method to evaluate measures of global alignment. METHODS Adults with no back or neck symptoms were recruited. Age, body mass index, Neck Disability Index, and Oswestry Disability Index scores were recorded. The following parameters were measured: center sacral vertebral line, Occiput-C2 (O-C2) lordosis, cervical lordosis (C2-C7, CL), thoracic kyphosis (T2-12, TK), T2-T5 kyphosis, T5-T12 kyphosis, thoracolumbar kyphosis (T10-L2), lumbar lordosis (L1-S1, LL), sacral slope, pelvic tilt, pelvic incidence (PI), knee flexion angle, global sagittal angle, T1-pelvis angle, C2-S1 sagittal vertical axis (SVA), C7-S1 SVA, Basion-C7 SVA, B-S1 SVA and Basion to the center of the femoral head SVA and PI minus LL. Comparisons of sagittal alignment parameters between different age groups were performed. A Pearson correlation was used to determine relationships. RESULTS One hundred fifteen volunteers had imaging suitable for analysis; average age as 50.1 years (range 22-78), average body mass index was 28, average Neck Disability Index was 3.4 ± 4.4, and average Oswestry Disability Index was 1.7 ± 4.9. CL (r = -0.34, P = 0.001), T1-pelvis angle (r = 0.44, P

Hemivertebrae result from a failure of complete formation of the vertebral body and present as a challenging clinical entity. Progression and ultimate curve magnitude is associated with the degree of segmentation. An accurate assessment and a close follow-up are necessary to make appropriate treatment decisions. The goal of any intervention is to stop progression and provide the smallest degree of deformity at skeletal maturity. If a high degree of deformity is anticipated, intervention should be attempted sooner rather than later. In these cases, an in situ fusion may be appropriate. Single-stage hemivertebra excision is an effective method of both correction and stabilization; however, the procedure is technically demanding.

Background Several studies have identified risk factors for proximal junctional kyphosis (PJK) after instrumentation for scoliosis, but the relative risks are unclear.

Surgery for adults with spinal deformity is undergoing a transition towards use of minimally invasive techniques that have promise to reduce procedural morbidity, speed recovery, and overall make corrective interventions more tolerable. Using a survey of the past year's literature, highlights into a

Pediatric scoliosis is a relatively uncommon condition typically first noticed due to altered stature or by routine spine screenings by a school nurse or pediatrician. The formal diagnosis is made with spine radiographs, with coronal curvature measurement of 10° or greater. Treatment may consist of serial observation, bracing until skeletal maturity, or surgery for correction and fusion/stabilization of severe or progressive deformity. Overall success for non-operative management of scoliosis is affected by the etiology for the deformity, close follow up and monitoring for evolution of the deformity, and patient compliance with their treatment regimen. The most common surgical technique is a posterior approach spine fusion with implanted instrumentation, and patients are typically back to their activities of daily living by 6 months postoperatively. Continued intermittent monitoring of the scoliosis throughout adulthood is recommended, to detect late deformity progression, development of arthritis symptoms, or other associated issues.

Nonbiological total disc replacement is currently being used for the treatment of intervertebral disc (IVD) disease and injury, but these implants are prone to mechanical wear, tear and possible dislodgement. Recently, tissue-engineered total disc replacement (TE-TDR) has been investigated as a possible alternative to more fully replicate the native IVD properties. However, the performance of TE-TDRs has not been studied in the native disc space. In this study, MRI and microcomputed tomography imaging of the rat spine were used to design a collagen (annulus fibrosus)/alginate (nucleus pulposus) TE-TDR to a high degree of geometric accuracy, with less than 10% difference between TE-TDR and the native disc dimensions. Image-based TE-TDR implants were then inserted into the L4/L5 disc space of athymic rats (n = 5) and maintained for 16 weeks. The disc space was fully or partially maintained in three of five animals and proteoglycan and collagen histology staining was similar in composition to the native disc. In addition, good integration was observed between TE-TDR and the vertebral bodies, as well as remnant native IVD tissue. Overall, this study provides evidence that TE-TDR strategies may yield a clinically viable treatment for diseased or injured IVD.

BACKGROUND CONTEXT The U.S. opioid epidemic has been declared a national public health emergency with the HHS, FDA, and CDC all taking steps to address the alarming rates of opioid addiction and abuse. Since 2000, the annual death toll from an opioid associated overdose has increased by over 300%. In an effort to reduce the amount of opioids, physicians have used alternative approaches, which have proven to not only be effective, but also reduce the side effects such as nausea, constipation, and addiction. IV acetaminophen has been shown to successfully accomplish the reduction in opioid use, however, it is an expensive alternative. Testing the efficacy of IV acetaminophen versus its oral formulation will likely modify future postoperative pain management regimens while also addressing its cost-effectiveness. PURPOSE The objective of the study is to prospectively evaluate clinical outcomes and determine the cost effectiveness of IV versus oral (PO) acetaminophen following lumbar circumferential spine surgery. STUDY DESIGN/SETTING A prospective, single center, randomized controlled trial. PATIENT SAMPLE Patients between the ages of 18-80 who underwent circumferential lumbar fusion surgery were included in the study. Patients had failed conservative management for more than 12 months. Patients were excluded if they had already undergone lumbar surgery at the index level(s), were diagnosed with osteoporosis, had dysphagia prohibiting oral administration, or had a history of substance abuse. OUTCOME MEASURES Outcome measures included opioid equivalence, length of hospital stay, VAS measurements, and Oswestry Disability Index (ODI) scores. METHODS Patients were randomized to either the IV or PO acetaminophen treatment groups. Preoperatively, patients completed a baseline analgesic regimen questionnaire, surveys including VAS, SF-12, and ODI, and were administered their first acetaminophen dose within three hours of first incision. Postoperatively, patients received seven subsequent doses of their assigned acetaminophen, with access to supplemental analgesics if needed. Analgesic usage and VAS scores were monitored until discharge. Surveys were completed at six weeks and six months follow up. RESULTS Postoperatively, the daily morphine equivalence taken by the IV acetaminophen group was 66% less than the oral acetaminophen group (p CONCLUSIONS In conjunction with an overall reduction in opioid usage, patient reported surveys indicate better improvement of pain management with the use of IV acetaminophen following circumferential lumbar spine surgery. Despite the large discrepancy between the two formulations in cost to perceived benefit ratio, by significantly reducing the opioid usage and, therefore, its costs due to associated side effects, that discrepancy becomes far less dramatic. Our findings suggest that IV acetaminophen is a safe and effective alternative to current opioid-based postoperative analgesic regimens with a promising answer to the national public health emergency plaguing communities across the U.S.

STUDY DESIGN Multi-center, retrospective review. OBJECTIVE Identify age associated clinical and radiographic features correlating with AS treatment. SUMMARY OF BACKGROUND DATA Little information exists about factors determining treatment for adult scoliosis (AS). Existing studies have not evaluated age stratified differences. METHODS Multicenter, retrospective review of 290 patients treated for AS. Patients divided into operative (OP) or nonoperative (NON), and age stratified into 3 groups (G1 = 65 years). Demographic and spinopelvic radiographic parameters evaluated. Health-related quality of life (HRQL) measures included SRS-22, Oswestry Disability Index (ODI), visual analog pain scale. RESULTS Treatment groups (OP, n = 137; NON, n = 153) demonstrated similar age (OP = 52.7 years; NON = 55.5 years; P > 0.05) and comorbidities. OP had larger thoracic curves than NON (OP = 51 degrees, NON = 45 degrees; P < 0.05). OP had worse HRQL scores than NON (SRS = 2.95 vs. 3.12, P < 0.05; ODI = 33.4 vs. 28.7, P < 0.05; visual analog pain scale = 6.9 vs. 5.6, P < 0.05, respectively). Age stratification of OP demonstrated larger curves in G1 and G2 versus G3, progressively worsening sagittal imbalance in older age groups, and worse HRQL scores in G3 versus G1 and G2. Age stratification of NON demonstrated worsening sagittal imbalance with age, however, other radiographic values and HRQL scores were similar between all NON age groups. Treatment stratification of age groups demonstrated G1-OP had greater deformity than G1-NON (mean thoracic curve: G1-OP = 53 degrees, G1-NON = 43 degrees; P < 0.05) but similar HRQL values. Whereas G2 and G3-OP had similar radiographic coronal and sagittal values as G2 and G3-NON, but worse HRQL scores. CONCLUSION Counter to previous reports, age, comorbidities, and sagittal balance did not influence treatment modality for AS. Operative treatment for younger patients was driven by increased coronal plane deformity. Conversely, pain and disability mandated treatment for older patients, independent of radiographic measures. These findings suggest that AS patients do not become uniformly disabled with age, and that disability can not be solely predicted by radiographic findings. These data should be considered when considering treatment for AS.

Growing children with intractable spinal deformity are a very challenging clinical problem. Surgical management is similarly difficult, with efforts made to preserve growth remaining in the spine and to avoid complications. The revision pediatric spinal surgeon must understand the mechanisms involved in the failure of their patient’s prior surgeries, and the surgeon needs to develop a revision strategy that will manage the identified issues, as well as those reasonably to be expected in the remainder of the patient’s growth to maturity. Reviewed here are concepts for thorough evaluation, development of a surgical revision plan, and introduction of techniques that are routinely used in revision spine surgery. Among the most powerful techniques in the “tool box” of the revision spine surgeon are spinal osteotomies, including posterior column only variations and those that traverse all three columns. Revision surgeries will at times require both an anteroposterior approach, and attempts are made to do these under a single anesthesia; however, when “softening” of the spine is required to obtain additional correction, such as with use of a halo, staging is typically well tolerated. Surgical goals for these patients include obtaining a balanced spine in both the coronal and sagittal planes, solid arthrodesis, and minimizing postoperative pain, while minimizing risk for complications and postoperative morbidity. Excellent outcomes can be expected in patients appropriately diagnosed, operated, and postoperatively convalesced.

Adult spinal deformity (ASD) patients may gain minimal clinically important difference (MCID) in one or more of the health-related quality-of-life instruments without surgical intervention. The present study identifies the baseline characteristics of this subset of nonoperative patients and proposes predictors of those most likely to benefit.The study aims to determine the factors that affect likelihood of nonoperative patients to reach MCID.This is a retrospective review of a prospective, multicenter database.The study includes nonoperative ASD patients.Health-related quality-of-life measures, including the Scoliosis Research Society (SRS)-22 questionnaire, were used.The study used a multicenter database of 215 nonoperative patients with ASD and with minimum 2-year follow-up. Using a multivariate analysis, two groups were compared to identify possible predictors: those who reached MCID in the SRS pain or activity (N=86) at 2 years and those who did not reach MCID (N=129). A subgroup multivariate analysis of patients with a deficit (potential improvement) in both SRS pain and activity (N=84) was performed. Data collection was supported by a grant from DePuy for the International Spine Study Group Foundation.At baseline, the nonoperative patients who reached MCID had a significantly lower SRS pain score (3.0 vs. 3.6), smaller thoracolumbar Cobb (TL Cobb) angle (29.6° vs. 36.5°; 87 patients with SRS-Schwab classification of lumbar or double), lower sacral slope (33.1° vs. 36.4°), and less lumbar lordosis (46.5° vs. 52.8°) (all p.05). The SRS pain and TL Cobb were significant predictors for reaching MCID. The pelvic incidence minus lumbar lordosis (PI-LL) was significant on univariate analysis but not on multivariate analysis (7.5° vs. 2.6°; p=.14). In the subset of severely disabled patients, worse vertebral obliquity was a predictor for not achieving MCID (p.05).Nonoperative ASD patients who achieved MCID in SRS activity or pain had a lower baseline SRS pain score and less coronal deformity in the TL region. Greater baseline pain offers significant room for potential improvement, which may be important in identifying ASD patients who have the potential to reach MCID nonoperatively. Coronal deformities in the TL region and associated vertebral obliquity may negatively impact potential for improvement in nonoperative care.

Lymphangiomas are a group of benign malformations of the lymphatic system, and hemolymphangioma (or hemangiolymphangioma) is a rare congenital malformation of the lymphatic system with vascular involvement. These benign malformations are most commonly diagnosed at an early age, and may be present as a part of an associated syndrome. In this case report, we describe the first case of adolescent scoliosis associated with a large, paraspinous hemolymphangioma. A 15-year-old girl with an incidental finding of a paraspinous hemolymphangioma is presented along with her history, physical exam, radiographic findings, and operative course. The possible pathogenesis, treatment approach, and clinical dilemmas are also discussed. Given the well-known relationship between tumors and scoliosis, a benign paraspinous vascular and lymphatic tumor may be responsible for the presence of scoliosis in a small number of patients.

Progressive and/or painful adult spinal deformity in the thoracolumbar and lumbar spine is sometimes treated surgically by long posterior fusions from the thoracic spine down to the pelvis, especially where there is a major thoracic curve component. Recent advances in anterior spinal instrumentation and spinal surgery technique have demonstrated the improved corrective ability offered by anterior stabilization systems, and the added benefit of limiting the number of vertebral fusion levels required for control of the deformity. The “hybrid technique” is a novel use of anterior instrumentation that applies limited anterior instrumentation down to the low lumbar spine (rods and screws), and partially overlapping short-segment posterior instrumentation to the sacrum (pedicle screws and rods). These constructs avoid posterior thoracic instrumentation and fusions, and avoid extension of posterior instrumentation to the pelvis. In the first 10 patients treated using this technique, thoracolumbar and lumbar major curve correction has averaged 71 and 82% in the immediate postoperative period (n = 7), respectively, and 59 and 68% at 2-year follow-up, respectively. The technique is an appealing and attractive alternative for treatment of thoracolumbar and lumbar scoliosis in the adult population, and avoids the requirement for applying spinal fixation to the thoracic spine and the pelvis.

Spinal infections are relatively uncommon but have potentially devastating consequences if not diagnosed and treated correctly. Compromised immunologic responsiveness, either transient or permanent, predisposes patients to more frequent and more severe infections. Through a Medline review of the English-language literature from 1990 to 2005, we examined the current understanding of the etiology of common immunocompromising conditions, how these diagnoses impact the relative spine infection rates including diagnosis and therapeutic monitoring, and practice trends regarding surgical intervention.Level V (expert opinion). Please see Guidelines for Authors for a complete description of the levels of evidence.

Nerve injuries in the upper extremity after trauma are common. Typically nerve damage is the result of traction, crush injury, ischemic insult, or direct laceration of the peripheral nerve. Examination of the literature shows that nerve damage in closed traumatic injury is much less common than in open trauma, especially when this standard is applied to closed nerve injuries distal to the wrist. We report a case of closed partial neurotomy of a common digital nerve.

Spondylolisthesis is characterized by the abnormal translation of one vertebral body on another. The exact cause of spondylolisthesis is not well understood but certainly involves specific anatomic and mechanical factors that predispose for a slip to occur. In this chapter we discuss the principle of spinal balance and the important role that sacropelvic morphology and spinopelvic alignment play in overall sagittal alignment. Patients with high pelvic incidence with associated increased pelvic tilt are at high risk for progression of spondylolisthesis due to the large shear forces present at the lumbosacral junction. Lastly, we describe the different types of dysplasia that can occur at the lumbosacral junction, including a domed S1 endplate, lumbosacral kyphosis, and dysplasia at the pedicles, lamina, or facets. These anatomic and biomechanical factors are critical to understanding the pathogenesis and risk for progression of spondylolisthesis and help guide both non-operative and operative treatment.