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The study objectives were to use a large national claims data resource to examine rates of preoperative epidural steroid injections (ESI) in lumbar spine surgery and determine whether preoperative ESI or the timing of preoperative ESI is associated with rates of postoperative complications and reoperations. A retrospective longitudinal analysis of patients undergoing lumbar spine surgery for disc herniation and/or spinal stenosis was undertaken using the MarketScan® databases from 2007–2015. Propensity-score matched cohorts were constructed to compare rates of complications and reoperations in patients with and without preoperative ESI. Within the year prior to surgery, 120,898 (46.4%) patients had a lumber ESI. The median time between ESI and surgery was 10 weeks. 23.1% of patients having preoperative ESI had more than one level injected, and 66.5% had more than one preoperative ESI treatment. Patients with chronic pain were considerably more likely to have an ESI prior to their surgery [OR 1.62 (1.54, 1.69), p

Background Total knee arthroplasty (TKA) and lumbar spine surgery have been reported to affect the outcomes of each other. There is insufficient evidence to guide the choice of treatment order for patients with both disorders that are equally symptomatic. Methods Five clinical scenarios of concurrent, advanced, degenerative knee and lumbar spinal disorders were designed to survey surgeons’ choices of treatment order and rationale. The spinal disorder was consistently degenerative lumbar spinal stenosis, but the knee conditions varied to include (1) osteoarthritis (OA) with varus deformity, (2) OA with valgus deformity, (3) rheumatoid arthritis with a severe flexion contracture, (4) OA without deformity, and (5) bilateral OA with windswept deformities. The survey was distributed to selected clinical members of the Knee Society and Scoliosis Research Society in North America. The surgeons’ choices were compared among the 5 scenarios, and their comments were analyzed using text-mining. Results Responses were received from 42 of 74 (57%) knee arthroplasty surgeons and 55 of 100 (55%) spine surgeons. The percentages of knee arthroplasty surgeons recommending “TKA first” differed significantly among scenarios: 29%, 79%, 55%, 7%, and 81% for scenarios 1 through 5, respectively (P Conclusion For patients with concurrent degenerative knee and lumbar spinal disorders, the severity and type of knee deformity influenced the preference of treatment order in both specialties. Severe valgus deformity and windswept deformities of the knee would drive the decision toward “TKA first.”

BACKGROUND CONTEXT 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. PURPOSE 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. STUDY DESIGN/SETTING Review of radiological reports using the technique of text-mining, followed by a survey of surgeons. PATIENT SAMPLE A total of 210 patients diagnosed with nontraumatic cervical spinal disorders at our hospital, and 24 senior spine surgeons nationwide. OUTCOME MEASURES 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. METHODS 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. RESULTS 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. CONCLUSIONS 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. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

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 prior to 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 35-54 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.

Βackground Both limb length inequality and scoliosis are associated with pelvic obliquity. Methods This is an observational study of adolescents with growth potential presenting for evaluation of thoracic or thoracolumbar idiopathic scoliosis at an outpatient pediatric orthopedic clinic. Patients were evaluated for limb length discrepancy (LLD) (using bilateral femoral head height difference), pelvic obliquity (using bilateral iliac crest height difference and sacral takeoff angle), and scoliotic curve (using Cobb angle and rotation) on full spine standing radiographs. The same radiographic parameters were measured at a follow-up visit at least 2 years later. Results Seventy-three consecutive patients with a mean (SD) age of 13.3 (0.2) years at initial examination were included in the study. Scoliosis (major curve Cobb angle ≥ 10°) was confirmed in all 73 patients, pelvic obliquity (iliac crest height difference > 1 cm or sacral takeoff angle > 5°) appeared in 23 (31.5%) patients with scoliosis, and LLD (> 1 cm femoral head height difference) was identified in 6 (8.2%) patients with scoliosis and pelvic obliquity. At a subsequent visit, a mean of 2.8 (range 2–5.8) years later, no significant change (p > 0.05) in limb length inequality was observed but a statistically significant increase (p

This is a retrospective study.To compare (1) recurrence of radiculopathy and (2) back pain after decompression with and without fusion for patients with a symptomatic synovial cyst.Previous work described favorable outcomes following cyst excision with and without fusion. Because of the association of facet cysts with spinal instability it is hypothesized that a decompression with fusion will lead to better outcomes. However, previous studies present contradicting results.We included 314 consecutive patients that underwent operative treatment for a facet cyst between 2003 and 2013 at 2 tertiary spine referral centers: 224 (71%) underwent decompression without fusion (35% spondylolisthesis), 90 (29%) underwent decompression with fusion (63% spondylolisthesis). Baseline data were compared between the groups. Bivariate log-rank analysis was used to compare outcomes between groups, followed by multivariable Cox regression analysis accounting for differences in baseline characteristics.Patients undergoing decompression with fusion presented with a higher incidence of back pain (P=0.004) and spondylolisthesis (P0.001), had more often bilateral decompressions (P0.001), more facetectomies (P0.001), and more levels of decompression (P=0.004) than those who underwent decompression alone. We found a difference in recurrence of radiculopathy (no fusion: 25% vs. fusion: 9.4%, P=0.029) in bivariate analysis. However, this difference did not hold when accounting for confounders (hazard ratio, 0.50, 95% confidence interval, 0.19-1.31, P=0.16). There was no difference in recurrence of back pain in bivariate (no fusion: 29% vs. fusion: 22%, P=0.51) and multivariable analysis (hazard ratio 0.51, 95% confidence interval, 0.23-1.14, P=0.10).We found, with the numbers evaluated, no difference in recurrence of radiculopathy or back pain between patients undergoing decompression with or without fusion after accounting for confounders. The decision for fusion should be considered in light of the extent of decompression and the existence of other pathology.Level III-therapeutic study.

Study design This was a retrospective cohort study. Objective The objective of this study was to compare implant-related complications between mixed-metal and same-metal rod-screw constructs in patients who underwent posterior fusion for adult spinal deformity. Summary of background data Contact between dissimilar metals is discouraged due to potential for galvanic corrosion, increasing the risk for metal toxicity, infection, and implant failure. In spine surgery, titanium (Ti) screws are most commonly used, but Ti rods are notch sensitive and likely more susceptible to fracture after contouring for deformity constructs. Cobalt chrome (CC) and stainless steel (SS) rods may be suitable alternatives. No studies have yet evaluated implant-related complications among mixed-metal constructs (SS or CC rods with Ti screws). Methods Adults with spinal deformity who underwent at least 5-level thoracic and/or lumbar posterior fusion or 3-column osteotomy between January 2013 and May 2015 were reviewed, excluding neuromuscular deformity, tumor, acute trauma or infection. Implant-related complications included pseudarthrosis, proximal junctional kyphosis, hardware failure (rod fracture, screw pullout or haloing), symptomatic hardware, and infection. Results A total of 61 cases met inclusion criteria: 24 patients received Ti rods with Ti screws (Ti-Ti, 39%), 31 SS rods (SS-Ti, 51%), and 6 CC rods (CC-Ti, 9.8%). Median follow-up was 37-42 months for all groups. Because of the limited number of cases, the CC-Ti group was not included in statistical analyses. There were no differences between Ti-Ti and SS-Ti groups with regard to age, body mass index, or smokers. Implant-related complications did not differ between the Ti-Ti and SS-Ti groups (P=0.080). Among the Ti-Ti group, there were 15 implant-related complications (63%). In the SS-Ti group, there were 12 implant-related complications (39%). There were 3 implant-related complications in the CC-Ti group (50%). Conclusion We found no evidence that combining Ti screws with SS rods increases the risk for implant-related complications.

Background With the use of constrained condylar knee (CCK) prostheses, dislocation of the knee following total knee arthroplasty (TKA) with valgus deformity is rare. In our practice with such patients, however, an abnormally high dislocation rate was noted. It appeared to be associated with the extent of soft-tissue release which varied among surgeons following different sequences of release. We asked in CCK TKA with valgus deformity is releasing both the lateral collateral ligament (LCL) and popliteus tendon (PT) associated with the occurrence of dislocation. Methods This is a case-control study of consecutive patients with valgus deformity who underwent primary CCK TKA between July 2008 and October 2015. The cases and controls were patients with and without postoperative dislocation of the knee, respectively. The extent of the release of lateral soft-tissue structures was compared between the two groups. Other patient characteristics including age, body mass index, pre- and post-operative valgus deformity, preoperative flexion-contracture, and height of the polyethylene insert were compared as well to reduce confounding. Results Forty-three consecutive patients with a minimum 2-year follow-up were enrolled. 9.3% (4/43) of the patients had postoperative dislocation of the knee. While the dislocated patients did not significantly differ from the controls on most characteristics, they were more likely to have both the LCL and PT released together during the surgery [100% (4/4) vs. 2.6% (1/39), P

Aims Patients may present with concurrent symptomatic osteoarthritis (OA) of the hip and degenerative disorders of the lumbar spine, with surgical treatment being indicated for both. Whether arthroplasty of the hip or spinal surgery should be performed first remains uncertain. Materials and Methods Clinical scenarios were devised for a survey asking the preferred order of surgery and the rationale for this decision for five fictional patients with both OA of the hip and degenerative lumbar disorders. These were symptomatic OA of the hip and: 1) lumbar spinal stenosis with neurological claudication; 2) lumbar degenerative spondylolisthesis with leg pain; 3) lumbar disc herniation with leg weakness; 4) lumbar scoliosis with back pain; and 5) thoracolumbar disc herniation with myelopathy. This survey was sent to 110 members of The Hip Society and 101 members of the Scoliosis Research Society. The choices of the surgeons were compared among scenarios and between surgical specialties using the chi-squared test. The free-text comments were analyzed using text-mining. Results Responses were received from 51 hip surgeons (46%) and 37 spine surgeons (37%). The percentages of hip surgeons recommending ‘hip first’ differed significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (p < 0.001). The percentages of spine surgeons recommending ‘hip first’ were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the groups for scenarios 3 (more hip surgeons recommended ‘hip first’; p = 0.012) and 4 (more hip surgeons recommended ‘spine first’; p = 0.006). Conclusion In patients with coexistent OA of the hip and degenerative disorders of the spine, the question of ‘hip or spinal surgery first’ elicits relatively consistent answers in some clinical scenarios, but remains controversial in others, even for experienced surgeons. The nature of neurological symptoms can influence surgeons’ decision-making. Cite this article: Bone Joint J 2019;101-B(6 Supple B):37–44.

Overgrowth of epidural fat, known as spinal epidural lipomatosis (SEL), can cause symptomatic compression of the spinal cord, conus medullaris, or cauda equina. Suggested predisposing factors such as obesity, steroid use, and diabetes mellitus have been based on a few reported cases, many of which were not surgically confirmed. There is a paucity of epidemiological data in surgically confirmed cases for this disorder. The purpose of this independently reviewed, retrospective, matched cohort analysis was to compare the demographics and incidence of comorbidities of patients who underwent lumbar decompression for SEL vs degenerative stenosis without SEL. Two surgeons' databases were reviewed to identify patients older than 18 years who underwent decompression surgery for magnetic resonance imaging–verified, symptomatic lumbar SEL. A matched control group comprised an equal number of patients with degenerative stenosis (n=14). Demographic data, body mass index, symptom type/duration, comorbidities, complications, treatment history, and associated pathology were collected from medical records. Previously suggested risk factors, such as obesity, endocrinopathy, and epidural steroid injections, were not significantly different between the SEL and control groups. Furthermore, there were no differences in operative times, complications, or blood loss. The only noted difference between the 2 groups was the preoperative duration of symptoms, on average double in patients with SEL. This series represents the largest of its kind reported to date. Because symptom duration was the only difference noted, it is postulated to be the result of lack of awareness of SEL. Future prospective study in a larger group of patients is warranted. [ Orthopedics. 2016; 39(3):163–168.]

BACKGROUND CONTEXT Little information exists on the time course of patient health care resource utilization (HRCU) and direct costs in the years preceding and following spine surgery. PURPOSE 1) Better understand trends in HRCU and direct costs in patients undergoing lumbar spine surgery 2) Identify groups of patients with similar patterns of health care utilization STUDY DESIGN/SETTING Retrospective national claims data cohort (Marketscan® 2007—2015) PATIENT SAMPLE Adult patients undergoing primary single level lumbar surgery for stenosis (n=17,466, age 58.5±12.8 years, 49.9% female) OUTCOME MEASURES N(%) using each service category and total direct costs (2015 US$) per month. METHODS The percentage of patients using each service category and direct health care costs were tracked for 2 years pre- and postop. Group-based trajectory modelling was used to identify subgroups of patients following similar patterns in HRCU. Patient and surgical factors related to these patterns were examined via multivariable regression. RESULTS Prior to surgery, there was a gradual increase in median direct health care costs per patient, which accelerated in the 6 months before surgery. This was driven by increased office visits, medication use, radiology, injections, and physical therapy (PT). Healthcare costs decreased gradually after surgery, as prescription medication, PT, home health services, and radiology use decreased, with costs plateauing by 16 months. At this point, 67% of patients had lower costs relative to 2 years preop (median: -$592 [IQR: -$202, -$1626]/month); however, 27% had increased healthcare costs (median: $409 [IQR: $128, $1401]/month). Four patterns in costs were identified both pre- and postop. The strongest predictor of membership in the high preop cost group (59% of patients, direct costs during 2 years preop=$9,806) was a diagnosis of depression (Odds ratio 9.1 [95% CI: 4.7, 20.2]; p CONCLUSIONS Four patterns of HRCU were identified in patients undergoing primary single level lumbar surgery for stenosis. While 2/3 of patients had lower costs after surgery, patients with high costs preop were most likely to have high costs postop; and nearly 20% of patients in the lower costs groups transitioned to the high cost following surgery. Patient factors and postop complications were associated with transitioning from a low preop cost group to a high postop cost group. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Low back pain is one of the most common chronic pain conditions and pain medication use is common among lumbar spine surgery patients. Patients undergoing spine surgery have an increased risk for chronic opioid dependence, which is associated with poorer outcomes and increased surgical costs. However, details of specific patterns of opioid and non-opioid pain medication use pre- and postsurgery and how these might relate to chronic use are not well understood. PURPOSE 1) Characterize patterns in prescription medication use before and after surgery for lumbar spinal stenosis; 2) Identify phenotypes of patients that have similar patterns of medication utilization. STUDY DESIGN/SETTING Retrospective analysis of national claims data (Marketscan® 2007—2015). PATIENT SAMPLE Adult patients undergoing primary single level lumbar surgery for a diagnosis of stenosis (n=17,466, age 58.5±12.8 years, 49.9% female). Patients were required to have continuous enrollment in a health plan providing outpatient pharmacy data for at least 2 years before and after surgery to track medication usage and costs. OUTCOME MEASURES Percentage of patients using each class of pain medication pre- and postoperatively, median morphine milligram equivalents (MME), and medication costs (2015 US$). METHODS We conducted a retrospective analysis of national claims data (Marketscan® 2007—2015)Adult patients undergoing primary single level lumbar surgery for a diagnosis of stenosis (n=17,466, age 58.5±12.8 years, 49.9% female). Patients were required to have continuous enrollment in a health plan providing outpatient pharmacy data for at least 2 years before and after surgery to track medication usage and costs. RESULTS Median annual prescription costs were $1,810 (IQR: $410, $4,423) 2 years prior to surgery and $2,125 (IQR: $604, $4,908) in the year prior to surgery. Postoperatively, annual prescription costs were $2,021 (IQR: $553, $4,826) in the first year and $1,656 (IQR: $286, $4,697) in the second year. The percentage of patients taking opioids prior to surgery increased dramatically leading up to surgery and remained elevated 2 years postsurgery. To a lesser degree, the percentage of patients taking anxiolytics, muscle relaxants, and anticonvulsants also increased prior to surgery and remained elevated 2 years post-surgery. 84.3% of patients used opioids in the two years preoperatively, while 95.2% used opioids in the 2 years postoperatively. Of all prescriptions filed, the 3 most common opioid medications were hydrocodone bitartrate-acetaminophen (54.3%), oxycodone HCl-acetaminophen (15.6%), and oxycodone-HCl (5.5%). While the number of users increased dramatically leading up to surgery, in opioid users, the median dose of opioids taken remained relatively stable. However, the median MME taken per patient per month remained elevated 2 years after surgery (720 MME/month 2 years postop vs 492 MME 2 years preop). CONCLUSIONS The proportion of patients taking prescription drugs increased in the months leading up to spine surgery, and in many cases remained elevated 2 years postsurgery. In particular, the proportion of patients using opioids never dropped to levels observed 2 years preoperatively and opioid users were taking greater quantities of opioids 2 years postoperatively than they were 2 years preoperatively. Spine surgery has a lasting impact on medication use patterns. However, we hope that with greater attention paid to medication use, better progress can be made in the future to reverse these patterns. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Retrospective review and prospective validation study.To develop a classification system of lumbar lateral listhesis that suggests different likelihoods of having radiculopathy in adult scoliosis.The association of lumbar lateral listhesis with radiculopathy remains uncertain.A retrospective cohort of patients with adult scoliosis enrolled from 2011 to 2015 was studied to develop a classification system of lateral listhesis that can stratify the likelihood of having radiculopathy. Four radiological aspects of lateral listhesis, including Nash and Moe vertebral rotation, L4-L5 lateral listhesis, the number of consecutive listheses, and the presence of a contralateral lateral listhesis at the thoracolumbar junction above a caudal listhesis, were evaluated on radiographs. Their associations with the presence of radicular leg pain were evaluated using multivariable logistic regression. The classification system of lateral listhesis was thus developed using the most influential radiological factors and then validated in a prospective cohort from 2016 to 2017.The retrospective cohort included 189 patients. Vertebral rotation is more than or equal to grade 2 (odds ratio [OR] = 9.45, 95% confidence interval [CI]: 4.07-25.14) and L4-5 listhesis (OR = 4.56, 95%CI: 1.85-12.35) were the two most influential listhesis factors associated with radiculopathy. The classification system of lateral listhesis was thus built based on the combinations of their respective presence: Type 0, 1, 2, 3 were defined as not having listhesis at all, none of the two factors present, one of the two presents, and both present, respectively. This classification significantly stratified the probability of radiculopathy, in both the retrospective cohort (0%, 6.4%, 33.8%, and 68.4% in Type 0, 1, 2, and 3, respectively; P 0.001) and a prospective cohort of 105 patients (0%, 16.7%, 46.9%, and 72.7%; P 0.001).Lumbar lateral listhesis is associated with the presence of radiculopathy in adult scoliosis. Types 2 and 3 lateral listhesis on radiographs may alert surgeons treating patients with spinal deformity.2.

This is a retrospective cohort study.To evaluate the long-term outcomes of selective one- to two-level anterior lumbar interbody fusions (ALIFs) in the lower lumbar spine versus continued nonsurgical management.Low back pain associated with lumbar intervertebral disc degeneration is common with substantial economic impact, yet treatment remains controversial. Surgical fusion has previously provided mixed results with limited durable improvement of pain and function.Seventy-five patients with one or two levels of symptomatic Pfirrmann grades 3 to 5 disc degeneration from L3-S1 were identified. All patients had failed at least 6 months of nonsurgical treatment. Forty-two patients underwent one- or two-level ALIFs; 33 continued multimodal nonsurgical care. Patients were evaluated radiographically and the visual analog pain scale (VAS), Oswestry Disability Index (ODI), EuroQol five dimensions (EQ-5D), and Patient-Reported Outcomes Measurement Information System scores for pain interference, pain intensity, and anxiety. As-treated analysis was performed to evaluate outcomes at a mean follow-up of 7.4 years (range: 2.5-12).There were no differences in pretreatment demographics or nonsurgical therapy utilization between study arms. At final follow-up, the surgical arm demonstrated lower VAS, ODI, EQ-5D, and Patient-Reported Outcomes Measurement Information System pain intensity scores versus the nonsurgical arm. VAS and ODI scores improved 52.3% and 51.1% in the surgical arm, respectively, versus 15.8% and -0.8% in the nonsurgical arm. Single-level fusions demonstrated improved outcomes versus two-level fusions. The pseudarthrosis rate was 6.5%, with one patient undergoing reoperation. Asymptomatic adjacent segment degeneration was identified in 11.9% of patients.Selective ALIF limited to one or two levels in the lower lumbar spine provided improved pain and function when compared with continued nonsurgical care. ALIF may be a safe and effective treatment for low back pain associated with disc degeneration in select patients who fail nonsurgical management.3.

BACKGROUND CONTEXT 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. PURPOSE To compare, in spine and arthroplasty surgeons respectively, the treatment order preference among four typical scenarios of hip-spine syndrome with different neurological symptoms. STUDY DESIGN/SETTING Prospective survey at a professional society level. PATIENT SAMPLE Eighty-eight experienced spine (37) and total hip arthroplasty (51) surgeons from the Scoliosis Research Society (SRS) and The Hip Society, respectively. OUTCOME MEASURES Percentage of surgeons, in each specialty, choosing "spine first" in each scenario. METHODS 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. RESULTS 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. CONCLUSIONS 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. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Study design Prospective cohort study in consecutive patients. Objective To investigate and compare the use of 2 diagnostic modalities in the evaluation of stability in lumbar spondylolisthesis. Summary of background data Evaluating potential instability in lumbar spondylolisthesis is significant to its management. Lateral lumbar flexion-extension (FE) radiograph is frequently obtained on the basis of a thought that this forward-backward movement can actually describe hypermobility at the listhetic segment. However, simply comparing standard upright lumbar lateral radiograph (U) with a supine sagittal magnetic resonance image (S) (combined, US), something typically conducted for patients with lumbar spondylolisthesis, may also be used. Methods This prospective study included a cohort of 68 consecutive patients with lumbar spondylolisthesis seen in the outpatient clinic of a single hospital. The mobility observed in US was compared with that observed in FE. The ability to identify "instability" using US was compared with that using FE. In addition, the relationships between mobility determined using FE or US and sex, age, height, weight, body mass index, primary symptom (with or without back pain), nature of spondylolisthesis (degenerative or isthmic), listhetic segment, slippage grade, and focal disc height were examined. Results Overall, the mobility in US was significantly higher than that in FE (7.68 ± 5.34% vs. 4.90 ± 3.82%, t =-3.545, P = 0.001). The ability to identify "instability" on the basis of US was improved compared with that obtained using FE. Female patients demonstrated higher mobility in FE than male patients to a significant degree. Back pain, isthmic spondylolisthesis, and slippage grade also showed some relevance with mobility but without statistical significance. Conclusion US may offer an easily available, alternative diagnostic modality in lumbar spondylolisthesis, with the potential of reducing both radiation exposure and costs. Further studies should focus on its influence in clinical decision making. Level of evidence 2.

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.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.This is a retrospective cohort study from a tertiary care spine referral center.A total of 3,721 patients underwent laminectomy and/or arthrodesis of the lumbar spine.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.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.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.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.

Background: We previously reported that functional recovery of rats with spinal cord contusions can occur after acute transplantation of neural stem cells distal to the site of injury. To investigate the effects of timing of administration of human neural stem cell (hNSC) distal to the site of spinal cord injury on functional outcomes in an animal model. Methods: Thirty-six adult female Long-Evans hooded rats were randomized into three experimental and three control groups with six animals in each group. The T10 level was exposed via posterior laminectomy, and a moderate spinal cord contusion was induced by the Multicenter Animal Spinal Cord Injury Study Impactor (MASCIS, W.M. Keck Center for Collaborative Neuroscience, Piscataway, NJ, USA). The animals received either an intrathecal injection of hNSCs or control media through a separate distal laminotomy immediately, one week or four weeks after the induced spinal cord injury. Observers were blinded to the interventions. Functional assessment was measured immediately after injury and weekly using the Basso, Beattie, Bresnahan (BBB) locomotor rating score. Results: A statistically significant functional improvement was seen in all three time groups when compared to their controls (acute, mean 9.2 vs. 4.5, P=0.016; subacute, mean 11.1 vs. 6.8, P=0.042; chronic, mean 11.3 vs. 5.8, P=0.035). Although there was no significant difference in the final BBB scores comparing the groups that received hNSCs, the group which achieved the greatest improvement from the time of cell injection was the subacute group (+10.3) and was significantly greater than the chronic group (+5.1, P=0.02). Conclusions: The distal intrathecal transplantation of hNSCs into the contused spinal cord of a rat led to significant functional recovery of the spinal cord when injected in the acute, subacute and chronic phases of spinal cord injury (SCI), although the greatest gains appeared to be in the subacute timing group.

Evidence-based systematic review.To define the optimal treatment of fractures involving the C2 body, including those with concomitant injuries, based upon a systematic review of the literature.Axis body fractures have customarily been treated nonoperatively, but there are some injuries that may require operative intervention. High-quality literature is sparse and there are few class I or class II studies to guide treatment decisions.A literature search was conducted using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials, and Scopus (EMBASE, MEDLINE, COMPENDEX). The quality of literature was rated according to a grading tool developed by the Center for Evidence-based Medicine. Operative and nonoperative treatment of axis body fractures were compared using fracture bony union as the primary outcome measure. As risk factors for nonunion were not consistently reported, cases were analyzed individually.The literature search identified 62 studies, of which 10 were case reports which were excluded from the analysis. A total of 920 patients from 52 studies were included. The overall bony union rate for all axis body fractures was 91%. Although the majority of fractures were treated nonoperatively, there has been an increasing trend toward operative intervention for Benzel type III (transverse) axis body fractures. Nearly 76% of axis body fractures were classified as type III fractures, of which 88% united successfully. Nearly all Benzel type I and type II axis body fractures were successfully treated nonoperatively. The risk factors for nonunion included: a higher degree of subluxation, fracture displacement, comminution, concurrent injuries, delay in treatment, and older age.High rates for fracture union are reported in the literature for axis body fractures with nonoperative treatment. High-quality prospective studies are required to develop consensus as to which C2 body fractures require operative fixation.

OBJECTIVEThis study aimed to compare the clinical results of using posterior fixation and fusion with or without anterior decompression to treat os odontoideum with atlantoaxial dislocation.METHODSTwenty-five consecutive patients with os odontoideum were included in this study. Sixteen patients with reducible atlantoaxial dislocation were treated by single-level posterior fusion and stabilization; the other 9 were treated with posterior fusion and stabilization combined with transoral decompression. Pre- and postoperative CT scans and MR images were obtained.RESULTSTwenty-four patients were followed for 24–54 months (average 36.5 months). Postoperative CT scans indicated that all pedicle screws were placed satisfactorily except in 2 cases, in which the screws slightly penetrated the transverse foramen. Postoperative MR images demonstrated that sufficient decompression of the spinal cord was obtained in all patients. Complications included 1 case each of pedicle screw breakage, pharynx ulcer, and persistent pharynx discomfort. Statistical analysis of all cases revealed that mean Japanese Orthopaedic Association scores improved from a preoperative score of 10.2 (range 7–13) to a postoperative score of 15.6 (range 11–18).CONCLUSIONSPatients who have os odontoideum with a reducible atlantoaxial dislocation can be effectively treated with single-level posterior fusion and stabilization. Combined transoral decompression and posterior fusion and stabilization is recommended for those with irreducible atlantoaxial dislocation.

STUDY DESIGN Cross-sectional study reviewing 62 magnetic resonance imaging or computed tomography scans from consecutive adult patients with scoliotic spinal deformity in the thoracolumbar spine. OBJECTIVE To investigate the variation in anatomic position of retroperitoneal vessels in relationship to curve direction, location, magnitude, and axial rotation of curves in adult scoliosis. SUMMARY OF BACKGROUND DATA The minimally invasive lateral approach to the thoracolumbar spine avoids manipulation of abdominal and retroperitoneal structures and decreases risk of injury to paraspinal musculature. In adult patients with scoliosis, the varying anatomic relationship between retroperitoneal vessels and intervertebral disk spaces can increase the risk of vascular injury. MATERIALS AND METHODS Axial images were used to measure the anterior-posterior diameter of the inferior vertebral endplate with respect to the disk space perpendicular to the widest length of the disk. The overlap of the retroperitoneal vessels with the endplate were measured at the cephalad end vertebra, apex, and caudad end vertebra of each curve. Overlap and accessible disk space for individual disk spaces were also measured. RESULTS There was a significant difference in percentage overlap of the apex and cephalad vertebral endplate and inferior vena cava in right versus left-sided curves (P=0.002). Overlap between the inferior vertebral endplate and inferior vena cava at the cephalad, apex, and caudad end of the curve was significantly different between thoracolumbar and lumbar curves (P

STUDY DESIGN Retrospective radiographic study. OBJECTIVE To radiographically evaluate sagittal plane profile and fusion rates of polyetheretherketone (PEEK) cages versus femoral ring allografts (FRAs) in patients with adult spinal deformity fused to the sacrum. SUMMARY OF BACKGROUND DATA FRAs have been widely used in various degenerative lumbar spine disorders and in adult deformity to achieve interbody fusions with promising results. PEEK cages have gained increasing popularity of late; however, there is little documentation to the radiographic comparisons between PEEK cages and FRAs used in patients with adult spine deformity treated with long fusions to the sacrum. METHODS From March 2006 to February 2010, we analyzed 48 patients (mean age, 56.3±13.9 y) of 61 consecutive adult patients with global coronal and sagittal adult spine deformities who underwent first stage ALIF using PEEK cages or FRAs at L4-L5, L5-S1 segments followed by long (>6 levels) posterior instrumentation. PEEK cages and FRAs were used randomly according to surgeon's preference. Two independent observers retrospectively evaluated preoperative and postoperative disk height, foraminal height, segmental lordosis, and the interbody fusion rates at different postoperative intervals. RESULTS Both PEEK cages and FRAs significantly (P

Objective The aim of this study is to evaluate prospectively the efficacy of caudal epidural steroid injection (CESI) and transforaminal epidural steroid injection (TFESI) in lumbar spinal stenosis patients with sciatic pain. Design Prospective clinical study. Setting and Patients Thirty-one patients (average age 62 years) from two hospitals, with single dermotomal distribution of sciatic pain due to spinal stenosis were included in the study. Interventions Patients underwent epidural steroid injections done by the same injectionist. Eleven patients from one hospital were included in the CESI group, while the TFESI group consisted of 20 comparable patients from the second site. Outcome Measures Primary outcome measure was the complete relief or at least 50% reduction of pain (visual analog scale [VAS]) at 6 months postinjection. Secondary outcome measures were the improvement of function (of at least 15 points of Oswestry Disability Index [ODI]) at 6 months and the changes of VAS and ODI and at 2 weeks, at 3 months, and at 6 months postinjection. Results A significantly greater number of stenosis patients showed pain relief at 6 months postinjection with TFSI (90%) than with CESI (54.54%). All patients with TFSI showed improvement of function at 6 months while only three (27.27%) patients with caudal epidural improved functionally. Out of the total 31 patients, two patients from group A underwent a second CESI at 15 days postinjection and decompressive spine surgery between 3 and 6 months postinjection. Conclusions The effectiveness of transforaminal steroid injection for the stenosis patients with sciatica was superior to caudal at 6 months postinjection.

BACKGROUND CONTEXT 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. PURPOSE To develop and validate a radiographic classification system of lumbar lateral listhesis that stratifies the probability of having radicular leg pain in adult scoliosis. STUDY DESIGN/SETTING Derivation and validation of a risk-based classification system, at a tertiary university hospital. PATIENT SAMPLE A total of 294 consecutive adult scoliosis patients enrolled in a retrospective derivation cohort (189 patients) and a prospective validation cohort (105 patients). OUTCOME MEASURES 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. METHODS 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. RESULTS 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 CONCLUSIONS 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. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

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.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.A case-control study.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.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).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.

STUDY DESIGN Multicenter, retrospective series. OBJECTIVE To analyze the incidence, mode, and location of acute proximal junctional failures (APJFs) after surgical treatment of adult spinal deformity. SUMMARY OF BACKGROUND DATA Early proximal junctional failures above adult deformity constructs are a serious clinical problem; however, the incidence and nature of early APJFs remain unclear. METHODS A total of 1218 consecutive adult spinal deformity surgeries across 10 deformity centers were retrospectively reviewed to evaluate the incidence and nature of APJF, defined as any of the following within 28 weeks of index procedure: minimum 15° post-operative increase in proximal junctional kyphosis, vertebral fracture of upper instrumented vertebrae (UIV) or UIV + 1, failure of UIV fixation, or need for proximal extension of fusion within 6 months of surgery. RESULTS Sixty-eight APJF cases were identified out of 1218 consecutive surgeries (5.6%). Patients had a mean age of 63 years (range, 26-82 yr), mean fusion levels of 9.8 (range, 4-18), and mean time to APJF of 11.4 weeks (range, 1.5-28 wk). Fracture was the most common failure mode (47%), followed by soft-tissue failure (44%). Failures most often occurred in the thoracolumbar region (TL-APJF) compared with the upper thoracic region (UT-APJF), with 66% of patients experiencing TL-APJF compared with 34% experiencing UT-APJF. Fracture was significantly more common for TL-APJF relative to UT-APJF (P = 0.00), whereas soft-tissue failure was more common for UT-APJF (P < 0.02). Patients experiencing TL-APJF were also older (P = 0.00), had fewer fusion levels (P = 0.00), and had worse postoperative sagittal vertical axis (P < 0.01). CONCLUSION APJFs were identified in 5.6% of patients undergoing surgical treatment of adult spinal deformity, with failures occurring primarily in the TL region of the spine. There is evidence that the mode of failure differs depending on the location of UIV, with TL failures more likely due to fracture and UT failures more likely due to soft-tissue failures.

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.

Introduction: Rotatory olisthesis is a common finding of adult degenerative scoliosis. An in vitro model of rotatory olisthesis of the lumbar spine and its correlation with the center of rotation (COR) and lumbosacral lordosis (L3eS1) are presented. Methods: Different centers of rotation and various angles of lumbosacral lordosis were tested for the production of rotatory olisthesis. The radiological finding of rotatory scoliosis was excacerbated with the center of rotation lying in the posterior column and with a normolordotic or hyperlordotic lumbosacral spine. Twenty-one synthetic models of L3esacrum with simulation of certain anatomic restraints (ligaments and capsules) and disc disruption at L4eL5 were used. The COR was reproduced at the anterior, middle, or posterior column. A combination of a constant axial load at the lateral side of the upper vertebra and a similar size contralateral-side horizontal axial rotation force at the level of L4 vertebral body were applied to produce a rotatory olisthesis. The loaded specimens were immobilized at the end of the dynamic procedure and were imaged in two planes by fluoroscopy. The lateral and anteroposterior olisthesis at L4eL5 levels as well as L3eL5 scoliotic, L3eS1 lordotic Cobb angles and L4eL5 intervertebral rotation were measured. Results: The radiologic finding of rotatory olisthesis (translation > 1mm with rotation) appeared in the spinal units with the COR in the posterior column, although olisthesis was less than 1mm in specimens with the COR in the anterior or middle column. With COR in the posterior column and 40 to 60 of L3eS1 lordosis, rotatory olisthesis at the L4eL5 level was produced with anteroposterior olisthesis as the main component (p ! .05). In specimens with 20 to 40 lordosis, lateral olisthesis was the main component of rotatory olisthesis (p ! .05), and in less than 20 lordosis, rotatory olisthesis was minimum (translation less than 1 mm). Conclusion: During an in vitro study for the appearance of rotatory olisthesis in the lumbar spine, the COR has been identified to lie in the posterior elements. The main component of rotatory olisthesis is anteroposterior olisthesis and lateral olisthesis in normolordotic and hypolordotic lumbosacral spine, respectively. The described model of rotatory olisthesis in the lumbar spine may serve as a guide for the formation of this deformity and can be the base for future research in the treatment of rotatory olisthesis in degenerative lumbar scoliosis. 2013 Scoliosis Research Society.

In vivo patient biomechanical study.To investigate the dimensions of lumbar intervertebral foramen (LIVF) of patients with degenerative disc disease (DDD) during a flexion-extension motion of the body.LIVF narrowing may result in nerve root compression. The area changes of degenerated and adjacent nondegenerated LIVFs in DDD patients under physiologic loading conditions are unknown.Nine symptomatic low back pain patients with radiological evidence of L4-S1 DDD were recruited. Each subject was magnetic resonance imaging scanned for construction of three-dimensional lumbar vertebral models, and fluoroscopically imaged when the body extended from 45 flexion to full extension for reconstruction of LIVF dimensions. The data of the adjacent segment L3/4 and diseased segments L4/5 and L5/S1 were compared with a normal control group at 45 flexion, upright, and full extension of the body.The mean LIVF areas of DDD segments were significantly smaller than those of the normal subjects in all positions (P 0.05). In upright position, the LIVF areas of the DDD patients were 32.8% and 33.6% smaller than the normal subjects for L4/5 and L5/S1, respectively. For the adjacent L3/4, the LIVF area of the DDD patients was 32.3% smaller than that of the normal controls (P 0.05). The total change of L3/4 LIVF area in DDD patients from flexion to extension was significantly smaller than that of the normal subjects, but the changes in L4/5 and L5/S1 LIVF areas were similar between the two groups (P 0.05).Similar reductions of the LIVF dimensions were observed at the adjacent and the involved levels of the DDD patients, implying that biomechanical changes might have already occurred at the adjacent segment despite the lack of radiographic evidence of degeneration. Subsequent research should focus on the effects of surgical fusion on the biomechanical features of the adjacent segment.N/A.

Burst fractures of the thoracolumbar spine are a common injury and can be source of great pain and disability. Fortunately, in most instances, treatment can be nonoperative with excellent results. However, there are certain situations in which a surgical approach may be indicated: a fracture with a significant neurological deficit or an “unstable” burst fracture with disruption of the posterior ligamentous complex. The literature is reviewed and surgical outcomes are presented.

Although some studies have reported on the kinematics of the lumbar segments with degenerative spondylolisthesis (DS), few data have been reported on the in vivo 6 degree-of-freedom kinematics of different anatomical structures of the diseased levels under physiological loading conditions. This research is to study the in vivo motion characteristics of the lumbar vertebral segments with L4 DS during weight-bearing activities.Nine asymptomatic volunteers (mean age 54.4) and 9 patients with L4 DS (mean age 73.4) were included. Vertebral kinematics was obtained using a combined MRI/CT and dual fluoroscopic imaging technique. During functional postures (supine, standing upright, flexion, and extension), disc heights, vertebral motion patterns and instability were compared between the two groups.Although anterior disc heights were smaller in the DS group than in the normal group, the differences were only significant at standing upright. Posterior disc heights were significantly smaller in DS group than in the normal group under all postures. Different vertebral motion patterns were observed in the DS group, especially in the left-right and cranial-caudal directions during flexion and extension of the body. However, the range of motions of the both groups were much less than the reported criteria of lumbar spinal instability.The study showed that lumbar vertebra with DS has disordered motion patterns. DS did not necessary result in vertebral instability. A restabilization process may have occurred and surgical treatment should be planned accordingly.

Scheuermann kyphosis is a structural hyperkyphosis defined radiographically as anterior wedging of ≥5° of at least three consecutive vertebral bodies. Typically, the disease develops during adolescence but may not present until adulthood. The etiology remains unknown. Indications for management include progressive deformity, pain, cosmesis, neurologic deficit, and cardiopulmonary compromise. Surgical intervention is indicated in patients with persistent pain and unacceptable deformity caused by significant kyphosis. Surgery can be performed through posterior-only, anterior-only, or combined anterior-posterior approaches. Correction should include the entire length of the kyphosis and should not exceed 50% of the original deformity. The most common postoperative complications are wound infection and loss of correction.

To evaluate the biomechanical effect of the X-Stop device on the intervertebral foramen (IVF) and segmental spinal canal length (SSCL), as well as the intervertebral disc space at the implanted and the adjacent segments in patients with lumbar spinal stenosis (LSS).Eight elderly patients with LSS, scheduled for X-stop implantation, were CT or MRI scanned to construct 3D vertebral models (L2-S1). Before and after the surgery, each patient was also imaged using a dual-fluoroscopic image system during weight-bearing standing and maximum extension-flexion. The positions of the vertebrae were then determined using an established 2D-3D model matching method.The data revealed that the postoperative IVF area was significantly increased by 32.9% (or 32 mm2) (p0.05) and the IVF width was increased by 24.4% (or 1.1 mm, p=0.06) during extension, but with minimal change in standing and flexion. The IVF heights were significantly (p0.05) increased at standing by 1.2 mm and extension by 1.8 mm, but not at flexion. The SSCL were significantly (p0.05) increased at extension by 1.2 mm, but not at standing and flexion. Anterior disc space of the implanted level was significantly decreased from 8.0 to 6.6 mm during standing.The X-Stop implantation efficiently enlarged the IVF area in the elderly patients with LSS at the operated level with little biomechanical effect immediately on the superior and inferior adjacent levels. However, it reduced the anterior disc space at the implanted level.

Management of odontoid fractures has been recognized as a challenge, since these injuries were first described in the early 20th century.1 Despite significant advances in diagnostic and treatment methods, such fractures remain problematic, particularly in the geriatric population.1–8 Odontoid fractures are the most common cervical spine fracture in the elderly.1,8 Because of their age associated comorbidities and the ubiquitous presence of degenerative changes in the aging cervical spine,6 such individuals are at a higher risk for complications and poorer outcomes than younger patients sustaining similar injuries.1–4,6,7,9–11 Furthermore, as the number of elderly patients continues to rise in the United States, the prevalence of such fractures can be expected to increase in the future. Several prior studies have documented increased morbidity and mortality among geriatric patients sustaining odontoid fractures.1–7,9,10,12,13 The nonunion rate in this population has been reported to be as high as 85% (range, 20%–85%),3–7,9,10,12–14 whereas the mortality rate has approached 60% (range, 10%–57.1%).2–7,9,10,12,13 Moreover, the choice of management (operative vs. nonoperative, halo-vest immobilization vs. cervical orthosis) has been postulated to influence mortality. The halo vest, in particular, has been associated with an increased risk of complications and death in elderly patients.1,3,4,7,9,12,15 One study reported high complication rates of pneumonia (34%), cardiac arrest (26%), and mortality (42%) in elderly patients treated with a halo vest.7 Most information on mortality in patients with odontoid fracture is derived from reviews of small cohorts comprising less than 50 patients.3,4,5,7,9,11,13 Furthermore, only one study specifically examined treatment-based outcomes,7 while none have analyzed mortality in relation to age, or medical comorbidities. Given the paucity of data, this investigation sought to define the influence of age, treatment, and comorbidities on mortality in a cohort (n = 156) of elderly patients sustaining Anderson and D’Alonzo16 Type II fractures of the odontoid in the cervical spine. The hypothesis was that patients treated surgically would have lower mortality than those treated nonoperatively with either a halo vest or cervical orthosis. It was also anticipated that patients with fewer medical comorbidities would have lower mortality regardless of treatment method.

Low back pain (LBP) secondary to lumbar degenerative disc disease (DDD) is one of the most common causes of disability in working population.1,2 It has been reported that in patients with DDD, the intervertebral discs (IVD) adjacent to the diseased levels have a greater tendency to degenerate,3–5 especially after surgical fusion treatment of the diseased segments.6–9 Numerous studies have suggested that altered biomechanics, such as abnormal loading and/or motion patterns,10–12 are the causative factors of adjacent segment degeneration (ASD). However, it remains unclear whether these changes are due to the natural development triggered by the DDD13–16 or to the consequence of spinal surgeries.6,17,18 Therefore, a quantitative knowledge of the disc deformation at the adjacent segments under physiologic weight-bearing conditions is instrumental to delineate the biomechanical factors associated with ASD. Many studies have examined the biomechanics of the adjacent segments after lumbar fusion or disc arthroplasty in vivo and in vitro. For example, segmental mobility19–23 and change in disc height9,18,19,24,25 have been measured using sagittal plane radiographs in patients after surgical treatments of the diseased discs. In vitro cadaveric tests and computational simulations have been used to investigate the effect of surgical treatments on loadings of the facet joints,26–30 intradiscal pressure,31–34 disc bulging,35 and stress-strain distribution.36–38 Few studies have investigated the effect of DDD on the biomechanics of the adjacent segments before surgical treatments. In finite element studies,35,39 disc degeneration was simulated by changing the disc height and its material properties, and adjacent segmental motions and disc stress-strain distributions were calculated under combined axial compressive forces and moments.35,39 However, the disc deformation at the segments adjacent to the DDD levels in living patients remains unclear. We have recently developed a combined magnetic resonance imaging (MRI) and dual fluoroscopic imaging system (DFIS) technique to quantify the disc geometric deformation in vivo.40 The purpose of this study was to quantitatively evaluate the effect of lumbar DDD on the disc deformation at the adjacent level and the level one above the adjacent level during in vivo end ranges of lumbar spine motions, which corresponded to the extreme motions experienced during daily activities. In 10 patients with DDD with degenerated discs between L4 and S1, disc L3–L4 and L2–L3 were studied and compared with those of eight asymptomatic healthy subjects. We hypothesized that DDD can cause the healthy cephalic L3–L4 and L2–L3 segments to undergo larger deformation than normal subjects.

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.To determine mortality associated with cervical fractures in patients with hyperostotic disease.Retrospective case-control study.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.Mortality at 3 months and 1, 2, and 3 years after fracture.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.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.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 IV.

Study design Retrospective radiographic study of the technique for C1 lateral mass screw (C1LMS) and C2 pedicle screw (C2PS) fixation. Objective To evaluate (1) the accuracy of the C1LMS and C2PS placement; (2) the fusion rate between C1 and C2; (3) the risk for vertebral artery (VA) injury. Summary of background data C1LMS and C2PS fixation is widely used when treating atlantoaxial instability. Several authors have reported their experience focusing on the technical outcomes, with many reporting fusion rates near 100%. However, most of them are relatively small series, and many have applied only plain postoperative radiographs instead of computed tomography (CT). Thus, we feel that the accuracy of C1LMS and C2PS placement has not been fully analyzed, as well as the anatomic relationship between the VA and the screws. Methods Between December 2000 and September 2008, the fusion status and accuracy of the screws were evaluated on the postoperative reconstructive CT of 319 patients with atlantoaxial instability. Cases with malpositioned screws underwent CT angiography or magnetic resonance angiography after surgery, to evaluate potential VA injury. Results C1LMS of 95.5% and C2PS of 92.8% were found to be in a "good" position. After 2007, six cases had malpositioned screws, which were all in the "out" or "down" area of the C2 pedicle. Five cases underwent CT angiography and 1 had magnetic resonance angiography to evaluate potential VA injury. No occlusion, associated aneurysm or fistula of the VA was found. All cases (100%) achieved solid fusion between C1 and C2. Conclusion C1LMS of 95.5% and C2PS of 92.8% were confirmed to be in good position. None of the screws including the malpositioned caused VA injury, clinically or radiographically. The technique for C1LMS and C2PS fixation appears to be safe and effective.

Study design Systematic literature review. Objective A systematic review was designed to answer 3 primary research questions: (1) What is the most useful classification system for surgical and nonsurgical decision-making with regard to thoracolumbar (TL) spine injuries? (2) For a TL burst fracture with incomplete neurologic deficit, what is the optimal surgical approach and stabilization technique? (3) Is complete disruption of the posterior ligamentous complex an indication for surgical intervention for TL burst fractures? Summary of background data Despite a long history of descriptive and clinical series, there remains considerable controversy and wide variation in the treatment of traumatic TL spine injuries. Methods A comprehensive search of the English literature was conducted using Medline and the Cochrane Database of Systematic Reviews. Standardized grading systems were used to assess the level of evidence and quality of articles impacting the research questions. Results Recommendations for the primary research questions were as follows: (1) Thoracolumbar Injury Classification System seems to be the best system available for therapeutic decision-making for TL spine injuries (strength of recommendation: weak; quality of evidence: low). (2) There is no specific surgical approach in the case of a TL burst fracture with incomplete neurologic deficit that has any advantage with regard to neurologic recovery (strength of recommendation: weak; quality of evidence: low). (3) Complete disruption of the posterior ligamentous complex as determined collectively by morphologic criteria using plain radiographs and computed tomography is an indication for surgical intervention in TL burst fractures (strength of recommendation: strong; quality of evidence: low). Conclusion Based on this systematic review of the literature only very low to moderate quality studies could be identified to address clinical questions related to TL spine trauma. These findings suggest the need for further study, including emphasis on higher quality studies.

Multinational survey of spine trauma surgeons.To survey a multinational group of spine trauma surgeons and develop an updated consensus definition of posttraumatic kyphosis (PTK), and the most current methods for diagnosis and treatment.PTK remains a potential problematic sequela of thoracolumbar trauma. Although most surgeons have devised their own approaches for detecting and treating this condition, broad agreement in terms of the diagnosis and management of PTK has not been achieved. There is a lack of consensus-based guidelines, as the current literature largely consists of small case series or anecdotal expert opinions.A survey questionnaire was circulated among 35 multinational spine trauma surgeons. The questionnaire consisted of 29 questions divided into 8 domains: definition, diagnosis, risk factors, symptoms, radiographic evaluation, surgical indications, treatment, and expected outcome. Answers from respondents were compiled and evaluated to generate a consensus.All 35 surgeons completed the survey. Consensus was achieved that PTK represents "a painful kyphotic angulation that can occur anywhere in the posttraumatic spine." Agreement was also reached that asymptomatic PTK can exist, although no true consensus could be reached on the extent of angular deformity that results in PTK. Untreated or maltreated flexion-distraction injuries, or severe burst fractures of the thoracolumbar spine, were felt to be the 2 injuries most likely to produce PTK. Computed tomography, magnetic resonance, and dynamic radiographs were all recommended for evaluation. If surgery is necessary, posteriorly based osteotomies, especially pedicle subtraction osteotomies, have become the principal means of correction.An updated understanding of PTK and its treatment has been achieved. Posterior osteotomies seem to be the most popular means of surgical correction. In the future, multicenter prospective studies are necessary to ascertain, with greater precision, the most appropriate treatment for this condition.

An experimental study to investigate the characterization of 3 chordoma cell lines.To characterize chordoma cell lines and generate hypothesis for further chordoma studies.Three cultured human chordoma cell lines have been successfully generated; however, their characterization is incomplete. Complete characterization of chordoma cell lines is necessary for these reagents to be a useful preclinical model.Three chordoma cell lines, CH 8, U-CH1, and GP 60, were cultured in different commercially available tissue culture media. They were also cultured in different environments, which included collagen substrate, various concentrations of glucose, and various levels of hypoxic conditions. The rate of cell proliferation was assessed by either MTT or numeration assay. A 3-dimensional (3D) cell culture model of these chordoma cell lines was also studied, and the expression of vimentin and cytokeratin was measured by immunofluorescence and Western blot. Additionally, the sensitivity of the 3 chordoma cell lines to 6 chemotherapeutic drugs was analyzed.CH 8, GP 60, and U-CH1 cells proliferate more actively in Iscove Modified Dulbecco Medium or Dulbecco modified Eagle Medium and less actively in RPMI medium. All 3 chordoma cell lines universally grow better in collagen substrate and survive in hypoxic conditions, whereas glucose concentration has no significant influence on their growth properties. Chordoma cell lines grew well in 3D culture systems and formed acini-like spheroids and retained the expression of vimentin and cytokeratin. MTT analysis indicates that all 3 chordoma cell lines are sensitive to doxorubicin, yondelis, zalypsis, and cisplatin.We characterized 3 chordoma cell lines for differential growth properties in a variety of media and response to chemotherapeutic agents.

Study Design: A prospective study was performed in 8 patientswith severe ankylosing spondylitis.Objectives: To observe the feasibility, reliability, and complica-tions of a method of transpedicular bivertebrae wedge osteo-tomy and discectomy to manage the sagittal plane deformity inankylosing spondylitis with chin-brow vertical angles beyond 90degrees.Summary of Background Data: In ankylosing spondylitis, thecorrection of sagittal plane deformity can be achieved bylengthening the anterior elements, shortening the posteriorelements, or a combination of the 2. Neither Smith-Petersenosteotomy, nor pedicle subtraction osteotomy in 1 segment canachieve adequate correction for cases of severe ankylosingspondylitis kyphosis.Methods: From January 2003 to May 2007, 8 patients (3 malesand 5 females) with severe ankylosing spondylitis in ourinstitution underwent a single stage transpedicular bivertebraewedge osteotomy and discectomy. The operation techniqueincludes resection of the posterior elements of 2 adjacentvertebrae, resection of the inferior-posterior aspect of proximalvertebra, and the superior-posterior aspect of the distal vertebra,followed by posterior instrumentation with pedicle screws andspinal fusion. Preoperative and postoperative height, chin-browvertical angle, sagittal balance, and sagittal Cobb angle of thevertebral osteotomy segment were documented. Intraoperative,postoperative, and general complications were registered.Results: The mean follow-up was 18.7±6.1 months (range: 14to 54mo). The mean duration of surgery was 236 minutes(range: 198 to 310min), and the average volume of intraopera-tive blood loss was 2200mL (range: 1600 to 3860mL). Thepatients’ height increased from 120.5±12.0cm to 159.6±12.4cm(P=0.000). The mean chin-brow vertical angle was improvedfrom 102.8±9.7 to 19.3±13.9 degrees (P=0.000). The spinalsagittal Cobb angle of the vertebral osteotomy segment wascorrected from kyphosis 38.6±16.5 degrees to lordosis26.6±10.1 degrees (P=0.000). One patient with the involve-ment of the cervical spine suffered an extension spinal fracture atC5/6 as the operating table was extended. Translation at theosteotomy site occurred in 1 patient during the correction.Fusion of the osteotomy was achieved in all patients, and noloosening or breakage of pedicle screws was found.Conclusions: In cases of severe ankylosing spondylitis kyphosiswith chin-brow vertical angles beyond 90 degrees, a single stagetranspedicular bivertebrae wedge osteotomy and discectomy isan effective corrected method of correction.Key Words: ankylosing spondylitis, kyphosis, osteotomy,discectomy(J Spinal Disord Tech 2010;23:186–191)

Study design Surgeon survey. Objective To characterize the incidence of epidural hematoma in postoperative spinal patients; to assess the effect of chemical thromboprophylaxis on the risk of epidural hematoma. Summary of background data The precise indications and/or timing of anticoagulation for thromboembolic prophylaxis following spinal surgery are not clear. Patients who endure periods of extended recumbency and limited mobility after major operative spinal interventions may be at increased risk of thromboembolic disease. Among other factors, spine surgeons must weigh the risk of a symptomatic postoperative epidural hematoma against the benefit of DVT/PE prevention when deciding to initiate chemoprophylaxis. However, the incidence of postoperative epidural hematoma is not well-known, leading to uncertainty regarding the real versus perceived risk of this complication. Methods The MEDLINE database was queried using the search terms epidural hematoma and spinal or spine surgery. Abstracts of all identified articles were reviewed. Studies were deemed eligible if they specifically documented the incidence of clinically significant epidural hematoma in a series of patients who underwent spinal surgery. Detailed information from eligible articles was extracted. Data were compiled and analyzed to examine incidences of clinically relevant postoperative epidural hematoma (i.e., resulted in new, associated neurologic deficit). Results Of 493 abstracts that were identified in the search, a total of sixteen articles were eligible for full review. From this review, the range of reported incidences of epidural hematoma in the literature ranges from 0% to 0.7% in studies where patients received chemical anticoagulation and 0% and 1% in all of the included studies. In no study was the incidence of clinically relevant epidural hematoma greater than 1%. Conclusion The catastrophic morbidity of a symptomatic postoperative epidural hematoma remains a substantial disincentive to start chemoprophylaxis after spinal surgery. The rarity of this complication makes study of its risk factors difficult. Although many surgeons perceive the risk to be higher, the reported incidences of clinically relevant postoperative epidural hematoma are lower, ranging from 0% to 1%. Despite this finding, there is insufficient published data available to precisely define the safety of postoperative chemoprophylaxis. Though not pertaining to prophylaxis, the available evidence does suggest that use of therapeutic doses of heparin in postoperative spinal patients who sustain a PE may have a higher incidence of bleeding complications.

STUDY DESIGN Systematic review. OBJECTIVE To document the incidence and consequences of vascular injury in lumbosacral surgery, to identify factors contributing to this injury, and to determine whether there are any effective measures to decrease the occurrence of vascular injury. SUMMARY OF BACKGROUND DATA Anterior lumbosacral surgery encompasses all aspects of spine surgery, including trauma, deformity, and degenerative conditions. Although it has theoretical advantages, anterior lumbosacral surgery carries with it certain definite risks, one of the most critical of which is injury to the surrounding vasculature. It is important for both the patient and the surgeon to understand the risks, patterns, and outcomes of injury to the vascular structures associated with this surgery. METHODS A systematic review of the English-language literature was undertaken for articles published between January 1993 and December 2008. Electronic databases and reference lists of key articles were searched to identify published studies examining vascular injury in anterior lumbosacral surgery. Vascular injury was defined as any case in which a suture was required to control bleeding. Two independent reviewers assessed the strength of literature using the Grading of Recommendations Assessment, Development, and Evaluation criteria assessing quality, quantity, and consistency of results. Disagreements were resolved by consensus. RESULTS A total of 88 articles were initially screened, and 40 ultimately met the predetermined inclusion criteria. Vascular injuries after anterior lumbosacral surgeries were rare (

Osteosarcoma is the most common primary malignant bone tumor affecting children and adolescents. The majority of patients are treated by surgery and chemotherapy but have limited alternative therapeutic options. Kinases play an important role in the growth and survival of tumor cells. We aim to identify specific kinases to be vital in the survival of osteosarcoma cells and thus may be a key target in creating novel anticancer therapies. A lentiviral short hairpin RNA kinase library, screened osteosarcoma cells, identified kinase minibrain-related kinase (Mirk) (Dyrk1B) as a potential target. Knockdown Mirk expression could inhibit cell growth and induce apoptosis. Chemically synthetic small interfering RNA knockdown and complementary DNA rescue assay further confirmed the results from the decrease of Mirk gene expression. The relationship between Mirk gene expression and the clinical characteristics of patients with osteosarcoma was investigated using tissue microarray and immunohistochemistry analysis. The data indicate that the overall survival rate of patients with Mirk high staining (high levels of Mirk protein expression) is significantly shorter than those with Mirk low staining and moderate staining. This highlights Mirk’s potential to serve as a promising target for molecular therapy in the treatment of osteosarcoma.

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.

A major obstacle in the effective treatment of chordoma is that there are no identifiable biomarkers capable of predicting prognosis. Recent research has indicated that signal transducers and activators of transcription (Stat3) may be an important prognostic marker in some cancers, but its role in chordoma tumors has not been elucidated. In this study, the expression of Stat3 was evaluated in chordoma tissue microarray that contains 70 chordoma samples. Cells in the tissue microarray showed nuclear staining for phosphorylated Stat3 in all instances. The level of phosphorylated Stat3 expression correlated with the survival and severity of the disease. Three chordoma cell lines were exposed to SD-1029, a novel inhibitor of Stat3 activation. MTT assay showed that the growth of all chordoma cell lines was inhibited by SD-1029. The expression of Stat3 signaling cascade was inhibited in all chordoma cell lines after treatment with SD-1029. The cytotoxicity of the combination of SD-1029 and chemotherapeutic drugs is significantly better than either agent alone. Phosphorylation of Stat3 in chordoma cells in vitro and cellular proliferation in three-dimensional culture were inhibited by SD-1029. In conclusion, the Stat3 pathway is constitutively activated in chordomas and the level of expression may serve as a predictor for prognosis. Blockade of the Stat3 pathway represents a potential strategy for future treatment. [Mol Cancer Ther 2009;8(9):2597–605]

Study design Retrospective case-control study. Objective The purpose of this study was to compare the self-reported outcomes between operatively and nonoperatively treated patients over the age of 65 with adult scoliosis, using 4 distinct self-assessment questionnaires (SRS-22, SF-12, EQ5D, and Oswestry disability index [ODI]) and standard radiographic measurement parameters. Summary of background data The current spine literature contains no studies that directly compare the self-reported and radiographic outcomes of operatively and nonoperatively treated patients over the age of 65 years with adult scoliosis. Methods We retrospectively analyzed the self-reported outcomes of 83 adult scoliosis in patients over the age of 65 years. A total of 34 patients were treated operatively, whereas 49 patients were managed nonoperatively. For each of these patients, standard radiographic measurements were recorded both before and after treatment, and each patient received 4 questionnaires (SRS-22, SF-12, EQ5D, and ODI) that were completed with a minimum of 2-year follow-up from the time the treatment was initiated. The outcomes of both groups were then statistically compared. Results As compared to the nonoperative group, the operative group reported significantly better self-assessment scores for the EQ5D index, EQ5D Visual Analogue Score, and SRS-22 questionnaires. However, no statistically significant difference between the groups was detected for the ODI, SF-12 Mental Health Component Summary, and SF-12 PCS. Furthermore, the operative group also had a significant improvement in radiographic measurements. Conclusion Adult scoliosis patients over the age of 65 years treated operatively had significantly less pain, a better health-related quality of life, self image, mental health, and were more satisfied with their treatment than patients treated conservatively. However, we found no statistically significant differences in their degree of disability as measured by the ODI as well as physical and mental health by the SF-12 instrument. Preoperative radiographic deformity was not determined to be a significant factor for predicting whether an operative or nonoperative treatment course was chosen.

Study design Systematic review of the literature and analysis of pooled data. Objectives To better understand the incidence of thromboembolic disease in postoperative spinal patients, and to establish a starting point for defining appropriate postoperative prophylaxis protocols. Summary of background data The risk of thromboembolic disease is well studied for some orthopedic procedures. However, the incidence of postoperative thromboembolic disease is less well-defined in patients who have had spinal surgery. Methods The MEDLINE database was queried using the search terms deep venous thrombosis or DVT, pulmonary embolus, thromboembolic disease, and spinal or spine surgery. Abstracts of all identified articles were reviewed. Detailed information from eligible articles was extracted. Data were compiled and analyzed by simple summation methods when possible to stratify rates of DVT and/or pulmonary embolus for a given prophylaxis protocol, screening method, and type of spinal surgery. Results Twenty-five articles were eligible for full review. DVT risk ranged from 0.3% to 31%, varying between patient populations and methods of surveillance. Pooling data from the 25 studies, the overall rate of DVT was 2.1%. DVT rate was influenced by prophylaxis method: no prophylaxis, 2.7%; compression stockings (CS), 2.7%; pneumatic sequential compression device (PSCD), 4.6%; PSCD and CS, 1.3%; chemical anticoagulants, 0.6%; and inferior vena cava filters with/without another method of prophylaxis, 22%. DVT rate was also influenced by the method of diagnosis, ranging from 1% to 12.3%. Conclusion As risk of DVT after routine elective spinal surgery is fairly low, it seems reasonable to use CS with PSCD as a primary method of prophylaxis. There is insufficient evidence to support or refute the use of chemical anticoagulants in routine elective spinal surgery. In addition, there is insufficient evidence to suggest that screening patients undergoing elective spinal surgery with ultrasound or venogram is routinely warranted.

To identify apoptosis genes involved in the multidrug resistance of osteosarcoma, a multidrug resistant human osteosarcoma cell line (U-2 OS MR) was established. Apoptosis gene microarray analysis demonstrated that GADD45alpha was significantly induced in U-2 OS cells after exposure to paclitaxel (P0.0001). However, the induction of GADD45alpha did not occur in U-2 OS MR cells. Subsequent analysis by Western blot confirmed that the expression of GADD45alpha could be significantly induced by paclitaxel and doxorubicin in U-2 OS cells but not in U-2 OS MR cells. Furthermore, the paclitaxel or doxorubicin treated U-2 OS and KH OS cells have a higher percentage of apoptotic cells when compared with U-2 OS MR and KH OS R2 cells treated with the same drugs. When GADD45alpha was transfected into U-2 OS MR or KH OS R2 and expressed, the cells became more sensitive to chemotherapeutic drugs. These results suggest that GADD45alpha may play a role in drug-induced apoptosis, as well as multidrug resistance in osteosarcoma cells.