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BACKGROUND The surgical management of adult spinal deformity (ASD) is a major surgical undertaking associated with considerable perioperative risk and a substantial complication profile. Although the natural history and risk factors associated with proximal junctional kyphosis (PJK) and proximal junctional failure are widely reported, distal junctional failure (DJF) is less well understood. STUDY DESIGN A systematic review was carried out. OBJECTIVES The primary objective is to identify the risk factors associated with DJF. The secondary objective is to delineate the incidence rate and causative factors associated with DJF. METHODS A systematic review of articles in Medline/PubMed and The Cochrane Library databases was performed according to preferred reporting items for systematic reviews and meta-analyses guidelines. Data was collated to determine the prevalence of DJF and overall revision rates, and identify potential risk factors for development of DJF. RESULTS Twelve studies were included for systematic review. There were 81/2261 (3.6%) cases of DJF. Overall, DJF represented 27.3% of all revision surgeries. Anterior-posterior surgery had a reduced incidence of postoperative DJF [5.0% vs. 8.7%; P=0.08; relative risk (RR)=1.73], as did patients below 60 years of age at the time of surgery (2.9% vs. 3.9%; P=0.09; RR=1.34). There was a higher incidence of DJF among those patients who received interbody fusion (9.9% vs. 5.1%; P=0.06; RR=1.93) compared with those who did not. However, none of these findings reached statistical significance. There were significantly more rates of DJF for fusions ending on L5 compared with constructs fused to the sacrum (11.7% vs. 3.6%; P=0.02; RR=3.28). CONCLUSIONS Cohorts 60 years and above of age at the time of surgery and patients managed with posterior-only fusion or interbody fusion have increased incidences of DJF. Fusion to L5 instead of the sacrum significantly influences DJF rates. However, the quality of available evidence is low and further high-quality studies are required to more robustly analyze the clinical, radiographic, and surgical risk factors associated with the development of DJF after ASD surgery.

BACKGROUND: Sarcopenia, defined as decreased skeletal mass, is an independent marker of frailty that is not accounted for by other risk-stratification methods. Recent studies have demonstrated a clear association between paraspinal sarcopenia and worse patient-reported outcomes and complications after spine surgery. Currently, sarcopenia is characterized according to either a quantitative assessment of the paraspinal cross-sectional area or a qualitative analysis of paraspinal fatty infiltration on MRI. No studies have investigated whether the cervical paraspinal cross-sectional area correlates with fatty infiltration of the cervical paraspinal muscles on advanced imaging. QUESTION/PURPOSE: Do patients undergoing anterior cervical discectomy and fusion (ACDF) with increasing paraspinal fatty degeneration on advanced imaging also demonstrate decreased cervical paraspinal cross-sectional area? METHODS: Between 2011 and 2017, 98 patients were prospectively enrolled in a database of patients undergoing one- to three-level ACDF for degenerative conditions at a single institution. To be eligible for this prospective study, patients were required to undergo an MRI before surgery, be older than 18 years, and have no previous history of cervical spine surgery. Two independent reviewers, both surgeons not involved in the patients’ care and who were blinded to the clinical outcomes, retrospectively assessed the paraspinal cross-sectional area and Goutallier classification of the right-sided paraspinal muscle complex. We then compared the patients’ Goutallier grades with their paraspinal cross-sectional area measurements. We identified 98 patients for inclusion. Using the Fuchs modification of the Goutallier classification, we classified the fatty degeneration of 41 patients as normal (Goutallier Grades 0 to 1), that of 47 patients as moderate (Grade 2), and that of 10 patients as severe (Grades 3 to 4). We used ANOVA to compare all means between groups. RESULTS: There was no difference in the mean paraspinal cross-sectional area of the obliquus capitus inferior (normal 295 ± 81 mm(2); moderate 317 ± 104 mm(2); severe 300 ± 79 mm(2); p = 0.51), multifidus (normal 146 ± 59 mm(2); moderate 170 ± 70 mm(2); severe 192 ± 107 mm(2); p = 0.11), or sternocleidomastoid (normal 483 ± 150 mm(2); moderate 468 ± 149 mm(2); severe 458 ± 183 mm(2); p = 0.85) among patients with mild, moderate, and severe fatty infiltration based on Goutallier grading. There was a slightly greater longus colli cross-sectional area in the moderate and severe fatty infiltration groups (74 ± 22 mm(2) and 66 ± 18 mm(2), respectively) than in the normal group (63 ± 15 mm(2); p = 0.03). CONCLUSION: Because our study demonstrates minimal association between paraspinal cross-sectional area and fatty infiltration of the cervical paraspinals, we recommend that physicians use the proven qualitative assessment of paraspinal fatty infiltration during preoperative evaluation of patients who are candidates for ACDF. Future studies investigating the relationship between cervical paraspinal cross-sectional area and patient-reported outcomes after ACDF are necessary to lend greater strength to this recommendation. LEVEL OF EVIDENCE: Level III, diagnostic study.

Degenerative disk disease is a pathologic state associated with axial skeletal pain, radiculopathy, and myelopathy, and will inevitably increase in prevalence in parallel with an aging population. The objective of regenerative medicine is to convert the inflammatory, catabolic microenvironment of degenerative disease into an anti-inflammatory, anabolic environment. This comprehensive review discusses and outlines both in vitro and in vivo efficacy of regenerative treatment modalities for degenerative disk disease, such as; mesenchymal stem cells, gene therapy, tissue engineering, and biologic treatments. To date, clinical applications have been limited secondary to a lack of standardized high quality clinical data. Additional research should focus on determining the optimal cellular makeup and concentration for each of these interventions. Nevertheless, modern medicine provides a new avenue of confronting disease, with methods surpassing traditional methods of removing the pathology in question, as regenerative medicine provides the opportunity to recover from the diseased state.

Study Design: Retrospective cohort study. Objectives: Studies in the lumbar spine suggest a correlation between sarcopenia and worse patient outcomes. The purpose of this study was to determine whether paraspinal Goutalier grade of fat degeneration is associated with patient-reported outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF). Methods: We performed a retrospective review of a prospective cohort of patients undergoing 1- to 3-level ACDF at a single institution between the years 2011-2014. We utilized preoperative magnetic resonance images to classify patients into Goutalier grades. Patient-reported outcomes, including Neck Disability Index (NDI), RAND score, and EQ-5D score were collected and analyzed according to patients’ Goutalier grade. Results: We identified 69 patients for inclusion. A total of 29 patients were classified as Goutalier 0-1 (group 1), 29 were Goutalier 1.5-2 (group 2), and 11 were Goutalier 2.5-4.0 (group 3). All Goutalier groups experienced significant improvement in all 3 outcome scores. Average postoperative NDI scores were 25.3 in group 1, 13.9 in group 2, and 25.1 in group 3 ( P = .02). The percentage of patients in each group reporting worse disability after surgery was 17.2%, 3.3%, and 9.1%, respectively ( P = .05). No statistically significant difference was seen between groups in postoperative EQ-5D ( P = .07) or RAND scores ( P > .05). Conclusions: The present study is the first to assess the association between cervical paraspinal muscle Goutalier grade and patient-reported outcomes following ACDF. Based on our study, patients with worse cervical paraspinal degeneration may benefit from improved symptom relief in comparison to patients with a lesser degree of degeneration undergoing ACDF.

Study Design: Retrospective, single institution, multisurgeon case control series. Objective: To determine whether there are differences in reoperation rates or outcomes for patients undergoing 2-level posterolateral fusion (PLF) augmented by a transforaminal lumbar interbody fusion (TLIF) at only one of the levels or at both. Methods: A total of 416 patients were identified who underwent 2-level PLF with a TLIF at either one of those levels (n = 183) or at both (n = 233) with greater than 1-year follow-up. Demographic, surgical, radiographic, and clinical data was reviewed for each patient. These included age, sex, race, body mass index, smoking status, Charleston Comorbidity Index, operative time, estimated blood loss, length of stay, and patient-reported outcome measures. Results: Each cohort underwent 24 reoperations. Although the number of overall reoperations was not significantly different ( P > .05), among the reoperation types, there were significantly more reoperations for adjacent segment disease in the 2-level group compared to the 1-level group (19 vs 12, P = .04). There was no difference in reoperation for pseudarthrosis between the groups ( P > .05). Although both groups experienced significant improvements in Oswestry Disability Index ( P < .001) and Short Form–12 health questionnaire ( P < .001), there were no differences between improvements for 1- versus 2-level cohorts. Conclusions: For patients undergoing 2-level PLF in the setting of a TLIF, using a TLIF at one versus both levels does not seem to influence reoperation rates or outcomes. However, reoperation rates for adjacent segment disease are increased in the setting of a 2-level PLF augmented by a 2-level TLIF.

Sarcopenia, defined as decreased skeletal muscle mass or function, has recently been found to have increased perioperative morbidity and mortality. The relationship between sarcopenia and clinical outcomes in patients undergoing lumbar fusion has not been examined. This study investigates whether sarcopenia affects fusion rates and outcomes following single-level lumbar decompression and fusion. A retrospective analysis was undertaken of 97 consecutive patients who underwent a single level lumbar fusion for degenerative spondylolisthesis. Demographics, perioperative data, and patient reported clinical outcomes were collected. Measurements of paraspinal muscle CSA were made using a standardized protocol at the level of the L3-4 disc space on a preoperative lumbar MRI. Univariate analysis was used to compare cohorts with regards to demographics, comorbidities, and clinical outcomes. Of 97 patients, 16 patients (15.8%) were in the sarcopenic cohort utilizing a threshold of 986.1 mm2/m2. Reoperation rates were not significantly different between the two groups (0% vs 3.6%, p = .451). The sarcopenia cohort had lower BMI (28.1 vs 31.8, p = .017) and less male patients (6.3% vs 55.6%, p

Study Design: Retrospective cohort review Objectives: Cervical pseudarthrosis is a frequent cause of need for revision anterior cervical discectomy and fusion (ACDF) and may lead to worse patient-reported outcomes. The effect of proton pump inhibitors on cervical fusion rates are unknown. The purpose of this study was to determine if patients taking PPIs have higher rates of nonunion after ACDF. Methods: A retrospective cohort review was performed to compare patients who were taking PPIs preoperatively with those not taking PPIs prior to ACDF. Patients younger than 18 years of age, those with less than 1-year follow-up, and those undergoing surgery for trauma, tumor, infection, or revision were excluded. The rates of clinically diagnosed pseudarthrosis and radiographic pseudarthrosis were compared between PPI groups. Patient outcomes, pseudarthrosis rates, and revision rates were compared between PPI groups using either multiple linear or logistic regression analysis, controlling for demographic and operative variables. Results: Out of 264 patients, 58 patients were in the PPI group and 206 were in the non-PPI group. A total of 23 (8.71%) patients were clinically diagnosed with pseudarthrosis with a significant difference between PPI and non-PPI groups ( P = .009). Using multiple linear regression, PPI use was not found to significantly affect any patient-reported outcome measure. However, based on logistic regression, PPI use was found to increase the odds of clinically diagnosed pseudarthrosis (odds ratio 3.552, P = .014). Additionally, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores ( P = .022). Conclusions: PPI use was found to be a significant predictor of clinically diagnosed pseudarthrosis following ACDF surgery. Furthermore, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores.

Objective To evaluate the impact of prematurity on fracture by age 5, controlling for medications and comorbidities of prematurity. Study design We performed a retrospective cohort study of infants born in Military Treatment Facilities in 2009-2010 with ≥5 years of follow-up care. Gestational age, low birth weight, comorbidities of prematurity (osteopenia, necrotizing enterocolitis, chronic lung disease, and cholestasis) and fractures were identified by International Classification of Disease, 9th Edition, codes. Pharmaceutical records identified treatment with caffeine, diuretics, postnatal corticosteroids, and antacids. Poisson regression analysis determined fracture rate by 5 years of life. Results There were 65 938 infants born in 2009-2010 who received care in the military health system for ≥5 years, including 3589 born preterm; 165 born at ≤286/7 weeks of gestation, 380 born at 29-316/7 weeks of gestation, and 3044 born at 32-366/7 weeks of gestation. Preterm birth at any gestational age was not associated with fracture rate in adjusted models. The fracture rate was increased with cholestasis, proton pump inhibitor exposure, and male sex. Conclusions Prematurity was not associated with fracture rate. Neonatal cholestasis and proton pump inhibitor treatment were associated with increased fractures by age 5.

Study Design Retrospective cohort study Objective Substantial variability in both the measurement and classification of subsidence limits the strength of conclusions that can be drawn from previous studies. The purpose of this study was to precisely characterize patterns of cervical cage subsidence utilizing computed tomography (CT) scans, determine risk factors for cervical cage subsidence, and investigate the impact of subsidence on pseudarthrosis rates. Methods We performed a retrospective review of patients who underwent one- to three-levels of anterior cervical discectomy and fusion (ACDF) utilizing titanium interbodies with anterior plating between the years 2018 and 2020. Subsidence measurements were performed by two independent reviewers on CT scans obtained 6 months postoperatively. Subsidence was then classified as mild if subsidence into the inferior and superior endplate were both ≤2 mm, moderate if the worst subsidence into the inferior or superior endplate was between 2 to 4 mm, or severe if the worst subsidence into the inferior or superior endplate was ≥4 mm. Results A total of 51 patients (100 levels) were included in this study. A total of 48 levels demonstrated mild subsidence (≤2 mm), 38 demonstrated moderate subsidence (2-4 mm), and 14 demonstrated severe subsidence (≥4 mm). Risk factors for severe subsidence included male gender, multilevel constructs, greater mean vertebral height loss, increased cage height, lower Taillard index, and lower screw tip to vertebral body height ratio. Severe subsidence was not associated with an increased rate of pseudarthrosis. Conclusion Following ACDF with titanium cervical cages, subsidence is an anticipated postoperative occurrence and is not associated with an increased risk of pseudarthrosis.

BACKGROUND The preoperative identification of osteoporosis in the spine surgery population is of crucial importance. Limitations associated with dual-energy x-ray absorptiometry, such as access and reliability, have prompted the search for alternative methods to diagnose osteoporosis. The Hounsfield Unit(HU), a readily available measure on computed tomography, has garnered considerable attention in recent years as a potential diagnostic tool for reduced bone mineral density. However, the optimal threshold settings for diagnosing osteoporosis have yet to be determined. METHODS We selected studies that included comparison of the HU(index test) with dual-energy x-ray absorptiometry evaluation(reference test). Data quality was assessed using the standardised QUADAS-2 criteria. Studies were characterised into 3 categories, based on the threshold of the index test used with the goal of obtaining a high sensitivity, high specificity or balanced sensitivity-specificity test. RESULTS 9 studies were eligible for meta-analysis. In the high specificity group, the pooled sensitivity was 0.652 (95% CI 0.526 – 0.760), specificity 0.795 (95% CI 0.711 – 0.859) and diagnostic odds ratio was 6.652 (95% CI 4.367 – 10.133). In the high sensitivity group, the overall pooled sensitivity was 0.912 (95% CI 0.718 – 0.977), specificity was 0.67 (0.57 – 0.75) and diagnostic odds ratio was 19.424 (5.446 – 69.275). In the balanced sensitivity-specificity group, the overall pooled sensitivity was 0.625 (95% CI 0.504 – 0.732), specificity was 0.914 (0.823 – 0.960) and diagnostic odds ratio was 14.880 (7.521 – 29.440). Considerable heterogeneity existed throughout the analysis. CONCLUSION In conclusion, the HU is a clinically useful tool to aide in the diagnosis of osteoporosis. However, the heterogeneity seen in this study warrants caution in the interpretation of results. We have demonstrated the impact of differing HU threshold values on the diagnostic ability of this test. We would propose a threshold of 135 HU to diagnose OP. Future work would investigate the optimal HU cut-off to differentiate normal from low bone mineral density.

To curb the unsustainable rise in health care costs, novel payment models are being explored which focus on value rather than volume. Underlying this reform is an accurate understanding of costs and outcomes. The Patient Protection and Affordable Care Act, the Institute of Medicine, and the Agency for Healthcare Research and Quality have specifically advocated for the use of registries to help define the real-world effectiveness of surgical interventions to help guide health care reform. Registries can help define value by documenting surgical efficacy, and specifically by reporting patient-based outcome measures. Over the past 10 years, several spine registries have been initiated and some others have expanded. These are providing a repository of evidence for surgical value. Herein, we will review the components of a well-designed registry and provide examples of such registries and their impact on health care delivery.

Surgical site infection (SSI) following spine surgery can be devastating for both the patient and the surgeon. It leads to significant morbidity and associated health care costs, from readmissions, reoperations, and subsequent poor clinical outcomes. Complications associated with SSI following spine surgery include pseudarthrosis, neurological deterioration, sepsis, and death. Its management can be very challenging. The diagnosis of SSI involves the interpretation of combined clinical, laboratory, and occasionally radiologic findings. Most infections can be treated with an appropriate course of antibiotics and bracing if required. Surgical intervention is usually reserved for infections resistant to medical management, the need for open biopsy/culture, evolving spinal instability or deformity, and neurologic deficit or deterioration. A thorough knowledge of associated risk factors is required and patients should be stratified for risk preoperatively. The multifaceted approach of risk stratification, early diagnosis and effective treatment, is essential for successful prevention and effective treatment and crucial for a satisfactory outcome.

Background To determine the incidence and risk factors for adverse cardiac events after lumbar spine fusion. Methods A total of 50 495 patients were identified through the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database who underwent lumbar spine fusion between 2005 and 2015. The 30-day postoperative data were analyzed to assess for the incidence of adverse cardiac events including cardiac arrest or myocardial infarction. Of those who experienced an event, patient- and surgery-specific parameters were evaluated to assess for risk factors. Results A total of 240 cardiac events occurred in the studied cohort (4.76 events/1000 patients). Factors that were associated with an increased cardiac risk were age (odds ratio [OR] = 1.039, 95% confidence interval [CI] = 1.03, 1.05, P P = .001), insulin-dependent diabetes (OR = 1.83, 95% CI = 1.29, 2.6, P = .001), American Society of Anesthesiologists (ASA) score >3 (OR = 1.92, 95% CI = 1.00, 3.65, P = .048), absolute hematocrit different from 45 (OR = 1.07, 95% CI = 1.04, 1.10, P P = .04). The impact of sustaining a cardiac event in the setting of single-level lumbar fusion is catastrophic as the 30-day postoperative mortality rate for those sustaining an event was 24.6% (59/240 patients), compared to 0.2% (87/50 255) for those not sustaining an event ( P < .001). Conclusions Cardiac events after lumbar fusion are a rare but devastating series of complications. Several risk factors were identified, including insulin-dependent diabetes mellitus, smoking, advanced age, male sex, ASA score of >3, and anemia/polycythemia. Considering the severity of these consequences, appropriate risk stratification is imperative, and optimization of modifiable risk factors may mitigate this risk.

This paper aims to review the cost benefits of performing spine surgeries at an ambulatory surgery center or an outpatient hospital department. The potential for cost savings associated with ambulatory based surgery centers or outpatient hospital departments will likely continue to increase the number of spine surgeries performed at such locations. Several types of ownership structures for ambulatory based surgery centers or outpatients hospital departments exist, and can be broadly categorized into sole physician ownership, sole hospital ownership, physician-hospital joint ownership, physician-management service joint ventures. It can be argued that a sole physician ownership of these centers can cause potential conflicts of interests; however, it can also decrease costs for patients and improve physician satisfaction.

BACKGROUND CONTEXT Posterior cervical fusion (PCF) is successfully used to treat cervical spondylotic myelopathy, multilevel cervical stenosis, and cervical deformity. However, limited evidence exists regarding the appropriate level of proximal and distal extension of PCF constructs. Further investigation is required to understand the effects of construct endpoint on fusion rate, junctional failure, and sagittal deformity correction. PURPOSE To compare the surgical and radiographic outcomes of patients undergoing posterior cervical fusion (PCF) with constructs extending from C2-T2 to patients with constructs extending from C3-T1. STUDY DESIGN/SETTING This was a multicenter retrospective review of two prospective cohorts of patients undergoing PCF from C2-T2 or C3-T1 for subaxial cervical stenosis at two academic institutions from 2012 to 2020. PATIENT SAMPLE We identified 106 patients for inclusion in the C2-T2 cohort and 49 patients for inclusion in the C3-T1 cohort. OUTCOME MEASURES Pre- and postoperative cervical alignment parameters, distal screw loosening, distal junctional failure, and pseudarthrosis were measured. Methods Cervical alignment parameters were measured on both preoperative and postoperative radiographs performed greater than 6 months postoperatively. The cohorts were compared based on preoperative cervical alignment, postoperative cervical alignment, and change in cervical alignment. Postoperative radiographs were also assessed for signs of distal screw loosening, distal junctional failure, and pseudarthrosis. We utilized Student's t-test to compare all means between groups with p Results A total of 155 patients were included in the study (C2-T2: 106 patients, C3-T1: 49 patients). There were no significant differences in demographics or preoperative symptoms between cohorts. Fusion rates were significantly higher in the C2-T2 (93%) than the C3-T1 (80%, p=0.040) cohort. When comparing the C2-T2 to the C3-T1 cohort, the C3-T1 cohort had a significantly greater rate of proximal junctional failure (2% vs 10%, p=0.006), distal junctional failure (1% vs 20%, p Conclusions In patients undergoing PCF, a C2-T2 construct demonstrated lower rates of pseudarthrosis, DJF, PJF, and compensatory upper cervical hyperextension compared to a C3-T1 construct. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Studies in the lumbar spine suggest a correlation between sarcopenia and worse patient outcomes. To our knowledge, no studies have investigated whether an association exists between fatty degeneration of the cervical paraspinal musculature and cervical disability in the perioperative period. PURPOSE The purpose of this study is to determine whether paraspinal Goutalier grade of fat degeneration is associated with patient-reported outcomes in patients undergoing ACDF. STUDY DESIGN/SETTING Retrospective review of a prospectively collected cohort of patients who underwent 1 to 3 level ACDF between the years 2011-2014 at a single academic medical center. PATIENT SAMPLE Sixty-nine patients who underwent 1-3 level ACDF between the years of 2011-2014. OUTCOME MEASURES Goutalier classification, patient-reported outcomes such as neck disability index (NDI), RAND score, and EQ-5D score were measured. METHODS We performed a retrospective review of a prospective cohort of patients undergoing 1 to 3 level ACDF at a single institution between the years 2011-2014. We utilized preoperative MRI's to classify patients into Goutalier grades. Patient-reported outcomes including NDI, RAND score and EQ-5D score were collected and analyzed according to patients’ Goutalier grade. We utilized Student's t-test and ANOVA to compare all means between groups. The mid-P exact test was used to compare proportional differences between groups. RESULTS We identified 69 patients for inclusion. The cohort was 47.3% male. 29 patients were classified as Goutalier 0-1 (Group 1), 29 were Goutalier 1.5-2 (Group 2), and 11 were Goutalier 2.5-4.0 (Group 3). Determination of Goutalier grade by the two reviewers resulted in 82.8% agreement with correlation coefficient of 0.69 (Pearson, r2), demonstrating moderate interrater reliability. All Goutalier groups experienced significant improvement in all three outcome scores. Average postoperative NDI scores were 25.3 in Group 1, 13.9 in Group 2, and 25.1 in Group 3 (p=0.02). The percentage of patients in each group reporting worse disability after surgery was 17.2%, 3.3% and 9.1%, respectively (p=0.05) No statistically significant difference was seen between groups in postoperative EQ-5D (p=0.07) or RAND scores (p>0.05). CONCLUSIONS The present study is the first to assess the association between cervical paraspinal muscle Goutalier grade and patient reported outcomes following ACDF. Based upon our study, patients with worse cervical paraspinal degeneration may benefit from improved symptom relief in comparison to patients with a lesser degree of degeneration undergoing ACDF. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Fractures of the odontoid process of C2 have become increasingly prevalent in the aging population and are typically associated with a high incidence of morbidity. Dens fractures comprise the majority of all cervical fractures in patients older than 80 years and remain the most common cervical fracture pattern in all geriatric patients. Type II odontoid fractures have been associated with limited healing potential, and both nonoperative and operative management are associated with high mortality rates. Historically, there has been some debate in the literature with regards to optimal management strategies to maximize outcomes in geriatric patients. Recent, high-quality evidence has indicated that surgical treatment of type II odontoid fractures in elderly patients is associated with improvements in both short- and long-term mortality. Additionally, surgical intervention has been shown to improve functional outcomes when compared with nonsurgical treatment. Factors to consider before surgery for geriatric type II odontoid fractures include associated comorbidities and the safety of general anesthesia administration. With appropriate measures of patient selection, surgery can provide an efficacious option for geriatric patients with type II odontoid fractures. We recommend surgical intervention via a posterior C1-C2 arthrodesis for geriatric type II odontoid fractures, provided that the surgery itself does not represent an unreasonable risk for mortality.

Background Context Lumbar epidural corticosteroid injections (LECIs) are frequently used in the treatment of lumbar intervertebral disc herniation with radiculopathy and lumbar spinal stenosis. Although widely used, their effect on the outcomes and complications of subsequent surgery is unclear. Postoperative infection can be a morbid complication following spine surgery, and recent literature has suggested that the risk may be increased in patients undergoing lumbar spinal surgery who had previously received LECIs. Purpose The purpose of this study is to define the overall postoperative infection rate in patients undergoing lumbar spine decompression surgery in the Military Health System (MHS) patient population and examine the effects of LECIs on postoperative infection rates. Study Design/Setting This is a retrospective case control database study (Level III study). Patient Sample The sample comprised all patients in the MHS who had a LECI before single-level lumbar decompression surgery from 2009 to 2014. Outcome Measures Postoperative infection within 90 days of surgery was used as the primary outcome measure for this study. Postoperative infection was identified using the International Classification of Diseases, 9th revision (ICD-9) diagnosis codes for postoperative infection. Methods The Military Health System Data Repository (MDR) database was searched for all patients who underwent single-level lumbar spine decompression surgery from 2009 to 2014 using Current Procedural Terminology (CPT) codes. Current Procedural Terminology codes were used to identify the subset of patients who received preoperative LECIs. For patients receiving an injection, cohorts were established based on the timing of the preoperative injection: 365 days. An age-based cohort, composed of patients 65 years of age and older, was also analyzed. A subgroup analysis of patients receiving more than one preoperative injection was performed. Postoperative infection within 90 days of surgery was identified using ICD-9 codes, and infection rates for all groups were calculated and compared with the control group who did not receive preoperative LECIs. No external funding was received for this study. Results We identified 6,535 patients (847 preoperative LECI and 5,688 control) for analysis. The overall infection rate for patients undergoing single-level lumbar decompression surgery in the MHS was 0.81%. The rate ranged from 0% to 1.57% in the injection groups, with an overall infection rate in the injection group of 1.18% versus 0.76% in the control group. Despite an increased odds ratio of 1.57 following injection, no statistically significant differences were found between the control group and any injection group based on timing of injection, patient age, or number of preoperative injections. Conclusions The results of this study suggest that within the MHS, preoperative LECIs do not significantly increase the risk of postoperative infection after single-level lumbar decompression. If a difference does exist, it is likely small.

Study Design This study is a retrospective case control. Objectives This study aims to determine whether cervical degenerative spondylolisthesis (DS) is associated with increased baseline neck/arm pain and inferior health quality states compared to a similar population without DS. Methods Patient demographics, pre-operative radiographs, and baseline PROMs were reviewed for 315 patients undergoing anterior cervical decompression and fusion (ACDF) with at least 1 year of follow-up. Patients were categorized based on the presence (S) or absence of a spondylolisthesis (NS). Statistically significant variables were further explored using multiple linear regression analysis. Results 49/242 (20%) patients were diagnosed with DS, most commonly at the C4–5 level (27/49). The S group was significantly older than the NS group (58.0 ± 10.7 vs 51.9 ± 9.81, P = .001), but otherwise, no demographic differences were identified. Although a higher degree of C2 slope was found among the S cohort (22.5 ± 8.63 vs 19.8 ± 7.78, P = .044), no differences were identified in terms of preoperative visual analogue scale (VAS) neck pain or NDI. In the univariate analysis, the NS group had significantly increased VAS arm pain relative to the S group (4.93 ± 3.16 vs 3.86 ± 3.30, P = .045), which was no longer significant in the multivariate analysis. Conclusions Although previous reports have suggested an association between cervical DS and neck pain, we could not associate the presence of DS with increased baseline neck or arm pain. Instead, DS appears to be a relatively frequent (20% in this series) age-related condition reflecting radiographic, rather than necessarily clinical, disease.

BACKGROUND CONTEXT Studies investigating the impact of interbody subsidence in ACDF suggest a correlation between subsidence and worse radiographic and patient-reported outcomes. Though some interbody subsidence is anticipated, a normal range of subsidence has yet to be defined. Furthermore, no study has investigated the variables influencing allograft subsidence in ACDF. PURPOSE The primary purpose of this study was to utilize computed tomography to characterize subsidence of allograft interbodies in ACDF. The secondary aim of this study was to determine the impact of patient- and graft-related variables on subsidence in ACDF. STUDY DESIGN/SETTING This was a retrospective study conducted at a single academic medical center. PATIENT SAMPLE Adult patients who underwent a 1 to 3 level ACDF with an allograft interbody and anterior plating between 2011-2017 were included. A total of 98 patients were included in the study. OUTCOME MEASURES Outcome measurements included superior endplate subsidence, inferior endplate subsidence, VAS scores, pseudoarthrosis, and reoperation rates. METHODS We performed a retrospective review of a prospective cohort of patients undergoing 1 to 3 level ACDF with an allograft interbody and anterior plating at a single institution between the years of 2011-2017. We collected demographic information, radiographic variables, and graft-related parameters. Graft subsidence was assessed on CT scan performed at least 6 months postoperatively. We classified subsidence as none if 4mm. Student's t-test and ANOVA were used to compare all means between groups. RESULTS We identified 98 patients (152 levels) for inclusion. On sagittal CT for the entire cohort, the mean superior endplate subsidence was 1.62mm+/-0.90 and the mean inferior endplate subsidence was 1.62mm+/-0.91. The number of levels that underwent 2mm, and >4mm of subsidence was 73 (48.0%), 79 (51.9%), and 18 (11.8%), respectively. Of the 18 levels with severe subsidence, 14 occurred in multi-level constructs, 2 of which occurred in both levels of a two-level ACDF in one patient. Of the remaining 12 levels of severe subsidence, 11 (92%) occurred at the caudal level and to a significantly higher degree at the inferior end plate (p 0.05). 16 patients (94.1%) with severe subsidence experienced pseudarthrosis compared to only 11 patients (13.6%) with CONCLUSIONS The present study is the first to utilize advanced imaging to quantify and characterize allograft subsidence in ACDF. Univariate analysis of patients with severe subsidence demonstrated that inferior screw placement in the caudal instrumented vertebra was associated with increased subsidence, likely due to decreased buttress support and an increased working length with an associated decrease in construct rigidity. Furthermore, excessive endplate resection was associated with an increase in both mild and severe subsidence. Based upon our study, some allograft subsidence in ACDF is expected, but too inferior screw placement at the caudal vertebral level and excessive endplate resection should be avoided to prevent severe subsidence. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Study design Retrospective analysis. Objective We set out to evaluate the radiographic and patient-reported outcomes following C1-C2 arthrodesis for atlantoaxial osteoarthritis (AAOA) using modern instrumentation and techniques. Summary of background data Few studies have evaluated outcomes following C1-C2 arthrodesis for AAOA using modern surgical fixation techniques. Methods Retrospective analysis of all patients following C1-C2 arthrodesis with recalcitrant AAOA from a single center, single surgeon from 2002 to 2012. Preoperative, immediate and final follow-up postoperative radiographic images were evaluated. Patient-reported outcomes scores were assessed preoperative, 1-year, and final postoperative follow-up. Results We found a total of 14 patients (13 female, 1 male) with average follow-up of 2.96 ± 2.26 years and mean age at surgery of 71.8 ± 9.3 years old. The most common construct was posterior C1-C2 bilateral screw-rod construct (SRC) (n = 9), and there were 3 patients with transarticular screw (TAS) constructs, and 2 patients with hybrid fixation (unilateral SRC and contralateral TAS). Mean change from baseline to final follow-up for Numeric Pain Rating Scale (NRS) was -4.7 ± 2.1, and Neck Disability Index (NDI) was -21.0 ± 13.6, with 11 (78.6%) patients demonstrated a substantial clinical benefit (change in NDI ≥ 10). There were no differences from baseline to all follow-up time points for SF-12 Physical and Mental Component Scores. All patients had evidence of solid C1-C2 arthrodesis and stable fixation at final follow-up, with no significant change in subaxial sagittal alignment. There were no perioperative or postoperative complications. Conclusion We report one of the largest series evaluating patient-reported outcomes in patients following arthrodesis for AAOA using modern C1-C2 fixation techniques. Our study found C1-C2 arthrodesis for AAOA to be safe and effective, with a significant improvement in patient-reported pain and neck disability and most patients reporting substantial clinical benefit. Level of evidence 4.

Study design Retrospective analysis. Objective The aim of the study was to report the incidence of undiagnosed osteoporosis in patients undergoing lumbar spine fusion using computed tomography (CT) Hounsfield units (HU). Summary of background data We used a recent technique utilizing HU to estimate bone mineral density (BMD) of the lumbar spine and hypothesized that this technique would reveal a high percentage of undiagnosed osteoporotic patients undergoing transforaminal lumbar interbody fusion (TLIF). Methods We reviewed patients older than 50 years undergoing TLIF from a single-center and multiple surgeons. We determined the mean HU of L4 on axial CT. Average HU values for patients with diagnosed lumbar osteoporosis (DEXA BMD 0.9 g/cm, respectively). The percentage of patients with HU values consistent with osteoporosis, but without any formal evaluation, was also calculated. Results Over 10 years, 143 patients older than 50 years underwent TLIF, and 128 had available perioperative lumbar CT scans. Men and Women comprised 60.2% and 39.8% of the population, respectively. Average age was 61.5 years (range: 50.0-83.5 years). Twenty-nine patients had both dual-energy X-ray absorptiometry and CT data available for analysis. There was a significant association with decreased HU in patients with lumbar BMD less than 0.75 g/cm (105.6 HU, 95% confidence interval [CI] 6.76) in comparison to patients with osteopenia (146.0 HU, 95% CI 4.09) and with normal BMD (165.9, 95% CI 21.35). Ten men (7.8%) and 15 women (11.7%) had HU values consistent with osteoporosis. Sixty-four percent of patients with osteoporotic HU values had never been formally evaluated for the disease. Conclusion HU may be an alternative to screening preoperative dual-energy X-ray absorptiometry scan and can minimize costs and resource utilization. We found a large proportion of patients older than 50 years undergoing TLIF had HU levels consistent with undiagnosed osteoporosis of the lumbar spine. Level of evidence 4.

BACKGROUND CONTEXT Postoperative subsidence of transforaminal lumbar interbody fusion (TLIF) interbody cages can result in loss of lordosis and foraminal height, and in some cases recurrence of nerve root impingement and radicular symptoms. Hounsfield unit (HU) values as measured on computed tomography (CT) can be used in the assessment of bone quality and bone mineral density. PURPOSE Determine the association between HU measurement of the first lumbar vertebral body and cage subsidence after TLIF. We hypothesized that the HU measured in the vertebral body of L1 would be lower in patients with postoperative TLIF cage subsidence. STUDY DESIGN/SETTING Retrospective case-control study. PATIENT SAMPLE NA OUTCOME MEASURES NA METHODS We retrospectively reviewed all patients undergoing instrumented TLIF from two institutions between July 2004 and June 2014. Postoperative imaging studies (radiographs and CT) were evaluated for evidence of implant subsidence. Hounsfield unit values were obtained from the first lumbar vertebral body on postoperative CT scan. Primary outcomes of this study were presence of cage subsidence and measured HU value of first lumbar vertebral body. RESULTS We identified 89 patients with complete imaging who met our inclusion criteria, with a mean clinical follow up of 27 months. Forty-five patients (50.5%) had evidence of interbody cage subsidence. Average cage subsidence was 5.5mm, with a range of 2.2 to 10.8mm. We found implant height was significantly higher in the subsidence group (12.6mm) when compared to the nonsubsidence group (11.2mm). First lumbar vertebral body coronal (170.69±15.61 vs 138.64±14.21; P=0.003), sagittal (175.14±17.26 vs 140.16±13.71; P=0.002), axial (157.57±12.26 vs 134.35±12.30.83; P=0.009), and average HU (167.8±14.04 vs 137.71±12.83; P=0.002) were significantly higher in the non-subsided group vs subsided group (167.8±14.04 vs 137.71±12.83; P=0.002). The subsidence group had a fusion rate of 82% compared to 93% in the nonsubsidence group, although this finding did not reach statistical significance (p=0.08). CONCLUSIONS We found that HU measurements of the first lumbar vertebra are significantly higher in patients without evidence of TLIF cage subsidence when compared to patients with cage subsidence. We identified a trend toward a decreased fusion rate in the subsidence group, yet this finding was not statistically significant. Our findings suggest that HU measurements may function as a surrogate measurement for bone mineral density, and as a predictor for cage subsidence following TLIF. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

OBJECTIVEPostoperative subsidence of transforaminal lumbar interbody fusion (TLIF) cages can result in loss of lordosis and foraminal height, and potential recurrence of nerve root impingement. The objectives of this study were to determine factors associated with TLIF cage subsidence. Specifically, the authors sought to determine if preoperative disc height compared to cage height could be used to predict TLIF interbody cage subsidence, and if decreased postoperative vertebral Hounsfield units (HUs) predisposed to cage subsidence.METHODSThe authors retrospectively reviewed all patients undergoing instrumented TLIF from two institutions between July 2004 and June 2014. The preoperative disc height was measured for the operative and adjacent-level disc on MRI. The difference between cage and disc heights was measured and compared between the subsidence and nonsubsidence groups. The average HUs of the L1 vertebral body were measured on CT scans.RESULTSEighty-nine patients were identified with complete imaging and follow-up information. Forty-five patients (50.6%) had evidence of interbody cage subsidence on follow-up CT. The average cage subsidence was 5.5 mm (range 2.2–10.8 mm). The average implant height was significantly higher in the subsidence group compared to the nonsubsidence group (12.6 vs 11.2 mm). Additionally, the difference between cage height and preoperative adjacent-level disc height was also significantly larger in the subsidence group (3.8 vs 1.2 mm). First lumbar vertebral body (L1) HUs were significantly higher in the nonsubsidence versus the subsidence group (167.8 vs 137.71 HUs, p = 0.002). Multivariate logistic regression analysis identified suprajacent disc height and L1 HUs to be independent predictors of interbody cage subsidence. Receiver operating characteristic curves identified a suprajacent to cage height difference > 1.3 mm to have a 93.3% sensitivity for cage subsidence.CONCLUSIONSThis study is the first of its kind to demonstrate the association between vertebral body HUs and suprajacent disc height with the development of interbody cage subsidence after TLIF. The authors found that patients with lower HUs in the L1 vertebral body were more likely to experience subsidence, regardless of surgical level. Additionally, the study demonstrated that interbody cage height > 1.3 mm above the height of the suprajacent level is an independent risk factor for cage subsidence, with 93.3% sensitivity. These findings suggest that these factors may be utilized to create a template preoperatively for intraoperative cage selection.

Background Amputations sustained owing to combat-related blast injuries are at high risk for deep infection and development of heterotopic ossification, which can necessitate reoperation and place immense strain on the patient. Surgeons at our institution began use of intrawound antibiotic powder at the time of closure in an effort to decrease the rate of these surgical complications after initial and revision amputations, supported by compelling clinical evidence and animal models of blast injuries. Antibiotic powder may be useful in reducing the risk of these infections, but human studies on this topic thus far have been inconclusive. Purpose We sought to determine whether administration of intrawound antibiotic powder at the time of closure would (1) decrease the risk of subsequent deep infections of major lower-extremity combat-related amputations, and (2) limit formation and decrease severity of heterotopic ossification common in the combat-related traumatic residual limb. Methods Between 2009 and 2015, 252 major lower extremity initial and revision amputations were performed by a single surgeon. Revision cases were excluded if performed specifically to address deep infection, leaving 223 amputations (88.5%) for this retrospective analysis. We reviewed medical records to collect patient information, returns to the operating room for subsequent infection, and microbiologic culture results. We also reviewed radiographs taken at least 3 months after surgery to determine the presence and severity of heterotopic ossification using the Walter Reed classification system. We grouped cases according to whether limbs underwent initial or revision amputations, and whether the limbs had a history of a prior infection. Apart from the use of antibiotic powder and duration of followup, the groups did not differ in terms of age, mechanism of injury, or sex. We then calculated the absolute risk reduction for infection and heterotopic ossification and the number needed to treat to prevent an infection. Results Overall, administration of antibiotic powder resulted in a 13% absolute risk reduction of deep infection (14 of 82 [17%] versus 42 of 141 [30%]; p = 0.03; 95% CI, 0.20%-24.72%). In revision amputation surgery, the absolute risk reduction of infection with antibiotic powder use was 16% overall (eight of 58 versus 17 of 57; 95% CI, 1.21%-30.86%), and 25% for previously infected limbs (eight of 46 versus 14 of 33; 95% CI, 4.93%-45.14%). The number needed to treat to prevent one additional deep infection in amputation surgery is eight in initial amputations, seven in revision amputations, and four for revision amputation surgery on previously infected limbs. With the numbers available, we observed no reduction in the risk of heterotopic ossification with antibiotic powder use, but severity was decreased in the treatment group in terms of the number of residual limbs with moderate or severe heterotopic ossification (three of 12 versus 19 of 34; p = 0.03). Conclusions Our findings show that administration of intrawound antibiotic powder reduces deep infection in residual limbs of combat amputees, particularly in the setting of revision amputation surgery in apparently aseptic residual limbs at the time of the surgery. Furthermore, administration of antibiotic powder for amputations at time of initial closure decreases the severity of heterotopic ossification formation, providing a low-cost adjunct to decrease the risk of two complications common to amputation surgery.Level of Evidence Level III, therapeutic study.

Cervical myelopathy and radiculopathy can be debilitating conditions that result in significant functional impairments. As one of the more common reasons that patients seek evaluation from spinal specialists, these degenerative disorders of the cervical spine place a substantial functional, psychosocial, and economic burden upon patients. The treating physician’s goal should be the rapid diagnosis and treatment of this condition in order to help patients return to their normal state of health. Conservative, nonoperative treatments should be initiated on all patients with new-onset radiculopathy, unless there are signs of significant motor deficit or myelopathy. The objectives of these treatment strategies are pain relief, improvements in function, and prevention of recurrence.

Study Design Retrospective review. Objective To compare clinical outcomes after transforaminal lumbar interbody fusion (TLIF) in patients with and patients without osteoporosis. Methods We reviewed all patients with 6-month postoperative radiographs and computed tomography (CT) scans for evaluation of the interbody cage. CT Hounsfield unit (HU) measurements of the instrumented vertebral body were used to determine whether patients had osteoporosis. Radiographs and CT scans were evaluated for evidence of implant subsidence, migration, interbody fusion, iatrogenic fracture, or loosening of posterior pedicle screw fixation. Medical records were reviewed for persistence of symptoms or recurrence of symptoms. Results The final data analysis included 18 (20.5%) patients with osteoporosis and 70 (79.5%) patients without osteoporosis. Males comprised 50% of patients with osteoporosis, and 64.3% of patients without osteoporosis. The mean age was significantly higher in the osteoporotic group (65.2 years) versus the nonosteoporotic group (56.9 years; p Conclusions Our data demonstrated significantly increased rates of cage subsidence, iatrogenic fracture, and overall radiographic complications in patients with osteoporosis. However, these radiographic complications did not predispose patients with osteoporosis to an increased risk of surgical revision or worse clinical outcomes.

Study design Retrospective review. Objective Report the 2-year operative and clinical outcomes of these service members with low lumbar fractures. Summary of background data The majority of spinal fractures occur at the thoracolumbar level, with fractures caudal to L2 accounting for only 1% of spine fractures. A previous report from this institution regarding combat-related spine burst fractures documented an increased incidence of low lumbar burst fractures in injured service members. Methods Review of inpatient and outpatient medical records in addition to radiographs for all patients treated at our institution with combat-related burst fractures occurring at the L3-L5 levels. Results Twenty-four patients with a mean age of 28.1± 7.2 underwent surgery for low lumbar (L3-L5) burst fractures. The mean number of thoracolumbar levels injured was 2.9 ± 1.4. Eleven patients had neurological injury, 4 of which were complete. The mean days to surgery were 16.8 ± 24.5. The mean number of levels fused was 4.3 ± 2.1, with fixation extending to the pelvis in 4 patients (17%). Fourteen (61%) patients had at least 1 postoperative complication, with 7 (30%) requiring reoperation. Five patients had a postoperative wound infection. Five patients had deep venous thromboses, 3 had pulmonary emboli. Mean clinical follow-up was 3.3± 2.2 years. At latest follow-up, all were separated from military service, 10 experienced persistent bowel/bladder dysfunction, 15 had lower extremity motor deficits, and 10 had documented persistent low back pain. Nineteen had chronic pain with 18 patients still taking pain medications and/or muscle relaxers. Conclusion Low lumbar burst fractures are a rare injury with an increased incidence in combat casualties engaged in the wars in Iraq and Afghanistan. We found a high rate of acute postoperative complications (61%), as well as a high reoperation rate (30%). At approximately 3 years of follow-up, most of these patients had persistent neurological symptoms and chronic pain. Level of evidence 4.

Injuries to the spinal column in combat casualties sustained during the conflicts in Iraq and Afghanistan are common, and the highest in reported wartime history. High-energy blast mechanisms from improved explosive devices have resulted in complex polytrauma and injury patterns, which are often markedly different from those injuries encountered in civilian trauma. Herein, we review the most current literature with regard to the distinct types of combat-related spine injuries/concomitant comorbidities sustained in Operations Enduring Freedom, Iraqi Freedom and New Dawn.

Osteoporosis is a burgeoning clinical problem that is characterized by decreased bone strength and density. It predisposes patients to fragility fractures and debilitating spine deformities. Several complications are associated with spine surgery in patients with osteoporosis, and there is currently no treatment algorithm to guide the spine surgeon. A multidisciplinary approach to treatment of patients with osteoporosis and spine deformity or fracture is encouraged, and preoperative planning is crucial for successful surgical outcomes. Several surgical techniques have been developed to treat osteoporosis-related deformities, including posterior instrumentation with fusion. However, achieving fixation and fusion in these patients can be difficult secondary to poor bone stock. Augmentation methods to improve pedicle screw fixation have evolved, including instrumentation at multiple levels, bioactive cement augmentation, and fenestrated or expandable pedicle screws, but their impact on clinical outcomes remains unknown. Management of osteoporosis in patients undergoing spine surgery is challenging, but with appropriate patient selection, medical optimization, and surgical techniques, these patients can experience pain relief, deformity correction, and improved function.

BACKGROUND: Premature infants are at risk for metabolic bone disease (MBD) during infancy despite improvements in nutritional support. MBD is associated with neonatal fracture, dolichocephaly and impaired linear growth. Limited research data suggest that prematurity does not increase fracture risk beyond the neonatal period. The impact of common neonatal medications and comorbidities of prematurity on fracture risk is unknown. OBJECTIVE: To evaluate …

Many techniques for fixation in the thoracolumbar spine have been described. Occasionally, particularly during operative management of unstable ligamentous or bony injuries, temporizing fixation may be required. The authors report the case of a patient with a ligamentous thoracolumbar flexion-distraction injury who underwent reduction, posterior instrumentation and fusion, and temporary fixation of the destabilized segment utilizing a novel interspinous process screw/rod construct. This construct was stable after placement and allowed for traditional instrumentation to be placed without causing secondary injury to the spinal cord. To the authors’ knowledge, this technique has not previously been described.

Fungal septic arthritis is rare, and there is a relative paucity of literature on the subject of joint infections caused by Candida albicans . Most described infections have been in adult patients; to the best of our knowledge, only a few cases have been reported in the pediatric population1. It is known that there is an increased risk for fungal joint infections in people with severe systemic immunosuppression, long-term central venous catheters, and prolonged broad-spectrum antibiotic therapy, as well as with intravenous drug abusers2,3. Hematogenous spread is a common mode of joint seeding, although direct inoculation from trauma or surgery has also been reported4,5. Most commonly, the vertebrae are affected; in the pediatric population, the most common sites of infection are the femur, the humerus, the vertebrae, and the ribs6. These infections can be difficult to diagnose since joint aspirations are often hemorrhagic, and Gram staining is negative in 20% of cases2,5. The synovial white blood-cell (WBC) count can vary widely2, reportedly from 15,000 to 100,000 cells/mL. In the literature, we did not find any reported cases of septic arthritis secondary to Candida albicans occurring in patients with cerebral palsy. We present a case report of a young girl with cerebral palsy who developed monoarticular Candida albicans septic arthritis of the knee two months after treatment for a central line infection. The patient’s parents were informed that data concerning the case would be submitted for publication, and they provided consent. A two-year-old girl with spastic cerebral palsy, necrotizing enterocolitis with a gastric tube, and global developmental delay was admitted to the pediatric intensive care unit (PICU) for respiratory failure secondary to infection from respiratory syncytial virus (RSV). Birth history was remarkable for …

BACKGROUND Hounsfield unit (HU) measurement obtained from computed tomography (CT) scans of the wrist is a potential new screening method for low bone mineral density (BMD). We hypothesized that HU measurements of the ulnar head obtained from CT scans would correlate with BMD assessed with dual x-ray absorptiometry (DXA) scans of the forearm. METHODS Patients with both upper-extremity CT and DXA scans performed at a single institution were included in the study. Hounsfield units were manually measured in the distal part of the ulna by 1 author blinded to the DXA results. Average values were then compared with forearm BMD values as determined with a DXA scan. RESULTS Seventy-seven CT scans of 74 patients were included. Average HU values were significantly lower in the osteoporotic and osteopenic groups in comparison with the normal BMD group. The upper limit of the 95% confidence interval for osteopenic patients was 145.9 HU. The average forearm T-score for patients with an HU value at or below the cutoff of 146 was significantly lower than the average T-score for those with an HU value of >146 HU (p < 0.0001). Sensitivity and negative predictive value for low BMD using this cutoff value were calculated to be 91% and 89%, respectively. CONCLUSIONS Distal ulnar HU measurements accurately reflect the BMD of the forearm as diagnosed with a DXA scan. Our results suggest that distal ulnar HU measurements of ≤146 HU are strongly associated with low BMD and that values above this cutoff accurately rule out low forearm BMD with a high degree of sensitivity and negative predictive value. Utilizing this technique may improve the capture of at-risk patients and streamline the screening process for osteoporosis. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Case A previously healthy military recruit underwent routine microdiscectomy after lumbar disc herniation. After a period of improvement, he developed recurrent pain without repeat injury. Advanced imaging showing loss of marrow signal, and disc height was concerning for discitis. Inflammatory markers remained negative. Conservative treatment without antibiotics led to symptom resolution. Conclusion This case demonstrates an unusual complication after lumbar microdiscectomy in a healthy individual. The recurrent symptoms and imaging changes were likely secondary to aseptic discitis and rapid degeneration rather than infection. A stepwise approach is critical for determining the cause of pain exacerbation after spinal procedures.

Several studies have established the short-term safety and efficacy of cervical disc arthroplasty (CDA) as compared to anterior cervical discectomy and fusion (ACDF). However, few single-center comparative trials have been performed, and current studies do not contain large numbers of patients. We retrospectively reviewed all patients from a single military tertiary medical center between August 2008 to August 2012 who underwent single-level CDA or single-level ACDF and compared their clinical outcomes and complications. A total of 259 consecutive patients were included in the study, 171 patients in the CDA group with an average follow-up of 9.8 (±9.9) months and 88 patients in the ACDF group with an average follow-up of 11.8 (±9.6) months. Relief of pre-operative symptoms was 90.1% in the CDA group and 86.4% in the ACDF group with rates of return to full pre-operative activity of 93.0% and 88.6%, respectively. Patients who underwent CDA had a higher rate of persistent posterior neck pain (15.8% versus 12.5%), and patients who underwent ACDF were at risk for symptomatic pseudarthrosis at a rate of 3.4%. Reoperation rates were higher in the ACDF group (5.7% versus 3.5%). To our knowledge, this review is the largest, non-funded, comparison study between single-level CDA and single-level ACDF. This study demonstrates that CDA is a safe and reliable alternative to ACDF in the treatment of cervical radiculopathy and myelopathy resulting from spondylosis and acute disc herniation.

Cervical disc arthroplasty has emerged as a viable technique for the treatment of cervical radiculopathy and myelopathy, with the proposed benefit of maintenance of segmental range of motion. There are relatively few, non-industry sponsored studies examining the outcomes and complications of cervical disc arthroplasty. Therefore, we set out to perform a single center evaluation of the outcomes and complications of cervical disc arthroplasty. We performed a retrospective review of all patients from a single military tertiary medical center undergoing cervical disc arthroplasty from August 2008 to August 2012. The clinical outcomes and complications associated with the procedure were evaluated. A total of 219 consecutive patients were included in the review, with an average follow-up of 11.2 (±11.0) months. Relief of pre-operative symptoms was noted in 88.7% of patients, and 92.2% of patients were able to return to full pre-operative activity. There was a low rate of complications related to the anterior cervical approach (3.2% with recurrent laryngeal nerve injury, 8.9% with dysphagia), with no device/implant related complications. Symptomatic cervical radiculopathy is a common problem in both the civilian and active duty military populations and can cause significant disability leading to loss of work and decreased operational readiness. There exist several surgical treatment options for appropriately indicated patients. Based on our findings, cervical disc arthroplasty is a safe and effective treatment for symptomatic cervical radiculopathy and myelopathy, with a low incidence of complications and high rate of symptom relief.

BACKGROUND CONTEXT Post-operative C5 palsy is a known complication following cervical decompression, occurring more frequently after posteriorly based procedures, but also occurring after approximately 2%–6% of anteriorly based surgeries. Although several risk factors for the development of a postoperative C5 palsy have been reported, including among others, excessive cord drift, change in overall cervical alignment, and increases in C4-5 intervertebral height, no consensus has emerged on definitive causation and the cause is likely multifactorial. PURPOSE To assess the rate of C5 palsy following anterior cervical decompression and fusion (ACDF) and determine whether any radiographic parameters can predict its occurance. STUDY DESIGN/SETTING Retrospective single institution, multisurgeon patient cohort. PATIENT SAMPLE A total of 226 patients who underwent ACDF between September 2015 and September 2016 were reviewed. The average age of the sample was 59years and 51% were female. A total of 122 patients were included in the final analysis. Patients were excluded if they underwent concomitant posterior surgery or corpectomy, if no postoperative motor strength was documented, or if radiographs were inadequate for accurate measurement. OUTCOME MEASURES The primary outcome measure was the development of a C5 palsy, defined as a decrease of at least one motor grade in deltoid and/or biceps brachii muscle function in the immediate postoperative period. Preoperative and immediate postoperative radiographs were reviewed to determine whether any parameters influenced the development of a C5 palsy. These parameters included: local (C4-5) cobb angle, C2-7 cobb angle, C2-7 sagittal vertical axis (SVA), C4-5 intervertebral height (measured from the superior endplate of C4 to the inferior endplate of C5), and C2-7 cervical height (measured from the superior endplate of C2 to the inferior endplate of C7). METHODS Patient demographic, surgical, and radiographic data was reviewed, including postoperative motor examination results and pre- and postoperative radiographs. Given the small sample size for the palsy group, Mann-Whitney U test was used to compare continuous variables between independent groups and Fisher's exact test was used to compare categorical variables between groups. RESULTS Seven patients developed a postoperative C5 palsy with an overall rate of 5.7%. There were no statistically significant differences in patient age, sex, or numbers of levels fused between the palsy and nonpalsy groups. Among all radiographic parameters evaluated, there were no statistically significant differences between the groups (p>.05). However, there was a trend toward increasing kyphosis within the palsy cohort compared to the nonpalsy cohort among the changes in C2-7 cobb angle (4.09°±10.2° of kyphosis vs. 1.25°±9.18° lordosis, p=.19), C4-5 cobb angle (3.04°±6.70° kyphosis vs. 2.91°±8.46° lordosis, p=.059), and SVA (8.46 mm±8.26vs. 5.31 mm±9.04, p=.32). There was marginal significance for increased change in C4-5 cobb angle predisposing toward palsy (1.24° vs. 4.01°, p=.059). There was also a nonsignificant trend toward increasing local (0.90 mm±6.95vs. 3.37 mm±5.46, p=.35) and overall intervertebral height (1.56 mm±10.34vs. 4.26 mm±7.54, p=.54) among the palsy versus nonpalsy groups, respectively. CONCLUSIONS In this single institution series, we identified a 5.7% postoperative C5 palsy rate following ACDF. Although some have suggested that certain radiographic parameters can predict the development of C5 palsy, in our series, we could not identify any radiographic parameters which increase this risk, including changes in overall cervical or local C4-5 alignment.

BACKGROUND CONTEXT Postoperative subsidence of the transforaminal lumbar interbody fusion (TLIF) cages can result in loss of lordosis and foraminal height, and in some cases recurrence of nerve root impingement and radicular symptoms. PURPOSE The purpose of this study is to determine factors associated with TLIF cage subsidence. Specifically, we sought to determine if preoperative disc height compared to cage height could be used to predict TLIF interbody cage subsidence. STUDY DESIGN/SETTING Retrospective case-control study. PATIENT SAMPLE We identified 127 patients with complete imaging who met our inclusion criteria, with a mean clinical follow up of 27 months. OUTCOME MEASURES The primary outcome of this study was presence of cage subsidence identified with radiograph or CT. METHODS We retrospectively reviewed all patients undergoing instrumented TLIF from two institutions between July 2004 and June 2014. Postoperative imaging studies (radiographs and CT) were evaluated for evidence of implant subsidence. Preoperative disc height was measured for the operative and adjacent level disc heights. The delta between cage height and disc heights were measured and compared between groups. RESULTS Fifty four patients (44.3%) had evidence of interbody cage subsidence. Average cage subsidence was 5.5mm, with a range of 2.2–10.8mm. We found implant height was significantly higher in the subsidence group (12.6mm) when compared to the nonsubsidence group (11.2mm). Additionally, the delta between cage height and preoperative disc height was significantly larger in the subsidence group delta (5.5mm vs. 3.9mm). Similarly, the delta between cage height and preoperative adjacent level disc height was also significantly larger (1.2mm vs. 3.8mm). CONCLUSIONS This study demonstrates that preoperative disc height and preoperative adjacent level disc height can be used to template TLIF cage height to potentially decrease rates of subsidence. Larger cages subsided more frequently than smaller cages. Patients with evidence of subsidence had larger deltas between cage height and preoperative disc height. Similarly, a significant difference existed if preoperative adjacent level disc height was compared to cage height. This demonstrates that preoperative imaging should be used for TLIF cage height templating to avoid subsidence.

BACKGROUND CONTEXT There has been increasing interest in examining the relationship of lumbar paraspinal muscle morphometry and outcomes after lumbar spinal surgery, as well as investigating any association between changes in paraspinal muscle density and low back pain.However, the relationship of the iliopsoas muscle to the posterior paraspinal muscles, and the effect of variation in psoas cross sectional area to lumbar disability in patients with degenerative spondylolisthesis, has not been extensively explored. PURPOSE We set out to compare the absolute psoas and paraspinal CSA in patients with degenerative lumbar spondylolisthesis and corresponding severe disability to similar patients with only mild or moderate disability. STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE Inclusion criteria were any patient undergoing single level lumbar fusion for degenerative spondylolisthesis greater than 18 years of age at one institution, based on the ICD-9 code 721.42, with a preoperative lumbar spine MRI and completed preoperative patient-reported outcome scores. Patients under the age of 18 years, those lacking a preoperative lumbar spine MRI or completed preoperative patient-reported outcome scores, or those with a diagnosis other than degenerative lumbar spondylolisthesis were excluded from the study. METHODS We retrospectively reviewed the medical records of 101 patients undergoing lumbar fusion for degenerative spondylolisthesis. Patients were divided into Oswestry Disability Index (ODI) score 40 (severe disability, SD) groups. The total CSA of the psoas and paraspinal muscles were measured on preoperative magnetic resonance imaging (MRI). Student's t-test was used to compare continuous variables between groups. Multivariable logistic regression was performed analyzing the effects of ASA class, history of heart disease, smoking status and psoas CSA on lumbar disability. P RESULTS There were 37 patients in the SD group and 64 in the MMD group. Average age and body mass index were similar between groups. For the paraspinal muscles, average iliocostalis CSA was 1093.5mm2 versus 1192.2mm2 for the SD group versus the MMD group, respectively (p=.168). Similarly, the longissimus CSA was 685.8mm2 versus 764.8mm2 (p=.329), respectively, and the multifidus CSA was 499.1mm2 versus 526.0mm2 (p=.125), respectively. Psoas muscle CSA was significantly decreased in the SD group compared to the MMD group (1010.08mm2 vs. 1178.6mm2, p=.041). Multivariable logistic regression demonstrated that active smoking was independently associated with severe disability (OR=12.9, range: 1.19–140.2, p=.035), while psoas size in the upper quartile was significantly protective against severe disability (OR=0.13, range: 0.03–0.66, p=.013). CONCLUSIONS In patients with severe lumbar disability and a diagnosis of degenerative spondylolisthesis, when compared to similar patients with mild or moderate disability, we found significantly decreased absolute cross sectional area of the psoas muscle. In addition, multivariate analysis found that increased psoas CSA was significantly protective against severe lumbar disability. Our findings are suggestive of a potential association between psoas atrophy and worsening severity of lumbar disability.

BACKGROUND CONTEXT Lumbar microdecompression is one of the most common procedures in orthopedic spine surgery with an overall low complication and high satisfaction rate. The procedure is typically performed with visualization aids, either loupes or an operating room microscope. Several studies to date have investigated differences between these two magnification tools, with conflicting results. Some authors argue in favor of the microscope, citing improved visualization, better ergonomics and improved patient outcomes, while others argue that its use makes no clinical difference. These studies consist primarily of small patient cohorts numbering 50-100 subjects. PURPOSE The purpose of this study is to determine how the routine use of an operating room microscope during single level lumbar microdecompression impacts intraoperative and short-term surgical outcomes through an examination of the largest retrospective cohort to date. STUDY DESIGN/SETTING Retrospective review of American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. PATIENT SAMPLE A total of 43,948 patients who underwent single level lumbar microdecompression from 2005 to 2015. OUTCOME MEASURES Assessment of surgical benchmarks of operative time and length of hospital stay as well as differences in early (30 day) complication rates. The specific complications evaluated included the need for blood transfusion, return to the operating room, pulmonary embolism, deep venous thrombosis, sepsis, cerebrovascular accident, cardiac arrest, ventilator time greater than 48 hours, urinary tract infection, pneumonia, myocardial infarction, surgical site infections, and patient mortality. METHODS Using the ACS-NSQIP database, we identified all patients who underwent single level lumbar microdecompression (CPT 63030). They were divided into two cohorts, those cases that involved the use of an operating room microscope (CPT 69990), and those that did not. We compared intraoperative and postoperative procedural data as well as the incidences of local and systemic complications. RESULTS The ACS-NSQIP database identified 43,948 patients who underwent single level lumbar microdecompression from 2005 to 2015. Of that patient cohort 4,654 cases included the use of an operating room microscope. There were no clinically significant demographic differences between patient cohorts. We identified clinically important statistical differences in length of stay (1.37 vs. 1.75 days, p CONCLUSIONS The routine use of an operating room microscope in single level lumbar microdecompression does not affect short-term patient outcomes. Importantly, there is no difference in mean operative time or infection rate with the addition of a microscope. There is a statistically significant trend toward decreased length of stay and fewer blood transfusions in the microscope cohort; however, in the setting of a large database study and small absolute differences, the clinical implications of these findings are difficult to interpret. Based on these results, we conclude that the decision to use an operating room microscope in single level lumbar microdecompression should be left to the treating surgeon and based upon considerations of improvements in visualization, surgeon ergonomics and ability to educate surgical assistants. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Case We present a 26-year-old active duty man who sustained a coccygeal fracture and gluteus maximus hematoma after a fall from height during training. The patient returned 3 weeks postinjury with symptoms and physical examination findings concerning for gluteal compartment syndrome. An expanding gluteal hematoma was confirmed on imaging and the patient was taken to the operating room for emergent evacuation and endovascular hemostasis. Conclusions This case of gluteal compartment syndrome is a unique contribution to the literature with respect to the specific vascular injury observed and the delayed presentation of gluteal compartment syndrome.

Proton pump inhibitors (PPIs) are widely prescribed medications that are utilized for the treatment of gastroesophageal reflux and similar gastrointestinal disorders in all patient populations.There is evidence that prolonged use of PPIs can lead to osteoporosis and altered bone metabolism and can e

BACKGROUND CONTEXT Cervical radiculopathy secondary to cervical spondylosis can manifest as pain, sensory disturbance, and/or motor deficit. While preoperative weakness is often used as an indication for early surgical intervention, few studies have examined the prognosis for upper extremity motor deficit following anterior cervical discectomy and fusion (ACDF). PURPOSE To determine the prognosis for motor recovery after anterior cervical discectomy and fusion in patients with preoperative motor weakness. STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE Consecutive patients undergoing elective ACDF from September 2015 until June 2016. OUTCOME MEASURES Postoperative motor strength in all affected myotomes. METHODS We retrospectively examined a cohort of 618 consecutive patients that underwent elective ACDF from September 2015 until June 2016. Cases were performed by ten fellowship trained spine surgeons at our tertiary academic center. Data was collected regarding patient demographics and comorbidities. Cervical magnetic resonance imaging imaging was reviewed for the presence of cord compression, myelomalacia, and foraminal stenosis. Patients were divided into a group exhibiting significant preoperative weakness (Medical Research Council motor grade less than 4) and a group without significant weakness. Data regarding affected muscle groups and significant improvement postoperatively (to a motor grade 4 or greater) was recorded. Univariate analysis was performed to determine risk factors for failure to improve. RESULTS Overall, out of the 618 patients, 47.5% were male with an average age of 56.3years. 43.0% of patients exhibited myeloradiculopathy with 57% having exclusively cervical radiculopathy. Of those patients with myelopathy and cord compression, 40.5% demonstrated myelomalacia on cervical MRI. Average follow up was 6.2 months. Two-level fusions were most commonly performed (44.6%) followed by one-level (29.3%), three-level (21.7%), and four-level (4.4%) fusions. A total of 4.3% of patients demonstrated significant preoperative weakness. Of these patients, 57.1% of them had more than one muscle group affected. Triceps were the most commonly affected muscle group (26.9%) followed by hand intrinsics (23.1%), finger flexors (20.5%), deltoids (15.4%), and biceps (14.1%). Postoperatively, 75.3% of patients experienced an improvement in muscle strength (≥4). Despite being the most commonly weak muscle preoperatively, triceps most frequently showed improvement (95.2%) followed by finger flexors (87.5%), hand intrinsics (83.3%), and biceps (63.6%). Deltoids were much less likely to show improvement following surgery (8.3%). In a univariate analysis, myelomalacia on imaging (OR 28.9, p CONCLUSIONS This cohort's outcomes would suggest with intermediate follow up one can expect the vast majority (over 70%) of patients to show marked strength improvement postoperatively after ACDF. These results are encouraging for patients undergoing ACDF with significant preoperative motor weakness. However, patients with myelomalacia seem to be at risk for not improving, and should be counseled that their prognosis for strength improvement is more guarded.

BACKGROUND CONTEXT Osteoporosis remains a major cause of morbidity and mortality, despite increasing efforts among provider organizations to promote awareness and screening. Recent attention has turned to the opportunistic utilization of Hounsfield unit (HU) measurements from computed tomography (CT) as a potential screening method for low bone mineral density (BMD). We hypothesized that thoracic spine CT HU measurements will correlate with BMD measurements conducted with dual X-ray absorptiometry (DXA) scans of the femoral neck. PURPOSE To compare thoracic spine HU and femoral neck T-scores determined by DXA, and determine the accuracy with which thoracic HU values estimate central BMD. STUDY DESIGN/SETTING Retrospective review of patients with applicable imaging. PATIENT SAMPLE Fifty-six patients with both computed tomography scans including the thoracic spine obtained for any indication, and dual X-ray absorptiometry T-scores of the femoral neck. METHODS Patients with thoracic CT and DXA scans at one institution were included in the study. Hounsfield units were manually measured from the cancellous bone in T4 vertebrae by one author blinded to DXA scans. HU measurements were compared with femoral neck DXA t-scores. A receiver operator characteristic curve (ROC) with associated dataset was utilized to aid in determining maximum screening HU values for sensitivity and specificity. RESULTS Fifty-six patients with 58 CT scans and femoral neck DXAs were included in the study. The average HU in the osteoporotic group was significantly lower than the normal group (148.89HU±56.53HU vs. 217.56HU±65.69HU, respectively; p CONCLUSIONS Thoracic vertebrae HU measurements correlate with low BMD of the femoral neck as determined by DXA scan T-score. Screening values of 218 HU captured over 95% of those with low BMD, with sensitivity of 90%. Opportunistic utilization of thoracic HU as a screening method provides a simple, quick, and easily assessable screening tool for assessing low BMD.

Military experience managing complex blast injuries during the long conflicts in Afghanistan and Iraq has advanced the understanding of the biophysics of blast trauma and has allowed for the development of treatment algorithms to manage associated injuries. Military blast-injured patients typically arrive in extremis, often with severe pelvic or perineal injuries and extremity amputations. Resource demand for even one of these patients can be quite significant, and in austere environments can severely impact the reserves of the managing facility.

Background Context There is very little literature examining optimal radiographic parameters for placement of cervical disc arthroplasty (CDA), nor is there substantial evidence evaluating the relationship between persistent postoperative neck pain and radiographic outcomes. Purpose We set out to perform a single-center evaluation of the radiographic outcomes, including associated complications, of CDA. Design This is a retrospective review. Patient Sample Two hundred eighty-five consecutive patients undergoing CDA were included in the review. Outcome Measures The outcome measures were radiological parameters (preoperative facet arthrosis, disc height, CDA placement in sagittal and coronal planes, heterotopic ossification [HO] formation, etc.) and patient outcomes (persistent pain, recurrent pain, new-onset pain, etc.). Methods We performed a retrospective review of all patients from a single military tertiary medical center from August 2008 to August 2012 undergoing CDA. Preoperative, immediate postoperative, and final follow-up films were evaluated. The clinical outcomes and complications associated with the procedure were also examined. Results The average radiographic follow-up was 13.5 months and the rate of persistent axial neck pain was 17.2%. For patients with persistent neck pain, the rate of HO formation per level studied was 22.6%, whereas the rate was significantly lower for patients without neck pain (11.7%, p=.03). There was no significant association between the severity of HO and the presence of neck pain. Patients with a preoperative diagnosis of cervicalgia, compared to those without cervicalgia, were significantly more likely to experience continued neck pain postoperatively (28.6% vs. 13.1%, p=.01). There were no differences in preoperative facet arthrosis, pre- or postoperative disc height, segmental range of motion, or placement of the device relative to the posterior edge of the vertebral body.However, patients with implants more centered between the uncovertebral joints were more likely to experience posterior neck pain (p=.03). Conclusions We found that posterior axial neck pain is relatively frequent after CDA, and patients with persistent neck pain were significantly more likely to have preoperative cervicalgia and develop HO postoperatively. We also found that patients with implants that were placed off-centered were less likely to also complain of neck pain, although the reasons for this finding remain unclear.