Search

Background: Chronic opioid use and polypharmacy are commonly seen in chronic pain patients presenting for spine procedures. Substance abuse and misuse have also been reported in this patient population. Negative perioperative effects have been found in patients exposed to chronic opioid, alcohol, and recreational substances. Toxicology screening testing (TST) in the perioperative period provides useful information for adequate preoperative optimization and perioperative planning., Methods: We designed a pilot study to understand this population's preoperative habits including accuracy of self-report and TST-detected prescribed and unprescribed medications and recreational substances. We compared the results of the TST to the self-reported medications using Spearman correlations., Results: Inconsistencies between TST and self-report were found in 88% of patients. Spearman correlation was 0.509 between polypharmacy and intraoperative propofol use, suggesting that propofol requirement increased as the number of substances used increased., Conclusions: TST in patients presenting for spine surgery is a useful tool to detect substances taken by patients because self-report is often inaccurate. Discrepancies decrease the opportunity for preoperative optimization and adequate perioperative preparation., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology.)

Current explanations of biomedical alloy degradation are focused on the physicochemical mechanisms of galvanic, pitting, crevice, and fretting corrosion. Ultimately, these studies dismiss the corrosion mechanism as a function of the local microbiome. Sixty spine hardware constructs were examined immediately after explantation for biofilm formation. Marked rod sections were imaged using scanning electron microscopy with energy dispersive x-ray spectroscopy. Backscatter mode was employed to better image the topology of the surface. There is clear differentiation between discoloration due to corrosion vs mechanical damage. Under scanning electron microscopy backscatter electron shadow examination, the authors noted that not all biofilm was removed using the surgical wipes. Corrosion pits were noticeably larger and numerous in areas of biofilm. In areas not associated with biofilms, there were few pits even if mechanical wear was evident. There is no evidence that the surface corrosion is modified between clinically diagnosed infected and noninfected patients. The surface damage present on explanted Ti6Al4V spine rods is uniquely similar to damage found in other industries where microbial-influenced corrosion is prevalent. Given that similar anaerobic, sulfur-reducing bacteria reside in and on human tissues, it is most likely that corrosion observed on explanted hardware is the result of microbial-influenced corrosion and not from inflammatory or other processes. Using analysis methods from other industries to characterize the microbiome present on explanted hardware is necessary. In so doing, a new definition of hardware-induced infection will be forthcoming. [Orthopedics. 2020;43(1):62-67.]., (Copyright 2020, SLACK Incorporated.)

The characteristic trait of metallosis is the presence of tissue staining. Analyzing explanted revision hardware from spine surgeries and performing ICPMS/AES analysis on removed tissue samples, a clinically relevant definition for metallosis may be developed. Results of the analysis identified hardware fretting wear and corrosion, and ICP-MS/AES analysis identified elevated metal ion concentrations in all cases. This supports the hypothesis that corrosion may be linked to poor health outcomes and potential need for revision surgery. Using failure analysis methods, corrosion products from orthopedic spine implants can be identified to begin to characterize metallosis in a clinically relevant manner. Failure analysis for patients undergoing revision spine surgery for other causes. Using failure analysis methods we conducted a retrieval analysis of explanted hardware and tissue. Implant failure with surrounding tissue metal staining is a current issue in the field of orthopedics. Specifically in spine, this issue is under reported and over looked as a clinically significant finding. Metallosis is most commonly used to describe the presence of tissue staining however this is not a clinically relevant definition. There is a need for further research to provide a better understanding of metallosis leading to better patient outcomes. Patients were screened for this study during a radiological review prior to surgery. All explanted hardware was documented and inspected for signs of wear and corrosion using non-destructive testing. A tissue sample that is normally removed and discarded was collected for ICP-MS/AES analysis. The presence of fretting corrosion, galling and corrosion fatigue was found on all explanted hardware. Cr levels are significantly higher than what was previously published as normal in muscle 0.03  μg/g. One case was a 4 order of magnitude elevation with the other 2 approximately 2 orders of magnitude increase. Titanium and Co concentrations are also significantly increased. The Ca to P ratio for all samples is approximately 1.7:1 suggesting some form of apatitic crystal present due to drying of the tissues. In all cases, the Al, Mo, V, Co, content in surrounding tissue is significantly elevated >10× above "normal," 8.4 ± 4.8; 1.61 ± 1.41; 0.06 ± 0.03; 1.35 ± 1.97 μg/g respectively. A "normal" reference titanium level could only be found for whole blood, 0.00072 ± 0.1412 μ/g. Iron and Ni measurements are within typical values presented in previous studies. No single mechanism for the release of metal ion in a patient is clear. Evidence suggests a tribocorrosive process due to both wear and environmental factors. Specific biologic mechanisms, such as the possible presence of bacteria may affect the fretting and corrosion of spinal instrumentation must be explored in conjunction with thorough review of patient outcomes. Such an effort can potentially reduce patient readmission and increase successful patient outcomes.

Study Design: A systematic review with meta-analysis., Objective: To combine published data, focusing on the development of optimal spinopelvic parameters in adult asymptomatic subjects without spine deformity while taking into consideration the impact of potential confounders., Summary of Background Data: A well-grounded approach to define the optimal spinopelvic parameters is necessary for planning surgical correction of spine deformity., Materials: Selection criteria: (1) randomized and nonrandomized prospective, cross-sectional, and retrospective studies; (2) participants: asymptomatic subjects without spine deformity aged above 18 years; (3) studied parameters: lumbar lordosis (LL), pelvic incidence, sacral slope, and pelvic tilt; (4) potential confounders: method of measurement, sex, age, ethnicity, weight, height, and body mass index. Search method: Ovid MEDLINE (1946-current) and EMBASE (1980-current), all years through October 2015 were included. Data were collected: number of enrolled subjects, means of the studied characteristics, SD, SE of the means, 95% confidence intervals. A meta-analysis was performed to evaluate the pooled means and range of optimal values (pooled mean±pooled SD) taking into consideration the impact of confounders. The GRADE approach was applied to evaluate the level of evidence., Results: Seventeen of 1018 studies were included (2926 subjects from 9 countries). The pooled means and the optimal ranges were: LL (L1-S1), 54.6 (42-67) degrees; LL (L1-L5), 37.0 (22-53) degrees; pelvic incidence, 50.6 (39-62) degrees; sacral slope, 37.7 (28-48) degrees; pelvic tilt, 12.6 (3-22) degrees. The pooled results were statistically significant (P<0.001), but heterogeneous. Impact of the following confounders was revealed: method of measurement, ethnicity, age, and body mass index. A methodology was created to define an individualized optimal value and range of each studied parameter taking into consideration the influence of confounders., Conclusions: The pooled results and developed methodology can be used as diagnostic criteria for evaluation of the spinopelvic parameters, planning of surgical interventions and evaluation of the treatment effect.

A substantial proportion of patients develop proximal junctional kyphosis following spinal surgery. To combat this postoperative change, several techniques have focused on maintaining the structural integrity of adjacent spinal levels and adapting the proximal end of the fusion construct to accommodate the increased mechanical stressors produced by long spinal fusion. The use of Mersilene tape (Ethicon, Somerville, New Jersey) for spine and orthopedic surgery is well documented, although considerably less is known about its use for preventing proximal junctional kyphosis. This article describes a proposed technique using Mersilene tape to provide a check-rein strap stabilization at the proximal end of fusion constructs. Initial data suggest that use of this technique may prevent formation of proximal junctional kyphosis. [Orthopedics. 2016; 39(4):e794-e799.]., (Copyright 2016, SLACK Incorporated.)

Objective: Studies have indicated that outcomes may differ by choice of flowable hemostat, but there is limited evidence in spine surgery. The objective of this study was to conduct a comparison of outcomes following use of advanced flowable hemostatic matrices in a large spine surgery population., Methods: This is an observational retrospective cohort analysis using Premier's US Perspective Hospital Database. Two commonly-used hemostatic matrices (Floseal and Surgiflo kitted with thrombin) were compared in cases categorized as either major or severe spine surgery. Outcomes included complications, blood product administration, hospital length of stay (LOS), surgery time, and amount of matrix used in surgery., Results: Major spine surgery patients treated with Surgiflo were associated with increased risk of blood product transfusion (OR = 2.56, 95% CI = 1.79-3.65, p < 0.001), longer surgery time (+8.84 min, p < 0.0001), and increased product usage (+3.34 mL, p < 0.001), compared to Floseal; however, risk of complications and LOS did not differ by choice of matrix in this patient group. Severe spine surgery patients treated with Surgiflo were associated with longer surgical time (+26.9 min, p < 0.001) and increased product usage (+1.52 mL, p < 0.01), compared to Floseal; however, risk of complications, transfusion and LOS did not differ by choice of matrix in this patient group., Limitations: Inherent to limitations associated with database analysis, this study did not evaluate potential physician differences such as skill and experience, assess long-term outcomes, nor include cases with missing data., Conclusion: The results from this analysis indicated that surgery time, risk of blood transfusion, and amount of matrix used are greater with Surgiflo patients, compared to Floseal patients. Choice of matrix did not appear to impact hospital LOS or risk of surgical complications. Future research should evaluate the cost consequences of increased clinical and resource utilization by choice of hemostatic matrix in spine surgery.

The motor control system may compensate for lumbar instability following cyclic work with differential response to load magnitude. In vivo felines were exposed to a cumulative 1 h of cyclic work at 0.25 Hz. One group exposed to light whereas the second to heavy load while recording lumbar displacement and multifidus EMG during work and in single test cycles over 7 h rest post-work. Significant laxity and reduced reflexive EMG activity were evident immediately post-work in both groups. EMG and laxity recovered over 7 h rest in the group exposed to light load whereas in the group exposed to heavy load, motor control compensation was triggered within 1-2 h post-work. The compensation was expressed by earlier and stronger muscular activation than in baseline. It is concluded that cyclic work is deleterious to spine stability immediately after work. Work with heavy loads elicits delayed motor control compensation whereas work with light loads leaves the spine unstable and exposed to injury for several hours. Overall, prolonged cyclic or repetitive work elicits a transient instability disorder, regardless of the load handled, exposing the individual to potential injury.

In spinal decompression and fusion surgery, a high speed burr is often used to remove bony material. The generated bone shavings are typically washed away and discarded. This study histologically examined the content of burr shavings to determine whether the collected tissue has the potential to augment local autograft. Our findings verified that burr shavings collected during spinal decompression are primarily composed of bone (65%) with blood product (32%). The bone shavings appear to remain viable after burring, as there was no microscopic evidence of damage to the cells. These findings indicate that bone shavings can be easily collected and could be added to local laminectomy bone with minimal cost. This technique is also beneficial given that it does not increase morbidity, as does iliac crest bone graft harvesting. Furthermore, the putty-like consistency of the bone shavings may facilitate the placement of morselized autograft bone. Despite these advantages, collected bone shavings are by no means a substitute for autograft or allograft bone. Their osteogenic potential is not comparable to that of iliac crest bone and the shavings lack the structural scaffolding of allograft bone. This technique, however, provides a resource for augmenting local autograft during spinal fusion, and is not associated with any significant cost or effort. Future studies should compare the clinical and radiographic fusion outcomes of high speed burr bony shavings combined with local laminectomy bone versus either iliac crest autograft or local laminectomy bone used with other bone graft extenders.

Although iliac crest autograft is the gold standard for fusion, many patien experience permanent pain at the donor site that is likely underestimated in the literature. As the population requiring reconstructive spine surgery increases, so does the need for a successful substitute for autologous bone. One such large surface bone graft substitute that has gained popularity in spine surgery is calcium phosphate. However, the characteristics of various calcium phosphate products have not been previously reviewed in the literature. Thus, this article presents a comparative analysis of the physiochemical attributes of calcium phosphate materials used in spine surgery.

Robust reference data, representing a large and diverse population, are needed to objectively classify measurements of spondylolisthesis and disc space narrowing as normal or abnormal. The reference data should be open access to drive standardization across technology developers. The large collection of radiographs from the 2nd National Health and Nutrition Examination Survey was used to establish reference data. A pipeline of neural networks and coded logic was used to place landmarks on the corners of all vertebrae, and these landmarks were used to calculate multiple disc space metrics. Descriptive statistics for nine SPO and disc metrics were tabulated and used to identify normal discs, and data for only the normal discs were used to arrive at reference data. A spondylolisthesis index was developed that accounts for important variables. These reference data facilitate simplified and standardized reporting of multiple intervertebral disc metrics. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Recombinant human bone morphogenetic protein-2 (rh-BMP2) has become popular for augmenting spine fusion in the lumbar and cervical spine. Concerns exist, however, over bone morphogenetic protein (BMP)-stimulated soft-tissue swelling and bone growth stimulation in areas where bone is not desired, especially as the material “leaks” into such spaces. The most detrimental effects of such leakage might be airway compromise, while heterotopic bone formation into the spinal canal has been reported in animal and human studies. Fibrin glue has been used as a carrier of many osteoinductive materials; however, its efficacy at modulating the clinical effects of BMP are not known. The amorphous nature of fibrin glue makes it a candidate to control diffusion of BMP and possibly limit bone formation by limiting BMP diffusion to areas where such bone is not desired. Purpose: To evaluate the use of fibrin glue to limit BMP diffusion and BMP-stimulated bone growth. Study design/setting: This is an in vitro basic science study and an in vivo prospective randomized animal study. Study sample: Eighteen Lewis rats. Outcome measures: In vitro study: Enzyme-linked immunosorbent assay measurement of rh-BMP2 concentration in saline. In vivo study: At day 60, rats were evaluated for neurologic deficits before sacrifice. Spines were harvested, and the following studies were performed: 1) manual testing for fusion and bone growth; 2) X-ray evaluation; 3) Micro–computed tomography (micro-CT) scans. Methods: In vitro study: Collagen sponges soaked with BMP at two different concentrations were incubated in saline solution with and without encapsulation by fibrin glue. Saline BMP concentrations were measured at consecutive time points. In vivo study: A rat fusion model using rh-BMP2 for fusion has been developed and tested with resultant100% fusion in over 100 rats. Lewis rats were divided into two groups and treated as follows: I: Exposure of L4–L5 transverse processes, decortication, and placement of BMP sponge in the lateral intertransverse space. II: Exposure and decortication as above and placement of fibrin glue before BMP sponge placement. Results: In vitro study: Peak rh-BMP2 concentrations in saline were 20% and 45% of the maximum possible for fibrin glue encapsulated sponges and controls, respectively, with a more gradual increase to peak concentration in samples encapsulated in fibrin glue. In vivo study: No rats exhibited any neurologic deficits. X-rays revealed at least partial bone formation in all rats. Manual testing of intertransverse fusion spines revealed 100% fusion in rats treated with BMP only, whereas rats treated with fibrin glue before placement of BMP sponges revealed only one possible fusion. Posterior-lateral bone formation was present on X-ray in both groups, and micro-CT imaging revealed bridging bone from transverse processes to the BMP-stimulated bone in the control groups. In spines treated with fibrin glue before rh-BMP2 placement, bone formation could still be seen within the soft tissues; however, bridging bone connecting to the transverse processes was either significantly decreased or not present. Conclusions: Fibrin glue can limit rh-BMP2 diffusion. Also, because it limited bone formation at the transverse processes, it can be inferred that fibrin glue can limit bone formation when used to separate areas of desired bone formation from areas where bone formation is not desired. [Copyright &y& Elsevier]

Study Design: Retrospective case series.Objective: To evaluate the short- and long-term treatment effect (TE) of spinopelvic parameters after surgical correction of adult spine deformity (ASD) utilizing preoperative planning and patient-specific spine rods (PSSRs), and to assess the correspondence between planned and real outcomes.Summary Of Background Data: PSSR have been used in ASD correction for the last decade. However, a TE and predictability of spinopelvic alignment at long-term follow-up has not been studied.Methods: Inclusion criteria: male or female; age more than 20 years; correction of ASD with PSSR; 24-month follow-up (or revision surgery). Studied parameters: sagittal vertical axis; lumbar lordosis (LL); pelvic tilt (PT); sacral slope; pelvic incidence (PI); and PI-LL. The measurement error, TE (the differences between postoperative and preoperative values), standardized TE, and predictability of the studied parameters assessed. The variables included categorical (optimal/nonoptimal) and continuous obtained by direct measurements and weighted by individual optimal values. Statistical significance was set at P ≤ 0.05.Results: Thirty-four patients were included: 56% women; the mean age, 63.4 (standard deviation, 12.7); at each follow-up: 32 at 1 to 3 months, 34 at 11 to 13, and 14 at 23 to 25 with 9 followed to the revision surgery. Strong or moderate TE was shown for sagittal vertical axis, LL, and PI-LL. The TE of PT and sacral slope was less significant and lower than planned. PI was not stable in 18%. The changes of continuous variables were more prominent and statistically significant then categorical. The mean values did not show significant differences between planned and postoperative outcomes except for PT. However, the individual deviations were substantial for all parameters. Significant predictability was shown only for LL and PI.Conclusion: Use of PSSR showed strong and relatively stable TE in ASD during 2 postoperative years. However, improvement of the planning accuracy may contribute to further enhancement of the method's efficacy.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Study Design: Meta-analysis of 4 randomized controlled clinical trials (RCTs).Objective: The aim of the study was to determine if patients with degenerative disc disease who achieve radiographic fusion after single-level lumbar interbody arthrodesis have better clinical outcomes than patients with radiographic pseudarthrosis at 12 and 24 months postoperative.Summary Of Background Data: The clinical relevance of successful fusion after lumbar arthrodesis with recombinant human bone morphogenetic protein-2 or iliac crest bone autograft has recently been questioned in the literature.Methods: Individual patient-level data of 4 RCTs were obtained from the Yale University Open Data Access Project project and analyzed. Clinical outcomes (Oswestry Disability Index [ODI]; Numeric Rating Scales [NRSs] for back and leg pain) were compared between patients with radiographically confirmed fusion and those with radiographic nonunion 1 and 2 years postoperative. The results of each study were first analyzed separately, and then were pooled by meta-analysis. The GRADE approach was applied to evaluate the level of evidence.Results: A total of 496 patients with clinical and radiographic data at 1- and 2-year follow-ups were identified. Of these, 5.5% (95% confidence interval: 3.7; 8.3) had radiographic nonunion which did not require reoperation. Patients with fusion had better improvements in ODI (P < 0.001) and NRS back pain scores (P < 0.001). The overall percentage of fused patients with ODI and NRS back pain scores that exceeded the criteria for minimal clinically important differences was also significantly higher than that of patients with nonunion (ODI, odds ratio [OR] = 2.7, P = 0.019; NRS back pain, OR = 3.5, P = 0.033). The predictive values of fusion for clinical outcomes, however, were poor, with low specificity and low negative predictive values.Conclusion: The presence of radiographic fusion is clinically significant, as patients with fusion had better clinical outcomes at 1 and 2 years postoperative than those with nonunion; however, patient-centered clinical outcomes should also be taken into consideration as independent, complimentary variables when assessing treatment success. [ABSTRACT FROM AUTHOR]

Abstract: The in vivo lumbar spine of the anaesthetized feline was subjected to passive cyclic anterior flexion–extension at 0.25Hz and 40N peak load for cumulative 60min duration. Displacement (or displacement neuromuscular neutral zones—DNNZ) and tension (or tension neuromuscular neutral zones—TNNZ) at which reflexive EMG activity from the multifidi muscles was initiated and terminated were recorded, for single-test cycles, before and for 7h after cyclic loading. Displacement and tension NNZs increased significantly after loading. The displacement NNZs decreased exponentially to near baseline by the 7th hour of rest. The tension NNZs, however, decreased to below the baseline by the 2nd to 3rd hour after loading and continued decreasing into the 7th hour. Peak EMG significantly decreased (49–57%) to below the baseline immediately after loading and then exponentially increased, exceeding the baseline by the 2nd to 3rd hour and reaching 33–59% above baseline by the 7th hour. EMG median frequency decreased after loading and then exceeded the baseline after the 3rd hour, indicating initial de-recruitment, followed by recruitment of new motor units. These findings suggest that the lumbar spine was exposed to instability for 2–3h after cyclic loading, due to concurrent laxity of the viscoelastic tissues and deficient muscular activity. A delayed neuromuscular compensation mechanism was found to exist, triggering the musculature significantly earlier and at higher magnitude than baseline, while the viscoelastic tissues were still lax. Thus, it is suggested that prolonged cyclic loading may compromise lumbar stability during the immediate 2–3h post-loading, increasing the risk of injury. [Copyright &y& Elsevier]

Abstract: Background: The impact of six sequential static loading and rest of the lumbar spine on the changes in the neuromuscular neutral zones and thereby on spine stability was assessed. Methods: Six 10min sessions of static load of a moderate level each spaced by 10min rest were applied to the in vivo feline model. Test cycles of 0.25Hz and at the same moderate peak load were applied before and every hour after the static loading sequence up to 7h. Load, displacement and electromyographic activity of the lumbar multifidi muscles were recorded throughout. Findings: Displacement and tension neuromuscular neutral zones were defined as the displacement or tension, in the increase and decrease phases of each cycle, when the electromyogram initiated and ceased activity, respectively. Displacement neuromuscular neutral zones demonstrated significant (P <0.001) increase immediately post-static loading, followed by an exponential decrease to pre-loading baseline by the 7th hour. Tension neuromuscular neutral zones, however, demonstrated significant (P <0.001) increase in the 2h immediately after the static loading and a significant decrease (P <0.001) thereafter. Peak electromyogram decreased in the first 3h post-loading, but significantly (P <0.001) increased thereafter to the 7th hour. Interpretation: It was concluded that the first 2–3h post-static loading finds the spine with significant laxity in the viscoelastic tissues concurrently with deficient muscular activation and therefore exposed to the risk of instability. It is also evident that a neural control compensation mechanism exists where it enhances the activation of the musculature to earlier and at higher activation magnitude, 2–3h post-loading, increasing lumbar stability while the viscoelastic tissues are still lax. [Copyright &y& Elsevier]

Abstract: Background: The epidemiology identifies cyclic lumbar loading as a risk factor for cumulative trauma disorder. Experimental biomechanical and physiological confirmation is lacking. The objective of this study was to asses the impact of different rest durations applied between periods of cyclic loading on the development of an acute lumbar disorder which, if continued to be subjected to loading, may develop into a cumulative disorder. Methods: Three groups of in vivo feline preparations were subjected to six sequential 10min loading periods of cyclic lumbar flexion at 40N with a frequency of 0.25Hz applied to the L-4/5 level. The rest durations varied from 5min in the first group, to 10min in the second and to 20min in the third. Reflexive EMG from the multifidi and lumbar displacement were used to identify significant (P <0.001) effects of time and rest duration for post-load EMG and displacement. Single-cycle test were performed hourly for 7h post-loading to assess recovery. A model developed earlier was applied to represent the experimental data. Findings: The groups allowed 5 and 10min rest exhibited an acute neuromuscular disorder expressed by a significant (P <0.001) delayed hyperexcitability 2–3h into the 7h recovery period with the intensity of the hyperexcitability significantly higher (P <0.001) for the group allowed only 5min rest. The group allowed 20min rest had a slow, uneventful recovery, free of delayed hyperexcitability. Interpretations: Occupational and sports activities requiring repetitive (cyclic) loading of the lumbar spine may be a risk factor for the development of a cumulative lumbar disorder and may require sufficient rest, as much as twice as long as the loading period, for prevention. Comparison to similar data for static lumbar loading shows that cyclic loading is more deleterious than static loading, requiring more rest to offset the negative effect of the repeated acts of stretch. [Copyright &y& Elsevier]

As COVID-19 reached pandemic status, in-person orthopedic clinics across the United States were forced to close as many states adopted stay-at-home orders. Previously, the use of telemedicine in orthopedic practices was minimal for a variety of reasons, one being the inability to perform a physical exam in a specialty reliant on direct patient contact for diagnosis and treatment. To evaluate the administration of a novel virtual physical exam for evaluation of spine patients in the telehealth setting. Prospective consecutive cohort at a large academic spine center. A prospective cohort of 52 patients consented to participating in a novel virtual physical exam protocol during routine telemedicine visits at a large, tertiary orthopedic spine practice. Participants were asked to perform a series of carefully designed physical maneuvers using readily available household objects to allow their provider to better assess sensory and motor function in the telemedicine setting. Patients were then asked to complete a short satisfaction survey. In total, 52 patients completed the physical exam and survey. Males and females were distributed evenly among the cohort at 50%. The average age was 52.1 +/- 15.5 years. The average score for ease of understanding the exam (1 = easiest, 5 = hardest) was 1.1 while the average score for ease of performance was 1.5. There were 97.56% of participants who felt their provider was better able to understand their condition using the virtual exam findings. This study highlights the utility of a virtual physical exam for assessment of spine patients in the telemedicine setting. Furthermore, this study illustrates the ease with which such an exam can implemented and performed to improve patient evaluation and satisfaction. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The numbering of vertebral transitional anatomy can be challenging and controversial. Disagreement exists on how to best report anomalous vertebra and which imaging modality (CT, MRI, X-ray, etc) is most consistent. For these reasons, there is often a discrepancy in the numbering of transitional levels between radiologists and surgeons. Moreover, correlating levels identified intraoperatively by fluoroscopy with inconsistently numbered vertebrae on preoperative MRI or CT is arduous. Errors in numbering can have devastating implications for patients. A simple and accurate vertebral numbering system that can be applied to routine imaging is needed. The purpose of this study was to describe a novel and more simplified vertebral numbering system that can be used amongst surgeons and radiologists. A retrospective imaging study analyzing full-length spine X-rays was performed with the approval of a Colorado Multiple Institutional Review Board (COMIRB protocol:17-1920). A total of 5,422 images were obtained that included all adult patients who presented to the Spine Center at the University of Colorado and obtained full-spine X-rays using the EOS imaging system between January 31st of 2018 and March 31st of 2020. Images from the same patient at multiple time points were excluded and 3,250 unique patient images were included in our study. After the initial period of data collection, 103 images were excluded from the final analysis due to poor image quality or missing image files. Total presacral mobile segments were identified and counted using 24 as the number found in conventional spinal anatomy. The total number of ribs were counted for each patient including hypoplastic ribs, and the level of the first-ribbed vertebrae and last-ribbed vertebrae were recorded. Image analysis was conducted by five experienced researchers. The results were reviewed and verified by the senior authors. Any disagreements were reviewed and resolved by two board-certified musculoskeletal radiologists. Final results were evaluated and a novel vertebral numbering system with the lowest probability of error was agreed upon. In our study cohort, 91.1% (2,868/3,147) demonstrated the conventional 24 presacral mobile segments, whereas 3.3% (104) had 23 presacral mobile segments, 5.5% (174) had 25, and 0.03% (1) had 26. Transitional anatomy, as defined by a number of presacral segments other than 24, was noted in 8.8% (279) of the total number of patients. Within this same group, the majority (94.6%; 2,976) had 12 ribs (including hypoplastic ribs), 4.5% (143) had 11 ribs, and 0.88% (28) had 13 ribs. Just 3.5% (112) had incomplete or hypoplastic ribs. Furthermore, 1.8% (56) of patients had both transitional anatomy and an abnormal number of ribs, with the pattern of transitional anatomy and 11 ribs being the most common combination identified. Considering the first nonribbed vertebrae as the first lumbar vertebrae yielded the lowest probability of a numbering error. We are proposing a novel vertebral numbering system that yields the lowest probability of error in reporting anomalous anatomy which can be applied to routine cervical, thoracic, and lumbar radiographs. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]