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Correction of severe spinal deformity is a significant challenge for spinal surgeons. Although halo-gravity traction (HGT) has been shown to be well-tolerated and safe, we report here a case of neurologic decline during treatment. A 24-year-old male presents with severe thoracic kyphoscoliosis with > 180° of 3-dimensional deformity. Magnetic resonance imaging showed his thoracic spinal cord draped across his T7-9 apex. His neurologic exam showed lower extremity myelopathy. During week 7 at a goal traction weight of 18.1 kg, his distal lower extremity exam declined from 4+/5 to 2/5. His traction weight was lowered to 11.3 kg. He subsequently sustained a ground-level fall and became paraparetic with a motor exam of 1-2/5. He subsequently underwent a T1-L4 posterior spinal instrumentation and fusion with a T7-9 vertebral column resection. Postoperatively, he was noted to have a complete return to his baseline neurologic exam. At his 4-month postoperative visit, he was now full strength in his lower extremities with complete resolution of his myelopathy. We present here a case of neurologic decline in a patient with severe kyphoscoliosis who underwent HGT and discuss the management decisions associated with this challenging scenario.

Postop shoulder imbalance is a common complication following Adolescent Idiopathic Scoliosis surgery. We found that the proximal thoracic curve must be carefully scrutinized in order to optimize shoulder balance, especially when larger correction of the main thoracic curve is performed., Study Design. Retrospective review of a prospectively collected multicenter database. Objective. To assess how “overcorrection” of the main thoracic curve without control of the proximal curve increases the risk for shoulder imbalance in Lenke type 1 Adolescent Idiopathic Scoliosis (AIS). Summary of Background Data. Postop shoulder imbalance is a common complication following AIS surgery. It is thought that a more cephalad upper-instrumented vertebra (UIV) decreases the risk of shoulder imbalance in Lenke type 1 and 2 curves; however, this has not been proven. Methods. Thirteen surgeons reviewed preop and 5-year postop clinical photos and PA radiographs of patients from a large multicenter database with Lenke type 1 and 2 AIS curves who were corrected with pedicle screw/rod constructs. Predictors of postop shoulder imbalance were identified by univariate analysis; multivariate analysis was done using the classification and regression tree method to identify independent drivers of shoulder imbalance. Results. One hundred forty-five patients were reviewed. The UIV was T3-T5 in 87% of patients, with 8.9% instrumented up to T1 or T2. Fifty-two (36%) had shoulder imbalance at 5 years. On classification and regression tree analysis when the proximal thoracic (PT) Cobb angle was corrected more than 52%, 80% of the patients had balanced shoulders. Similarly, when the PT curve was corrected less than 52% and the main thoracic (MT) curve was corrected less than 54%, 87% were balanced. However, when the PT curve was corrected less than 52%, and the MT curve was corrected more than 54%, only 41% of patients had balanced shoulders (P = 0.05). This relationship was maintained regardless of the UIV level. Conclusion. In Lenke type 1 and 2 AIS curves, significant correction of the main thoracic curve (>54%) with simultaneous “under-correction” (

Background Value-based episode of care reimbursement models is being investigated to curb unsustainable health care costs. Any variation in the cost of index spine surgery can affect the payment bundling during the 90-d global period. Objective To determine the drivers of variability in cost for patients undergoing elective anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease. Methods Four hundred forty-five patients undergoing elective ACDF for cervical spine degenerative diagnoses were included in the study. The direct 90-d cost was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multiple variable linear regression models were built for total 90-d cost. Results The mean 90-d direct cost was $17685 ± $5731. In a multiple variable linear regression model, the length of surgery, number of levels involved, length of hospital stay, preoperative history of anticoagulation medication, health-care resource utilization including number of imaging, any complications and readmission encounter were the significant contributor to the 90-d cost. The model performance as measured by R2 was 0.616. Conclusion There was considerable variation in total 90-d cost for elective ACDF surgery. Our model can explain about 62% of these variations in 90-d cost. The episode of care reimbursement models needs to take into account these variations and be inclusive of the factors that drive the variation in cost to develop a sustainable payment model. The generalized applicability should take in to account the differences in patient population, surgeons' and institution-specific differences.

BACKGROUND The costs and outcomes following degenerative spine surgery may vary from surgeon to surgeon. Patient factors such as comorbidities may increase the health care cost. These variations are not well studied. OBJECTIVE To understand the variation in outcomes, costs, and comorbidity-adjusted cost for surgeons performing lumbar laminectomy and fusions surgery. METHODS A total of 752 patients undergoing laminectomy and fusion, performed by 7 surgeons, were analyzed. Patient-reported outcomes and 90-d cost were analyzed. Multivariate regression model was built for high-cost surgery. A separate linear regression model was built to derive comorbidity-adjusted 90-d costs. RESULTS No significant differences in improvement were found across all the patient-reported outcomes, complications, and readmission among the surgeons. In multivariable model, surgeons #4 (P < .0001) and #6 (P = .002) had higher odds of performing high-cost fusion surgery. The comorbidity-adjusted costs were higher than the actual 90-d costs for surgeons #1 (P = .08), #3 (P = .002), #5 (P < .0001), and #7 (P < .0001), whereas they were lower than the actual costs for surgeons #2 (P = .128), #4 (P < .0001), and #6 (P = .44). CONCLUSION Our study provides valuable insight into variations in 90-d costs among the surgeons performing elective lumbar laminectomy and fusion at a single institution. Specific surgeons were found to have greater odds of performing high-cost surgeries. Adjusting for preoperative comorbidities, however, led to costs that were higher than the actual costs for certain surgeons and lower than the actual costs for others. Patients' preoperative comorbidities must be accounted for when crafting value-based payment models. Furthermore, designing intervention targeting "modifiable" factors tied to the way the surgeons practice may increase the overall value of spine care.

Retrospective cohort.This radiographic analysis using a full-body x-ray evaluated the ways in which the sagittal profiles of the unfused spinal segments, pelvic, and lower extremities spontaneously change after adolescent idiopathic scoliosis (AIS) surgery with segmental pedicle screw constructs.Reciprocal lordotic changes in unfused spinal segments after corrective surgery for AIS have been reported. However, a full-body analysis has not been studied.The sagittal profiles of 51 (age ≤18) patients with AIS undergoing corrective surgery with segmental pedicle screw constructs were investigated. Patients were divided into two groups: group T; selective thoracic fusion and group L; fusion to the low lumbar spine. They were further subcategorized according to preoperative thoracic kyphosis (TK: T5-12): hypokyphotic (TK20°) and normohyperkyphotic (TK20°) groups. The postoperative change in the sagittal parameters and the correlation between the instrumented thoracic alignment change (ΔT2-12) and reciprocal changes of unfused segments were analyzed.At baseline, the entire cohort had a relatively hypokyphotic thoracic spine (TK: 25.5° ± 13.7°), low T1 slope (13.6° ± 7.7°), and kyphotic cervical spine (C2-7 lordosis: 7.7° ± 13.1°). The lower extremities were in neutral alignment overall. Postoperatively, the cervical alignment changed significantly lordotic (average -13.4° increased lordosis) after the adequate preservation of TK (average 17.8° increased kyphosis) in the hypokyphotic group T. Linear correlations were observed between ΔT2-12 and spontaneous reciprocal changes in C2-7 lordosis, lumbar lordosis, and knee flexion angle in group T.The sagittal profiles of patients with AIS can significantly change after adequate restoration of TK which averaged 17.8°, particularly in the cervical spine. Lordotic reciprocal change in the cervical spine as well as increase in lumbar lordosis can occur in a linear correlation after adequate restoration of TK. There were no significant changes that occurred in the pelvis or lower extremities after AIS corrective surgery.4.

BACKGROUND Studies have investigated the impact of obesity in thoracolumbar surgery; however, the effect of obesity on patient-reported outcomes (PROs) following anterior cervical discectomy and fusion (ACDF) is unknown. OBJECTIVE To examine the relationship between obesity and PROs following elective ACDF. METHODS Consecutive patients undergoing ACDF for degenerative conditions were evaluated. Patients were divided into groups with a body mass index ≥35. The EuroQol-5D, Short-Form 12 (SF-12), modified Japanese Orthopaedic Association score, and Neck Disability Index were used. Correlations between PROs and obesity were calculated at baseline and 1 year. RESULTS A total of 299 patients were included, with 80 obese (27%) and 219 nonobese (73%). patients At baseline, obesity was associated with worse myelopathy (modified Japanese Orthopaedic Association score: 10.7 vs 12.2, P = .01), general physical health (SF-12 physical component scale score: 28.7 vs 31.8, P = .02), and general mental health (SF-12 mental component scale score: 38.9 vs 42.3, P = .04). All PROs improved significantly following surgery in both groups. There was no difference in absolute scores and change scores for any PRO at 12 months following surgery. Furthermore, there was no difference in the percentage of patients achieving a minimal clinically important difference for the Neck Disability Index (52% vs 56%, P = .51) and no difference in patient satisfaction (85% vs 85%, P = .85) between groups. CONCLUSION Obesity was not associated with less improvement in PROs following ACDF. There was no difference in the proportion of patients satisfied with surgery and those achieving a minimal clinically important difference across all PROs. Obese patients may therefore achieve meaningful improvement following elective ACDF. ABBREVIATIONS ACDF, anterior cervical discectomy and fusionBMI, body mass indexEQ-5D, EuroQol-5DMCID, minimal clinically important differenceMCS, mental component scalemJOA, modified Japanese Orthopaedic AssociationNDI, Neck Disability IndexNRS, Numerical Rating ScalePCS, physical component scalePROs, patient-reported outcomesSF-12, Short Form 12.

To investigate the relationship between lumbar facet fluid and dynamic instability in degenerative spondylolisthesis (DS), as well as the relationship between facet fluid and patient-reported outcomes following a posterior lumbar fusion. We analyzed consecutive patients with degenerative spondylolisthesis undergoing single level posterior lumbar fusion from December 2010 to January 2013 at a single academic institution. We investigated the relationship between fluid in the facet joint as measured on axial MRI and the presence of dynamic instability. We investigated the impact of facet fluid, Modic changes, and dynamic instability on patient-reported outcomes. There was a significant association between the amount of facet joint fluid and the presence of dynamic instability (p = 0.03); as facet fluid increases, the probability of dynamic instability also increases. For every 1 mm of facet fluid, there was a 41.6 % increase (95 % CI 1.8–97) in the odds of dynamic instability. A facet fluid amount less than 0.5 mm gave a 90 % probability that there was no dynamic instability. The presence of facet fluid and dynamic instability were associated with achieving minimal clinical important difference (MCID) in low back pain following lumbar fusion (p = 0.04 and 0.05, respectively). Facet joint fluid is associated with the presence of dynamic instability in DS. The presence of facet fluid and dynamic instability may predict increased likelihood of achieving MCID for improvement in back pain following posterior lumbar fusion.

BACKGROUND CONTEXT Effective alternatives to degenerative lumbar fusion have remained elusive. Fusion frequently results in adjacent level disease, reoperation, poor outcomes, and high costs. Anterior total disc replacement (TDR) does not address facet pathology or neural compression; thus, indications are limited. There is a need for a posterior-based motion-sparing option that allows for neural decompression, facetectomy, and disc replacement. PURPOSE To present the pilot data for the first 84 patients undergoing posterior lumbar total joint replacement for common degenerative conditions. STUDY DESIGN/SETTING Prospective case series. PATIENT SAMPLE Adult patients (age 18-79 years) with degenerative lumbar pathology were treated. Diagnoses included: degenerative spondylolisthesis, recurrent disc herniation, degenerative disc disease, foraminal stenosis, and central lumbar stenosis. Tumor, trauma, and infection cases were excluded. OUTCOME MEASURES Oswestry Disability Index (ODI), visual analogue scale (VAS) for back and leg pain, and opioid use. METHODS The implant is a motion-sparing lumbar reconstruction that replaces the function of both the disc and facets and is implanted using a bilateral trans-foraminal (TLIF) approach with complete facetectomies. For this IRB-approved pilot study, 84 adult patients (mean age 52.49) with degenerative lumbar pathology were treated. Diagnoses included: degenerative spondylolisthesis, recurrent disc herniation, degenerative disc disease, foraminal stenosis, and central lumbar stenosis. Tumor, trauma, and infection cases were excluded. ODI, VAS for back and leg pain, and opioid use were collected at baseline, 3 months, 6 months, and 1 year, with radiographs obtained at each time point. To date, follow up data is available for 70 patients at 3 months, 54 at 6 months, and 38 patients at 1 year. RESULTS A total of 125 levels were treated: L4-5 (57), L5-S1 (41), L3-4 (22), L2-3 (4), and L1-2 (1). Forty-seven patients had one level, 33 had two levels, and four patients had three levels treated. ODI improved significantly at each time interval following surgery (46.58 preop, 23.91 at 3 months, 18.87 at 6 months, and 13.80 at 1 year). VAS back and leg pain (calculated as the highest reported VAS score multiplied by the frequency of that pain level) also improved at each time point, from an average value of 51.59 at baseline to 17.40 at 3 months, 13.64 at 6 months, and 11.39 at 1 year. Minimal symptom state (ODI ≤ 20 and VAS back and leg pain ≤ 20) was maintained by 18 out of 27 one-level patients (67%), and by 7 out of 10 two-level patients (70%) at 1 year. Opioid usage was CONCLUSIONS Here we present pilot data for the first 84 patients undergoing a novel, posterior-based total joint replacement for the lumbar spine using a TLIF approach with complete facetectomies. The approach allows for wide neural decompression, facetectomy, and complete discectomy, with the implant working to replace the function of the disc and facets to preserve motion. ODI and VAS back/leg pain scores improved significantly at each time interval following surgery. At 1 year, a high percentage (66%) of patients have maintained a minimal symptom state, which is a significant improvement compared with the fusion literature where a recent study reported 18% of 396 patients maintained a minimal symptom state after 1 year following fusion. The greatest theoretical benefit of this device is preservation of lumbar motion segments resulting in more physiologic lumbar motion and the potential to decrease the risk for adjacent segment disease. Ongoing long-term follow-up is underway to evaluate the durability of this procedure and the impact on adjacent segments. FDA DEVICE/DRUG STATUS 3Spine BalancedBack Lumbar Joint Replacement (Investigational/Not approved)

Iatrogenic seeding of sarcoma cells into a joint is a feared, although uncommon, phenomenon. In 1983, Joyce and Mankin described twelve patients who had undergone arthroscopy for suspected intra-articular pathology and were later determined to have extra-articular malignancies. Failure to appreciate the extra-articular lesion in eight of these patients led to delays in definitive treatment as well as the introduction of diseased tissue into the joint space1. In 2003, Musculo et al. reported a similar series of twenty-five patients with suspected athletic injuries who were operated on first and only later diagnosed with benign or malignant bone tumors2. Microscopic seeding of a joint with tumor cells from an undiagnosed malignancy is a risk in treating bone and soft-tissue tumors3-5. Iatrogenic spread of a tumor by arthroscopy is a rare complication that can substantially alter surgical outcomes for patients, leading to more aggressive surgical treatment when conservative therapy may have initially been possible6-8. In a busy clinical practice, orthopaedic surgeons must remain vigilant in assessing all patients with musculoskeletal pain, particularly patients with an equivocal etiology. We report the case of a young man with osteosarcoma who had arthroscopy-related complications. The patient’s family was informed that data concerning this case would be submitted for publication, and they provided consent. A previously healthy nineteen-year-old man presented to his primary physician with knee pain, swelling, and limited weight-bearing. The patient offered a reportedly “vague” history of trauma to the knee, sustained while playing with the family dog. After evaluation, the physician decided on empiric treatment with rest and nonsteroidal anti-inflammatory drugs. Despite the medication, the pain continued to worsen, and the patient was subsequently referred for orthopaedic evaluation. The patient presented to the orthopaedist with poorly localized pain about the knee …

Background The healthcare reimbursement models are rapidly transitioning to pay-per-performance episode of care payment models. These models, if designed well, must account for the variability in the cost of index surgeries during the global period. Objective To analyze the variability in 90-d cost and determine the drivers of the variability in total 90-d cost associated with single-level microdiscectomy. Methods A total of 203 patients undergoing primary microdiscectomy for degenerative lumbar conditions were included in the study. The total 90-d cost was derived as the sum of cost of surgery, cost associated with postdischarge utilization. A multivariable linear regression model for total 90-d cost was built. Results The mean total cost within 90-d after single-level primary microdiscectomy was $7962 ± $2092. In a multivariable linear regression model, obesity, history of myocardial infarction, factors that lengthen the time of surgery and hospital stay, complications and readmission within 90-d, postdischarge healthcare utilization including emergency room visits, time to opioid independence, number of days on nonopioid pain medications, diagnostic imaging, and the number of days in outpatient and inpatient rehabilitation contribute to the total 90-d cost. The model performance as measured by R2 is 0.76. Conclusion Utilizing prospectively collected data, we highlight major drivers of variation in cost following a single-level primary microdiscectomy. Our model explains about three-quarters of the variation in cost. The risk-adjusted cost estimates powered by models such as the one presented here can be used to formulate a sustainable total 90-d episode of care bundle payment.

Objective To evaluate in-toeing consults to a pediatric orthopedic clinic to determine the proportion that could be managed by a primary care physician. Study design A prospective registry was created for 143 consecutive children referred to a pediatric orthopedic clinic for "in-toeing." Each patient underwent a careful history and physical examination, which included a rotational profile. We recorded the final diagnosis, treatment offered, follow-up visit results, and the source of the referral. Results After pediatric orthopedic evaluation, 85% of patients had a confirmed diagnosis of in-toeing, and 15% had a different final diagnosis. Seventy-four percent of patients had 1 consultation visit, 18% had 2, and 8% had >2 visits. None of the referred patients was a candidate for treatment by casting or surgery. Conclusion In most cases, in-toeing is a normal variation of development that can be managed by counseling and observation by the primary care physician alone. Rare cases of severe in-toeing >2 standard deviations from the mean should likely still prompt referral to a pediatric orthopedic surgeon for potential intervention.

Objective To investigate recent trends in the orthopaedic trauma workforce and to assess whether supply of orthopaedic trauma surgeons (OTS) matches the demand for their skills. Methods Supply estimated using Orthopaedic Trauma Association (OTA) membership and American Academy of Orthopaedic Surgeons census data. The annual number of operative pelvic and acetabular fractures reported by American College of Surgeons verified trauma centers in the National Trauma Data Bank (NTDB) was used as a surrogate of demand. Because surrogates were used, the annual rate of change in OTA membership versus rate of change in operative injuries per NTDB center was compared. Results From 2002 to 2012, reported operative pelvic and acetabular injuries increased by an average of 21.0% per year. The number of reporting trauma centers increased by 27.2% per year. The number of OTA members increased each year except in 2009, with mean annual increase of 9.8%. The mean number of orthopaedic surgeons per NTDB center increased from 7.98 to 8.58, an average of 1.5% per year. The annual number of operative pelvic and acetabular fractures per NTDB center decreased from 27.1 in 2002 to 19.03 in 2012, down 2.0% per year. Conclusions In the United States, from 2002 to 2012, the number of OTS trended upward, whereas operative pelvic and acetabular cases per reporting NTDB center declined. These trends suggest a net loss of such cases per OTS over this period.

Study Type – Prognosis (retrospective cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Upper-tract urothelial carcinoma (UTUC) is a relatively uncommon urological malignancy with survival and outcomes data largely determined from single-centre series which can be limited by relatively small case numbers. Through review of a large population based cohort, this study provides valuable information regarding epidemiological and survival patterns for over 13,000 patients with UTUC diagnosed over the past three decades. OBJECTIVE • To evaluate epidemiological and survival patterns of upper-tract urothelial carcinoma (UTUC) over the past 30 years through a review of a large, population-based database. PATIENTS AND METHODS • Data from the Surveillance, Epidemiology and End Results (SEER) database from 1973 to 2005 were reviewed in 10-year increments to evaluate disease trends. • Univariate and multivariate survival analyses identified prognostic variables for outcomes. RESULTS • In total, 13 800 SEER-registered cases of UTUC were included. The overall incidence of UTUC increased from 1.88 to 2.06 cases per 100 000 person-years during the period studied, with an associated increase in ureteral disease (0.69 to 0.91) and a decrease in renal pelvic cancers (1.19 to 1.15). • The proportion of in situ tumours increased from 7.2% to 31.0% (P < 0.001), whereas local tumours declined from 50.4% to 23.6% (P < 0.001). • There was no change in the proportion of patients presenting with distant disease. • In multivariate analysis, increasing patient age (P < 0.001), male gender (P < 0.001), black non-Hispanic race (P < 0.001), bilateral UTUC (P= 0.001) and regional/distant disease (P < 0.001) were all associated with poorer survival outcomes. CONCLUSIONS • The incidence of UTUC has slowly risen over the past 30 years. • Increased use of bladder cancer surveillance regimens and improved abdominal cross-sectional imaging may contribute to the observed stage migration towards more in situ lesions. • Although pathological disease characteristics impact cancer outcomes, certain sociodemographic factors also appear to portend worse prognosis.

BACKGROUND CONTEXT Postoperative shoulder height imbalance is a common complication following adolescent idiopathic scoliosis (AIS) surgery. It is thought that a more cephalad upper instrumented vertebra (UIV) decreases the risk of shoulder imbalance in Lenke type 1 curves, however this has not been proven. PURPOSE To test the hypothesis that “over-correction” of the main thoracic curve without control of the proximal curve increases the risk for shoulder imbalance in Lenke type 1 AIS. STUDY DESIGN/SETTING Clinical photo and x-ray review of patients with Lenke 1 Main Thoracic AIS curves. PATIENT SAMPLE Surgically-treated patients with Lenke type 1 AIS were reviewed from a large multicenter database. OUTCOME MEASURES Postoperative shoulder height balance on clinical photos and PA radiographs. METHODS A total of 13 surgeons reviewed preop and 5-year postop clinical photos and PA radiographs of patients from a large multicenter database with Lenke type 1 AIS curves who were corrected with pedicle screw or rod constructs. Predictors of postop shoulder imbalance were identified by univariate analysis; multivariate analysis was done using the classification and regression tree (CART) method to identify independent drivers of shoulder imbalance. RESULTS A total of 145 patients were reviewed. The UIV was T3-T5 in 87% of patients, with 8.9% instrumented up to T1 or T2. 52 (36%) had shoulder imbalance at 5 years. On CART analysis: when the proximal thoracic (PT) Cobb angle was corrected more than 52%, 80% of the patients had balanced shoulders. Similarly, when the PT curve was corrected less than 52% and the main thoracic (MT) curve was corrected less than 54%, 87% were balanced. However, when the PT curve was corrected less than 52%, and the MT curve was corrected more than 54%, only 41% of patients had balanced shoulders (p=0.05). This relationship was maintained regardless of the UIV level. CONCLUSIONS In Lenke type 1 AIS curves, “over-correction” of the main thoracic curve (>54%) with simultaneous “under-correction” (

BACKGROUND CONTEXT Intraoperative loss of neuromonitoring data can be detrimental for both the patient and the surgeon. We propose a classification system to identify spinal cords at risk for data loss with thoracic deformity correction based on the preop axial MRI images at the curve apex. PURPOSE To test the hypothesis that the architecture of the spinal cord and amount of CSF on MRI at the thoracic apex can identify patients at risk for intraoperative loss of neuromonitoring data during spinal deformity correction. STUDY DESIGN/SETTING Review of thoracic deformity patients undergoing surgical correction at a single large academic center. PATIENT SAMPLE Thoracic deformity patients undergoing surgical correction. OUTCOME MEASURES Occurrence of intraoperative loss of trans-cranial neuromonitoring data. METHODS We reviewed 128 consecutive patients undergoing surgical correction of a thoracic deformity with pedicle screw/rod constructs. On preop MRI axial imaging at the apical concavity, three types of spinal cord/CSF architecture were defined. Type 1: circular cord with visible CSF between the cord and the apical concave pedicle. Type 2: circular cord but no visible CSF between it and the concave pedicle. Type 3: cord deformed against the apical concave pedicle, with no intervening CSF. RESULTS Of the 128 pts: 81 (63%) had Type 1; 32 (25%) Type 2; and 12 (11.7%) Type 3 spinal cords. Lower extremity transcranial motor-evoked potentials (TcMEPs) and/or somatosensory evoked potentials (SSEPs) were lost intraoperatively in 21 (16%) cases, with full recovery of data in 20 of those. On regression analysis, a Type 1 spinal cord was protective against intraoperative data loss (odds ratio = 0.17, p=.0003). A Type 2 spinal cord had no association with data loss (OR=0.66, p=.49). Type 3 spinal cord had significantly higher odds of intraoperative data loss (OR=28.3, p CONCLUSIONS This MRI-based spinal cord risk classification scheme identifies patients at risk of losing monitoring data during surgery. Patients with the spinal cord deformed against the apical concave pedicle (Type 3) have 28 times greater odds of losing monitoring data during surgery versus Type 1 (normal cord with adequate CSF) and Type 2 (normal cord without CSF between cord and concave pedicle). FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background Context In cervical spondylotic myelopathy (CSM), cervical sagittal alignment (CSA) is associated with disease severity. Increased kyphosis and C2–C7 sagittal vertical axis (SVA) correlate with worse myelopathy and poor outcomes. However, when alignment is lordotic, it is unknown whether these associations persist. Purpose The study aimed to investigate the associations between CSA parameters and patient-reported outcomes (PROs) following posterior decompression and fusion for CSM when baseline lordosis is maintained. Study Design/Setting This is an analysis of a prospective surgical cohort at a single academic institution. Patient Sample The sample includes adult patients undergoing primary cervical laminectomy and fusion for CSM over a 3-year period. Outcome Measures The PROs included EuroQol-5D, Short-Form-12 (SF-12) physical composite (PCS) and mental composite scales (MCS), Neck Disability Index, and the modified Japanese Orthopaedic Association scores. Radiographic CSA parameters measured included C1–C2 Cobb, C2–C7 Cobb, C1–C7 Cobb, C2–C7 SVA, C1–C7 SVA, and T1 slope. Methods The PROs were recorded at baseline and at 3 and 12 months postoperatively. The CSA parameters were measured on standing radiographs in the neutral position at baseline and 3 months. Wilcoxon rank test was used to test for changes in PROs and CSA parameters, and Pearson correlation coefficients were calculated for CSA parameters and PROs preoperatively and at 12 months. No external sources of funding were used for this work. Results There were 45 patients included with an average age of 63 years who underwent posterior decompression and fusion of 3.7±1.3 levels. Significant improvements were found in all PROs except SF-12 MCS (p=.06). Small but statistically significant changes were found in C2–C7 Cobb (mean change: +3.6°; p=.03) and C2–C7 SVA (mean change: +3 mm; p=.01). At baseline, only C2–C7 SVA associated with worse SF-12 PCS scores (r=−0.34, p=.02). Postoperatively, there were no associations found between PROs and any CSA parameters. Similarly, no CSA parameters were associated with changes in PROs. Conclusions Although creating more lordosis and decreasing SVA are associated with improved myelopathy and outcomes in patients with kyphosis, our study did not find such associationsin patients with lordosis undergoing posterior laminectomy and fusion for CSM. This suggests that any amount of lordosis may be sufficient.

• To evaluate epidemiological and survival patterns of upper-tract urothelial carcinoma (UTUC) over the past 30 years through a review of a large, population-based database.• Data from the Surveillance, Epidemiology and End Results (SEER) database from 1973 to 2005 were reviewed in 10-year increments to evaluate disease trends. • Univariate and multivariate survival analyses identified prognostic variables for outcomes.•In total, 13,800 SEER-registered cases of UTUC were included. The overall incidence of UTUC increased from 1.88 to 2.06 cases per 100,000 person-years during the period studied, with an associated increase in ureteral disease (0.69 to 0.91) and a decrease in renal pelvic cancers (1.19 to 1.15). • The proportion of in situ tumours increased from 7.2% to 31.0% (P0.001), whereas local tumours declined from 50.4% to 23.6% (P0.001). • There was no change in the proportion of patients presenting with distant disease. • In multivariate analysis, increasing patient age (P0.001), male gender (P0.001), black non-Hispanic race (P0.001), bilateral UTUC (P = 0.001) and regional/distant disease (P0.001) were all associated with poorer survival outcomes.• The incidence of UTUC has slowly risen over the past 30 years. • Increased use of bladder cancer surveillance regimens and improved abdominal cross-sectional imaging may contribute to the observed stage migration towards more in situ lesions. • Although pathological disease characteristics impact cancer outcomes, certain sociodemographic factors also appear to portend worse prognosis.