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Understanding patient-specific trends in costs and healthcare resource utilization (HCRU) surrounding lumbar spine surgery is critically needed to better inform surgical decision making and the development of targeted interventions.1) Identify subgroups of patients following distinct patterns in direct healthcare payments pre- and postoperatively, 2) determine whether these patterns are associated with patient and surgical factors, and 3) examine whether preoperative payment patterns are related to postoperative payments, healthcare resource utilization (HCRU), and adverse events.Retrospective analysis of an administrative claims database (IBM Marketscan Research Databases 2007-2015).Adults undergoing primary single-level decompression surgery for lumbar stenosis (n=12,394).Direct healthcare payments, HCRU payments (15 categories), 90-day complications and all-cause readmission, 2-year reoperation METHODS: Group-based trajectory modeling is an application of finite mixture modeling that is able to identify meaningful subgroups within a population that follow distinct developmental trajectories over time. We used this technique to identify subgroups of patients following distinct profiles in preoperative direct healthcare payments. A separate analysis was performed to identify distinct profiles in payments postoperatively. Patient and surgical factors associated with these payment profiles were assessed with multinomial logistic regression, and associations with adverse events were assessed with risk-adjusted multivariable logistic regression.We identified 4 preoperative patient payment subgroups following distinct profiles in payments: Pre-Low (5.8% of patients), Pre-Early-Rising (4.8%), Pre-Medium (26.1%), and Pre-High (63.3%). Postoperatively, 3 patient subgroups were identified: Post-Low (8.9%), Post-Medium (29.6%), and Post-High (61.4%). Patients following the higher-cost pre- and postoperative payment profiles were older, more likely female, and had a greater physical and mental comorbidity burden. With each successively higher preoperative payment profile, patients were increasingly likely to have high postoperative payments, use more HCRU (particularly high-cost services such as inpatient admissions, ER, and SNF/IRF care), and experience postoperative adverse events. Following risk adjustment for patient and surgical factors, patients following the Pre-High payment profile had 209.5 (95% CI: 144.2, 309.7; p.001) fold greater odds for following the Post-High payment profile, 1.8 (1.3, 2.5; p=.003) fold greater odds for 90-day complications, and 1.7 (1.2, 2.6; p=.035) fold greater odds for 2-year reoperation relative to patients following the Pre-Low payment profile.There are identifiable subgroups of patients who follow distinct profiles in direct healthcare payments surrounding lumbar decompression surgery. These payment profiles are related to patient age, sex, and physical and mental comorbidities. Notably, preoperative payment profiles may provide prognostic value, as they are associated with postoperative costs, HCRU, and adverse events.III.

OBJECTIVE There are few prior reports of acute pelvic instrumentation failure in spinal deformity surgery. The objective of this study was to determine if a previously identified mechanism and rate of pelvic fixation failure were present across multiple institutions, and to determine risk factors for these types of failures. METHODS Thirteen academic medical centers performed a retrospective review of 18 months of consecutive adult spinal fusions extending 3 or more levels, which included new pelvic screws at the time of surgery. Acute pelvic fixation failure was defined as occurring within 6 months of the index surgery and requiring surgical revision. RESULTS Failure occurred in 37 (5%) of 779 cases and consisted of either slippage of the rods or displacement of the set screws from the screw tulip head (17 cases), screw shaft fracture (9 cases), screw loosening (9 cases), and/or resultant kyphotic fracture of the sacrum (6 cases). Revision strategies involved new pelvic fixation and/or multiple rod constructs. Six patients (16%) who underwent revision with fewer than 4 rods to the pelvis sustained a second acute failure, but no secondary failures occurred when at least 4 rods were used. In the univariate analysis, the magnitude of surgical correction was higher in the failure cohort (higher preoperative T1-pelvic angle [T1PA], presence of a 3-column osteotomy; p < 0.05). Uncorrected postoperative deformity increased failure risk (pelvic incidence–lumbar lordosis mismatch > 10°, higher postoperative T1PA; p < 0.05). Use of pelvic screws less than 8.5 mm in diameter also increased the likelihood of failure (p < 0.05). In the multivariate analysis, a larger preoperative global deformity as measured by T1PA was associated with failure, male patients were more likely to experience failure than female patients, and there was a strong association with implant manufacturer (p < 0.05). Anterior column support with an L5–S1 interbody fusion was protective against failure (p < 0.05). CONCLUSIONS Acute catastrophic failures involved large-magnitude surgical corrections and likely resulted from high mechanical strain on the pelvic instrumentation. Patients with large corrections may benefit from anterior structural support placed at the most caudal motion segment and multiple rods connecting to more than 2 pelvic fixation points. If failure occurs, salvage with a minimum of 4 rods and 4 pelvic fixation points can be successful.

STUDY DESIGN A laboratory study performed in a self-controlled fashion. OBJECTIVE The aim of this study was to examine whether "surgical smoke" generated by using the electrocautery on porcine spinal tissues could contain viable bacteria. SUMMARY OF BACKGROUND DATA The year 2020 has seen a surge in legislation regarding surgical smoke evacuation in the operating room across the United States. Surgical smoke contains numerous toxic and carcinogenic substances, which spine surgeons and operating room staff are regularly exposed to. Although the smoke's chemical toxicity has been extensively studied, little is known about its biohazard level. METHODS The electrocautery was used to "operate on" 20 segments of porcine spinal tissues on a clean bench. In each operation, the generated smoke was captured with a swab, which was positioned above the surgical site and within the smoke, to obtain bacteria cultures. Two other swabs-a tissue swab (swabbing the porcine tissue itself) and a blank swab (swabbing an empty sterile bowl)-were collected as controls. The culture results were compared among the three groups. An additional experiment was conducted to see whether using a mask can reduce the "infection rate" of the swab. RESULTS Although all blank swabs tested negative, 95% (19/20) of the smoke swabs tested positive, with a total of nine bacteria species identified. The most prevalent species observed in the smoke swabs included Serratia liquefaciens, Lactococcus garvieae, and Hafnia alvei, and so on. Among the positive smoke swabs, 84% (16/19) had one or more bacteria species that were consistent with the cultures of their corresponding tissue swabs. Using a surgical or N95 mask reduced the "infection rate" of the swab. CONCLUSION "Surgical smoke" generated by electrocauterization of porcine spinal tissues contains viable bacteria. Further research in actual spine surgery is needed next.Level of Evidence: N/A.

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

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

BACKGROUND CONTEXT While ordering the two-view cervical spine X-rays is a routine in evaluating patients with nontraumatic cervical spinal disorders, the anteroposterior (AP) view seems to provide relatively less information than the lateral view. Considering the radiation and cost of the examination, and given that most surgical patients would already have CT and/or MRI available, it is reasonable to examine the utility of the AP view in cervical spine radiography in nontraumatic conditions. PURPOSE This study aims to (a) examine how often the radiological reports of the cervical spine describe findings from an AP view and (b) survey senior spine surgeons nationwide regarding their utilization of the AP view in actual practice. STUDY DESIGN/SETTING Review of radiological reports using the technique of text-mining, followed by a survey of surgeons. PATIENT SAMPLE A total of 210 patients diagnosed with nontraumatic cervical spinal disorders at our hospital, and 24 senior spine surgeons nationwide. OUTCOME MEASURES Percentages of the radiological aspects of the cervical spine that are described in the radiological reports by view (AP vs lateral vs both views), percentages of the surgeons' responses. METHODS This study included two parts: a review of radiological reports and a survey of surgeons. In Part 1, radiological reports of the two-view cervical spine radiographs for patients diagnosed with nontraumatic cervical spinal disorders at a tertiary spine center were collected, excluding those with tumor or previous cervical spinal surgery. After the hospital's medical informatics service used programming algorithms to locate the first such radiography of each patient, the radiological reports were reviewed in two steps. Step 1 used the technique of text-mining to obtain 50 most frequently used words in the radiological reports so as to summarize the main radiological aspects of a cervical spine (eg, alignment, disc space, uncovertebral joint, etc.) Then, step 2 identified the source of each radiological aspect's description in the radiological report: Was it from the AP view, the lateral view, or both? For example, a sentence in the radiological report read, "Frontal view demonstrates no significant uncovertebral hypertrophy," and this indicates that this radiological aspect -the uncovertebral joint- was evaluated using the AP view. As another example, a report noted "disc space narrowing at C5-6 with prominent osteophyte." As disc space narrowing is inherently a lateral-view sign, this indicates that both the disc space and the osteophyte here in this report were described using the lateral view. In this way, each radiological aspect of the cervical spine was examined, recorded, and tallied in all of the radiological reports. Then in Part 2, a two-question survey asking surgeons whether they think the AP view is practically useful and why was distributed among a group of 37 senior spine surgeons nationwide, who were from a published survey study on a different topic. RESULTS A total of 210 radiological reports from 2006 and 2020 were eligible for inclusion. Together, they described 18 radiological aspects of the cervical spine. Of these 18 radiological aspects, 28% (5/18, eg, uncovertebral joint, transverse process) were described exclusively on the AP view, 50% (9/18, eg, lordosis, disc space) were exclusively on the lateral view, and 22% (4/18, eg, fracture, degenerative changes in general) could be from both views. These 18 radiological aspects varied in their frequency of presence in the radiological reports, ranging from disc degeneration (82%, 172/210) to cervical scoliosis (0.5%, 1/210). The AP view was used to describe uncovertebral joint (24%, 51/210), transverse process (3%, 6/210), lung apices (1%, 2/210), and some other signs. Three radiological aspects could be from both the AP and lateral views: alignment in general (81%, 171/210), fracture (53%, 112/210) and degenerative changes in general (26%, 54/210). The survey of surgeons obtained a response rate of 65% (24/37). Among the respondents, 63% (15/24) thought that the AP view is useful, and the reasons included showing deformity or alignment (47%, 7/15), showing facet osteoarthritis (27%, 4/15), showing clavicle or rib for spinal level localization (20%, 3/15) and showing the uncovertebral joints (20%, 3/15), among others. CONCLUSIONS For nontraumatic degenerative cervical spinal disorders, the AP view of the cervical spine radiography provides relatively less information than the lateral view. However, the radiological reports and surgeons' feedback suggest that the AP view is sometimes useful in actual practice. As such, the value of the AP view should be patient-specific and dependent upon whether the AP view is essential for the care of the specific patient. A granular practice guideline regarding when to and when not to order the AP view is needed, and warrants future research. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background During the follow-up visits after Adult Spine Deformity (ASD) surgery, obtaining surveillance radiographs is a usual practice, and this study tried to identify evidence to support or refute such practice. Methods This is a retrospective, diagnostic case series (Level IV) of 49 patients. We identified the abnormal radiographic findings and their association with need for revision surgery. We determined the odds of obtaining an abnormal radiographs that lead to revision surgery at each of the given time intervals of follow-up. We also estimated the risk versus benefit of obtaining radiographs at each of the given time intervals of follow-up. Results We identified a total of 11 individual types of abnormal postoperative radiographic findings. Of them, the two radiographic findings that always needed revision surgery because of the associated clinical presentation were pedicle screw pullout and bilateral rod fracture. One abnormal radiographic finding that was never associated with revision surgery was the halo around a pedicle screw. In each of the given postoperative time intervals of follow-up at which the routine radiographs were obtained, we noted that the odds of noticing abnormal radiographic finding that lead to revision surgery was always >1. We found that the cumulative hazard rate for exposure to radiation was significantly higher during the initial follow-up visits when compared to subsequent follow-up visits. Conclusion This study finds evidence to support the practice of routine postoperative radiographic evaluation of patients who come for follow-up after ASD surgery.

BACKGROUND CONTEXT Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain. PURPOSE This study sought to determine: 1) the proportion of patients having surgery following CESI, and 2) the timing of and factors associated with subsequent surgery. STUDY DESIGN Retrospective analysis of a large, national administrative claims database. PATIENT SAMPLE The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof. OUTCOME MEASURES The primary outcome was the time from index CESI to surgery. METHODS Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year prior to CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models. RESULTS Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35-54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery. CONCLUSIONS Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making.

The study objectives were to use a large national claims data resource to examine rates of preoperative epidural steroid injections (ESI) in lumbar spine surgery and determine whether preoperative ESI or the timing of preoperative ESI is associated with rates of postoperative complications and reoperations.A retrospective longitudinal analysis of patients undergoing lumbar spine surgery for disc herniation and/or spinal stenosis was undertaken using the MarketScan® databases from 2007-2015. Propensity-score matched cohorts were constructed to compare rates of complications and reoperations in patients with and without preoperative ESI.Within the year prior to surgery, 120,898 (46.4%) patients had a lumber ESI. The median time between ESI and surgery was 10 weeks. 23.1% of patients having preoperative ESI had more than one level injected, and 66.5% had more than one preoperative ESI treatment. Patients with chronic pain were considerably more likely to have an ESI prior to their surgery [OR 1.62 (1.54, 1.69), p 0.001]. Patients having preoperative ESI within in close proximity to surgery did not have increased rates of infection, dural tear, neurological complications, or surgical complications; however, they did experience higher rates of reoperations and readmissions than those with no preoperative ESI (p 0.001).Half of patients undergoing lumbar spine surgery for stenosis and/or herniation had a preoperative ESI. These were not associated with an increased risk for postoperative complications, even when the ESI was given in close proximity to surgery. Patients with preoperative ESI were more likely to have readmissions and reoperations following surgery.

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

Shared decision-making between patients and physicians involves educating the patient, providing options, eliciting patient preferences, and reaching agreement on a decision. There are different ways to measure shared decision-making, including patient involvement, but there is no consensus on the best approach. In other fields, there have been varying relationships between patient-perceived involvement and observed patient involvement in shared decision-making. The relationship between observed and patient-perceived patient involvement in decision-making has not been studied in orthopaedic surgery.(1) Does patient-perceived involvement correlate with observed measurements of patient involvement in decision-making in orthopaedic surgery? (2) Are patient demographics associated with perceived and observed measurements of patient involvement in decision-making?We performed a prospective, observational study to compare observed and perceived patient involvement in new patient consultations for eight orthopaedic surgeons in subspecialties including hand/upper extremity, total joint arthroplasty, spine, sports, trauma, foot and ankle, and tumor. We enrolled 117 English-literate patients 18 years or older over an enrollment period of 2 months. A member of the research team assessed observed patient involvement during a consultation with the Observing Patient Involvement in Decision-Making (OPTION) instrument (scaled 1-100 with higher scores representing greater involvement). After the consultation, we asked patients to complete a questionnaire with demographic information including age, sex, race, education, income, marital status, employment status, and injury type. Patients also completed the Perceived Involvement in Care Scale (PICS), which measures patient-perceived involvement (scaled 1-13 with higher scores representing greater involvement). Both instruments are validated in multiple studies in various specialties and the physicians were blinded to the instruments used. We assessed the correlation between observed and patient-perceived involvement as well as tested the association between patient demographics and patient involvement scores.There was weak correlation between observed involvement (OPTION) and patient-perceived involvement (PICS) (r = 0.37, p0.01) in decision-making (mean OPTION, 28.7, SD 7.7; mean PICS, 8.43, SD 2.3). We found a low degree of observed patient involvement despite a moderate to high degree of perceived involvement. No patient demographic factor had a significant association with patient involvement.Further work is needed to identify the best method for evaluating patient involvement in decision-making in the setting of discordance between observed and patient-perceived measurements. Knowing whether it is necessary for (1) actual observable patient involvement to occur; or (2) a patient to simply believe they are involved in their care can inform physicians on the best way to improve shared decision-making in their practice.Level II, therapeutic study.

BACKGROUND CONTEXT In the treatment of patients with adult spinal deformity, analysis of spinopelvic balance is essential in determining treatment options. This includes pelvic tilt (PT) and incidence (PI), lumbar lordosis (LL), and the sagittal vertical axis (SVA). Historically, the measurement of radiographs was done by hand with poor to moderate inter-observer reliability. More recently digital PACS tools provided improved accuracy and reliability, with the latest software semi-automating this process with a promise of increased efficiency. PURPOSE To our knowledge, no studies have examined the inter-observer reliability of semi-automated PACS software. This study aims to compare the reliability of this software versus PACS to determine if the improved efficiency occurs at the cost of reliability. Methods Full spine X-rays were retrospectively reviewed from 25 patients older than 18 years seen at a tertiary medical center between 2014 and 2017. Patients were included if they had greater than 5cm of sagittal imbalance, without prior surgical spinal fusion and/or instrumentation. Spinopelvic parameters were measured in two radiographic programs: one with basic, non-spine specific measurement tools (eUnity, Client Outlook, Waterloo, Canada); and a second with spine-specific measurement tools that semi-automate the measurement of these parameters (Sectra, Sectra AB, Linkoping, Sweden). Balance parameters included SVA, PI, PT, and LL. Two authors re-measured radiographs after a 6-month interval and results were compared to original measurements. Data were compared by examining inter-rater and inter-program reliability using interclass correlation coefficient (ICC). We hypothesized that modern semi-automated software, with its promise of increased measurement efficiency, would maintain reliable results. Results The subjects’ mean age was 67.9 +/- 13.8 years old, and 32% were male. The inter-program reliability was strong, with ICC values greater than 0.91 for each parameter. Similarly, there was strong inter-observer reliability with ICC values greater than 0.88. Delayed re-measurement also showed strong reliability with ICC values greater than 0.90 (p Conclusions There is excellent inter-observer and inter-program reliability between the basic PACS and semi-automated programs. These data demonstrate that the purported efficiency of semi-automated measurement programs does not come at the cost of measurement reliability. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

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

STUDY DESIGN This is a surgical strategy survey. OBJECTIVE The purpose of this study was to evaluate the variability in in surgical strategy planning of adult spinal deformity (ASD) based on patients' clinical and radiographic data. BACKGROUND Literature guiding the management of ASD consists primarily of studies with low levels of evidence. Recent studies have demonstrated good agreement among surgeons about the factors influencing surgical decision but poor agreement about the need for surgery. Therefore there is a relative lack of consensus and guidelines in the clinical practice and treatment of ASD. METHODS A total of 28 adult deformity surgeons were asked to fulfill an online survey of 10 spinal deformity cases. Case presentation included a clinical vignette with photographs, Oswestry Disability Index and Visual Analog Scale scores and imaging with radiographic measurements. For each case, the surgeons were asked whether surgical management would be beneficial and if so, their surgical plan (approach, staging, need for fusion, osteotomy or decompression and the techniques used). Intraobserver and interobserver reliability were studied using average Cohen and Feiss Kappa statistics, respectively. Descriptive statistics were calculated to evaluate the frequency of each of the alternatives in surgical planning. RESULTS Average intrarater and interrater agreement for surgical strategy were evaluated to be substantial (κ=0.62) and fair (κ=0.24), respectively. Detailed interrater statistics demonstrates that there was only slight agreement on the need for surgery (κ=0.15), the approach (κ=0.15), and the need for fusion (κ=0.16) while moderate agreement was reached for the need for decompression (κ=0.42) and osteotomy (κ=0.29). CONCLUSIONS Among surgeons, agreement about the need for surgery and the surgical strategy for ASD is limited. Findings from this survey highlight the need for comprehensive classifications for ASD, higher-level studies including randomized trials to set guidelines and lessen the variability in clinical practices, which would then hopefully lead to improved outcomes.

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

Background: Many patients are affected by concurrent disease of the hip and spine, undergoing both total hip arthroplasty (THA) and lumbar spinal fusion (LSF). Recent literature demonstrates increased prosthetic dislocation rates in patients with THA done after LSF. Evidence is lacking on which surgery to do first to minimize complications. The purpose of this study was to evaluate the effect of timing between the two procedures on postoperative outcomes. Methods: We queried the Medicare standard analytics files between 2005 and 2014. Four groups were identified and matched by age and sex: THA with previous LSF, LSF with previous THA, THA with spine pathology without fusion, and THA without spine pathology. Revision THA or LSF and bilateral THA were excluded. Comorbidities and Charlson Comorbidity Index were identified. Postoperative complications at 90 days and 2 years were calculated after the most recent surgery. Four-way chi-squared and standard descriptive statistics were calculated. Results: Thirteen thousand one hundred two patients had THA after LSF, 10,482 patients had LSF after THA, 104,820 had THA with spine pathology, and 492,654 had THA without spine pathology. There was no difference in the Charlson Comorbidity Index score between the THA after LSF and LSF after THA groups. There was a statistically significant difference in THA dislocation rate, with LSF after THA at 1.7%, THA without spine pathology at 2.3%, THA with spine pathology at 3.3%, and THA after LSF at 4.6%. There was a statistically significant difference in THA revision rate, with THA without spine pathology at 3.3%, LSF after THA at 3.7%, THA with spine pathology at 4.2%, and THA after LSF at 5.7%. Conclusion: LSF after THA is associated with a reduced dislocation rate compared with THA after LSF. Reasons may include decreasing pelvic mobility in a stable, well-healed THA or early postoperative spine precautions after LSF restricting positions of dislocation.

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

BACKGROUND CONTEXT Exposure to surgical smoke remains a potential occupational health concern to spine operating room personnel. Using a smoke evacuator (local exhaust ventilation) is currently regarded as a primary means of protection, yet few studies have evaluated its utility in actual surgeries. OBJECTIVE To examine the utility of two common types of local smoke evacuators, a para incisional evacuator and a smoke evacuation pencil, in reducing surgical smoke exposure in spine surgery. STUDY DESIGN A prospective self-controlled study. PATIENT SAMPLE After the pre-estimation of sample size, 51 consecutive spine surgeries (25 and 26 patients using the para incisional smoke evacuator and the smoke evacuation pencil, respectively) were enrolled between February 2018 and March 2019. OUTCOME MEASURES Two outcome measures were used to evaluate the level of surgical smoke exposure, which was defined as the concentration of ultrafine smoke particles in the air (number of particles per cm3, ppc) around the operating table: (a) the average smoke level was the arithmetic mean of all measurements recorded during the surgery; and (b) the peak smoke level was the highest measurement recorded. METHODS Consecutive surgeries that involved bilateral symmetrical surgical exposure of the spine via a posterior midline incision were evaluated. Cauterized smoke was evacuated by two smoke evacuators: a “para incisional evacuator,” which used a flat broad suction pad positioned immediately adjacent to the incision (25 patients), and a “surgical smoke evacuation pencil” which is an incorporated part of the electrocautery (26 patients). The level of smoke exposure was measured separately when surgically exposing the two sides of the spine: starting with one side (determined randomly) with the smoke evacuator being turned on and, then, the other side with the smoke evacuator off. The results were compared between the two sides. RESULTS The para incisional smoke evacuator significantly reduced the average smoke level by an average of 59.7% (287 [interquartile range {IQR}: 126, 526] vs. 1,177 [IQR: 395, 2,702], p CONCLUSIONS This study provides evidence supporting the utility of local smoke evacuation in reducing surgical smoke exposure in spine surgery. Such technology may help to improve the occupational health protection for spine operating room workers.

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

Increased out-of-pocket costs have led to patients bearing more of the financial burden for their care. Previous work has shown that financial burden and distress can affect outcomes, symptoms, satisfaction, and adherence to treatment. We asked the following questions: (1) Does patients' financial distress correlate with disability in patients with nonacute orthopaedic conditions? (2) Do patient demographic factors affect this correlation?We conducted a cross-sectional, observational study of new patients presenting to a multispecialty orthopaedic clinic with a nonacute orthopaedic complication. Patients completed a demographics questionnaire, the InCharge Financial Distress/Financial Well-Being Scale, and the Health Assessment Questionnaire Disability Index. Statistical analysis was done using Pearson's correlation.The mean score for financial distress was 4.10 (SD, 2.09; scale 1 [low distress] to 10 [high distress]; range, 1.13 to 10.0), and the mean disability score was 0.54 (SD, 0.65; scale 0 to 3; range, 0 to 2.75). A moderate positive correlation exists between financial distress and disability (r = 0.43; P0.01). Financial distress and disability were highest for poor, uneducated, Medicare patients.A moderate correlation exists between financial distress and disability in patients with nonacute orthopaedic conditions, particularly in patients with low socioeconomic status. Orthopaedic surgeons may benefit from identifying patients in financial distress and discussing the cost of treatment because of its association with disability and potentially inferior outcomes. Further investigation is needed to test whether decreasing financial distress decreases disability.Level III prospective cohort.

Study design Retrospective study. Objective To assess the relation between exposure to epidural steroid injection (ESI) before surgery and occurrence of surgical site infection (SSI) for degenerative lumbar spine conditions. Summary of background data The effect of local ESI on the occurrence of SSI is controversial. Methods Patients who underwent surgery for degenerative lumbar spine conditions at two centers between 2005 and 2015 were identified. Primary outcome measure was SSI within 90 days requiring surgical intervention. Results A total of 5311 patients (age 57 ± 16 years) were analyzed of which 945 (18%) had at least one ESI within 90 days of surgery. One hundred thirty-four (2.5%) patients developed an SSI requiring reoperation. No association of exposure or dose-response relationship was identified between ESI and SSI for any of the time periods (90-, 30-, and 30-90-day). Five (1.7%) of the 290 patients who had at least one ESI within 30 days before surgery had a postoperative infection compared to 129 (2.6%) of the 5021 in the non-ESI group (unadjusted odds ratio: 0.67, 95% CI: 0.27-1.64, P = 0.376). Fifteen (2.0%) of the 761 patients who had at least one ESI within 30 to 90 days before surgery had a postoperative infection, compared to 119 (2.6%) of the 4550 in the non-ESI group (unadjusted odds ratio: 0.75, 95% CI: 0.44-1.29, P = 0.296). Conclusion In this retrospective study we investigated whether an ESI and its timing influences the postoperative risk of an SSI. We found no association-exposure or dose-response relationship-between ESI and postoperative infection, even after adjusting for potential confounders, for any of the time periods (90-, 30-, and 30-90-day ESI). In addition, we did find that longer hospital stay, greater EBL, posterior approach, and drain placement were associated with higher infection rates. Level of evidence 3.

Study design A cross-sectional survey of orthopedic spine surgery fellowship directors in the United States. Objective The aim of this study was to investigate whether consensus exists with respect to spine-related adverse events and certain hospital-acquired conditions (HACs) or "never events." Summary of background data As part of a broad effort to improve health care outcomes, providers are no longer reimbursed for HACs, which are deemed avoidable. Although some HACs are unquestionably preventable with proper quality control measures, research suggests that even scrupulous adherence to evidence-based guidelines cannot eliminate others. Methods Surveys were distributed via email and post. Participants rated 27 HACs and selected spine-specific events on an ordinal scale. Interobserver reliability was assessed among all 46 spine directors (respondents) using the intraclass correlation coefficient (ICC), based on a two-way random effects model, assuming that the participants were a representative population sample of spine surgeons. Multivariable linear regression analyses were performed on each of the 27 complications to identify potential demographic factors that could be associated with variation among respondents in their ratings of "avoidable" to "unavoidable." Results Forty-six fellowship directors responded, of whom 98% were orthopedic spine surgeons. The majority (80.4%) of respondents had greater than 10 years' experience as a spine surgeon, and 66.7% had an annual surgical volume >201 cases. The multivariable linear regression analyses found that demographic factors were not predictive of the directors' ratings. The complications thought to be completely avoidable (median scores 1) included "Incompatible blood," "Retained foreign object," and "Wrong level surgery." The HAC considered least avoidable was "Site infection with risk factors" (median score 8). Among 17 spine-specific complications, "L4-L5 disc re-herniation within 3 months" (median score 9) was considered least avoidable. Conclusion This survey suggests that orthopedic spine surgeons consider most "never events" neither avoidable nor unavoidable. There is strong consensus only about the HACs resulting from obvious medical error. Level of evidence 4.

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

Background Context Neuroforaminal stenosis is one of the key factors causing clinical symptoms in patients with cervical radiculopathy. Previous quantitative studies on the neuroforaminal dimensions have focused on measurements in a static position. Little is known about dimensional changes of the neuroforamina in the cervical spine during functional dynamic neck motion under physiological loading conditions. Purpose This study aimed to investigate the in vivo dimensional changes of the neuroforamina in human cervical spine (C3–C7) during dynamic flexion-extension neck motion. Study Design A case-control study was carried out. Methods Ten asymptomatic subjects were recruited for this study. The cervical spine of each subject underwent magnetic resonance image scanning for construction of three-dimensional (3-D) vertebrae models from C3 to C7. The cervical spine was then imaged using a dual fluoroscopic system while the subject performed a dynamic flexion-extension neck motion in a sitting position. The 3-D vertebral models and the fluoroscopic images were used to reproduce the in vivo vertebral motion. The dimensions (area, height, and width) were measured for each cervical neuroforamen (C3/C4, C4/C5, C5/C6, and C6/C7) in the following functional positions: neutral position, maximal flexion, and maximal extension. Repeated measures analysis of variance and post hoc analysis were used to examine the differences between levels and positions. Results Compared with the neutral position, almost all dimensional parameters (area, height, and width) of the subaxial cervical neuroforamina decreased in extension and increased in flexion, except the neuroforaminal area at C5/C6 (p=.07), and the neuroforaminal height at C6/C7 (p=.05) remained relatively constant from neutral to extension. When comparisons of the overall change fromextension to flexion were made between segments, the overall changes of the neuroforaminal area and height revealed no significant differences between segments, and the width overall change of the upper levels (C3/C4 and C4/C5) was significantly greater than the lower levels (C5/C6 and C6/C7) (p Conclusions The dimensional changes of the cervical neuroforamina showed segment-dependent characteristics during the dynamic flexion-extension. These data may have implications for diagnosis and treatment of patients with cervical radiculopathy.

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

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

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

BACKGROUND CONTEXT It is recognized that radiological parameters of type 2 dens fractures, including displacement and angulation, are predictive of treatment outcomes and are used to guide surgical decision-making. The reproducibility of such measurements, therefore, is of critical importance. Past literature has shown poor interobserver reliability for both displacement and angulation measurements of type 2 dens fractures. Since such studies however, various advancements of radiological review systems and measurement tools have evolved to potentially improve such measurements. PURPOSE To re-examine the inter-rater reliability of measuring displacement and angulation of type 2 dens fractures using modern radiological review systems. Besides quantitative measurements, the reliability of raters in identifying diagnostic classifications based on translational and angulational displacement was also examined. STUDY DESIGN Radiographic measurement reliability and agreement study. PATIENT SAMPLE Thirty-seven patients seen at a single institution between 2002 and 2017 with primary diagnosis of acute type 2 dens fracture with complete computed tomography (CT) imaging. OUTCOME MEASURES Radiological measurements included displacement and angulation. Diagnostic classifications based on consensus-based clinical cutoff points were also recorded. METHODS Measurements were performed by five surgeons with varying years of experience in spine surgery using the hospital's electronic medical record radiological measuring tools. The radiological measurements included displacement and angulation. Diagnostic classifications based on consensus-based clinical cutoff points were also recorded. Each rater received a graphic demonstration of the measurement methods, but had the autonomy to select a best cut from the sagittal CT to measure. All raters were blinded to patient information. RESULTS Measurements for displacement and angulation among the five raters demonstrated “excellent” reliability. Intra-rater reliability was also “excellent” in measuring displacement and angulation. The reliability of diagnostic classification of displacement (above vs. below 5 mm), was found to be “very good” among the raters. The reliability of diagnostic classification of angulation (above vs. below 11°) demonstrated “good” reliability. CONCLUSIONS Advancement of radiological review systems, including review tools and embedded image processing software, has facilitated more reliable measurements for type 2 odontoid fractures.

We asked the following questions: 1. Does the use of an structured review instrument (SRI) at journal club increase presentation quality, as measured objectively by a standardized evaluation rubric? 2. Does SRI use increase the time required to prepare for journal club? 3. Does SRI use positively impact presenter perceptions about confidence while presenting, satisfaction, and journal club effectiveness, as measured by postparticipation surveys?A prospective study was designed in which a grading rubric was developed to evaluate journal club presentations. The rubric was applied to 24 presentations at journal clubs prior to introduction of the SRI. An SRI was developed and distributed to journal club participants, who were instructed to use it to prepare for journal club. The grading rubric was then used to assess 25 post-SRI presentations and scores were compared between the pre- and post-SRI groups. Presentations occurred at either trauma, pediatrics, or spine subspecialty journal clubs. Participants were also surveyed regarding time requirements for preparation, perceptions of confidence while presenting, satisfaction, and perceptions of overall club effectiveness.A single academic center with an orthopaedic surgery residency program.Resident physicians in the department of orthopaedic surgery.Mean presentation scores increased from 14.0 ± 5.9 (mean ± standard deviation) to 24.4 ± 5.2 after introduction of the SRI (p0.001). Preparation time decreased from a mean of 47 minutes to 40 minutes after SRI introduction (p = 0.22). Perceptions of confidence, satisfaction, and club effectiveness among trainees trended toward more positive responses after SRI introduction (confidence: 63% positive responses pre-SRI vs 72% post-SRI, p = 0.73; satisfaction: 64% vs 91%, p = 0.18; effectiveness: 64% vs 91%, p = 0.19).The use of a structured review instrument to guide presentations at orthopaedic journal club increased presentation quality, and there was no difference in preparation time. There were trends toward improved presenter confidence, satisfaction, and perception of journal club effectiveness. SRI utilization at orthopaedic journal club may be an effective method for increasing the quality of journal club presentations. Future work should examine the relationship between presentation quality and overall club effectiveness.

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

Value-based healthcare models rely on quality measures to evaluate the efficacy of healthcare delivery and to identify areas for improvement. Quality measure research in other areas of health care has generally shown that there is a limited number of available quality measures and that those that exist disproportionately focus on processes as opposed to outcomes. The purpose of this study was to assess the current state of quality measures and candidate quality measures in spine surgery.(1) How many quality measures and candidate quality measures are currently available? (2) According to Donabedian domains and National Quality Strategy (NQS) priorities, what aspects or domains of care do the present quality measures and candidate quality measures represent?We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures relevant to spine surgery. A systematic search for candidate quality measures was also performed using MEDLINE/PubMed and Embase as well as publications from the American Academy of Orthopaedic Surgeons, Congress of Neurological Surgeons, and the North American Spine Society. Clinical practice guidelines were included as candidate quality measures if their development was in accordance with Institute of Medicine criteria for the development of clinical practice guidelines, they were based on consistent clinical evidence including at least one Level I study, and they carried the strongest possible recommendation by the developing body. Quality measures and candidate quality measures were then pooled for analysis and categorized by clinical focus, NQS priority, and Donabedian domain. Our initial search yielded a total of 3940 articles, clinical practice guidelines, and quality measures, 74 of which met criteria for inclusion in this study.Of the 74 measures studied, 29 (39%) were quality measures and 45 (61%) were candidate quality measures. Fifty of 74 (68%) were specific to the care of the spine, and 24 of 74 (32%) were related to the general care of spine patients. The majority of the spine-specific measures were process measures (45 [90%]) and focused on the NQS priority of "Effective Clinical Care" (44 [88%]). The majority of the general care measures were also process measures (14 [58%]), the highest portion of which focused on the NQS priority of "Patient Safety" (10 [42%]).Given the large number of pathologies treated by spine surgeons, the limited number of available quality measures and candidate quality measures in spine surgery is inadequate to support the transition to a value-based care model. Additionally, current measures disproportionately focus on certain aspects or domains of care, which may hinder the ability to appropriately judge an episode of care, extract usable data, and improve quality. Physicians can steward the creation of meaningful quality measures by participating in clinical practice guideline development, assisting with the creation and submission of formal quality measures, and conducting the high-quality research on which effective guidelines and quality measures depend.

Retrospective cohort study.Assess differences between staged (≤3 days) and same-day surgery in perioperative factors, radiographic measures, and complications.Surgical adult spinal deformity correction may require combined anterior and posterior approaches. To modulate risk, some surgeons perform surgery that is expected to be longer and/or more complex in two stages. Prior studies comparing staged (≥7 days) and same-day surgery demonstrated mixed results and none have examined results with shorter staging intervals.Retrospective review of adults undergoing combined anterior/posterior approaches for spinal deformity over a 3-year period at a single institution (n=92). Univariate differences between staged and same-day surgery were assessed with chi-squared, Fisher exact, and Mann-Whitney U tests. Generalized estimating equations assessed whether differences in perioperative outcomes between groups remained after adjusting for differences in demographic and surgical characteristics.In univariate analyses, staged surgery was associated with a length of stay (LOS) 3 days longer than same-day surgery (9.2 vs. 6.3 days, p.001), and greater operative time, blood loss, transfusion requirement, and days in intensive care unit (p.001 for each). Staged surgery had a higher rate of thrombotic events (p = .011) but did not differ in readmission rates or other complications. Radiographically, improvements in Cobb angle (average 13° vs. 17°, p = .028), lumbar lordosis (average 14° vs. 23°, p = .019), and PI-LL mismatch (average 10° vs. 2° p = .018) were greater for staged surgery, likely related to more extensive use of osteotomies in the staged group. After risk adjustment, taking into account the procedural specifics including longer fusion constructs and greater number of osteotomies, LOS no longer differed between staged and same-day surgery; however, the total operative time was 98 minutes longer for staged surgery (p.001). Differences in blood loss between groups was accounted for by differences in operative time and patient and surgical characteristics.Although univariate analysis of our results were in accordance with previously published works, multivariate analysis allowing individual case risk adjustment revealed that LOS was not significantly increased in the staged group as reported in previous studies. There was no difference in infection rates as previously described but an increase in thrombotic events was observed.Level III.

BACKGROUND CONTEXT With the aging of society, patients with concurrent degenerative lumbar disorders and hip osteoarthritis, also referred to as the "hip-spine syndrome," are frequently evaluated by both spine and arthroplasty surgeons. The decision-making can be straightforward in many but in others, the optimal treatment order—spine surgery or total hip arthroplasty (THA) first—remains unclear and complicated, especially when neurological deficits are involved. PURPOSE To compare, in spine and arthroplasty surgeons respectively, the treatment order preference among four typical scenarios of hip-spine syndrome with different neurological symptoms. STUDY DESIGN/SETTING Prospective survey at a professional society level. PATIENT SAMPLE Eighty-eight experienced spine (37) and total hip arthroplasty (51) surgeons from the Scoliosis Research Society (SRS) and The Hip Society, respectively. OUTCOME MEASURES Percentage of surgeons, in each specialty, choosing "spine first" in each scenario. METHODS Four fictional patients were devised to have concurrent degenerative lumbar disorders and painful hip osteoarthritis, with the primary neurological symptom in each scenario being (a) radicular leg pain, (b) neurogenic claudication, (c) leg weakness, and (d) myelopathy, respectively. A survey with history, physical examination, and radiographs was formulated and sent to clinical members of SRS and The Hip Society soliciting their treatment order preference—spine surgery or THA first—and their rationale. Surgeons' choices, as measured by the percentage choosing "spine surgery first," were compared among the four scenarios and between the two specialties. Text-mining was used to summarize the rationale for decision-making by identifying the most frequently used words in surgeons' comments. RESULTS Responses were received from 37 (37/100, 37%) spine surgeons and 51 (51/101, 50%) arthroplasty surgeons across North America. In both specialties, the percentage choosing "spine first" varied in the same fashion among the four scenarios. Myelopathy, leg weakness, neurogenic claudication, and radicular pain, in that order, drove the decision-making toward "spine first" (97%, 73%, 46% and 8% of the spine surgeons and 86%, 45%, 33%, and 18% of the arthroplasty surgeons chose "spine first"). Only in the scenario of leg weakness did a significant disparity noted between the two specialties: spine surgeons were more sensitive to weakness than arthroplasty surgeons (73% vs 45% choosing "spine first," P=0.017). In both specialties, text-mining showed that the words that describe the symptoms or pathologies of the neurological deficits, such as "stenosis," "weakness," and "myelopathy," were most frequently used in surgeons' comments in most scenarios except for that of radicular pain. CONCLUSIONS The nature of neurological deficits influences the treatment order preference for hip-spine syndrome in both spine and arthroplasty surgeons, with myelopathy, weakness, neurogenic claudication, and radicular pain, in this order, driving the decision-making toward performing spine surgery first. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Patients with a previously fused thoracic curve that has remained and is accompanied by pain and cosmetic deformity may be treated with complex revision surgery. Strategies include multiple posterior osteotomies—with or without anterior release, pedicle subtraction osteotomy, or vertebral column resection. Large residual rib prominences can be approached with multi-rib thoracoplasty. However, the potential complication rate of these procedures can be considerable, and thus, a clear and thorough discussion regarding treatment objectives is strongly recommended.

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

Allogeneic blood transfusions have an immunomodulating effect, and the previous studies in other fields of medicine demonstrated an increased risk of infections after administration of allogeneic blood transfusions.Our primary null hypothesis is that exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery is not associated with postoperative infections after controlling for patient and treatment characteristics. Second, we assessed if there was a dose-response relationship per unit of blood transfused.This is a retrospective cohort study from a tertiary care spine referral center.A total of 3,721 patients underwent laminectomy and/or arthrodesis of the lumbar spine.Postoperative infections, pneumonia, endocarditis, meningitis, urinary tract infection, central venous line infection, surgical site infection, and sepsis, within 90 days after lumbar spine surgery were included.Multivariable logistic regression analyses were used to assess the relationship of perioperative allogeneic blood transfusion with specific and overall postoperative infections accounting for age, duration of surgery, duration of hospital stay, comorbidity status, preoperative hemoglobin, sex, type of operation, multilevel treatment, operative approach, and year of surgery.The adjusted odds ratio for exposure to allogeneic blood transfusion from multivariable logistic regression analysis was 2.6 for any postoperative infection (95% confidence interval [CI]: 1.7-3.9, p.001); 2.2 for urinary tract infections (95% CI: 1.3-3.9, p=.004); 2.3 for pneumonia (95% CI: 0.96-5.3, p=.062); and 2.6 for surgical site infection requiring incision and drainage (95% CI: 1.3-5.3, p=.007). Secondary analyses demonstrated no dose-response relationship between the number of blood units transfused and any of the postoperative infections. Because of the low number of endocarditis (1 case, 0.031%), meningitis (1 case, 0.031%), central venous line infection (1 case, 0.031%), and sepsis (14 cases, 0.43%), we abstained from multivariable analysis.Conscious of the limitations of this retrospective study, our data suggest an increased risk of surgical site infection, urinary tract infection, and overall postoperative infections, but not pneumonia, after exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery. These findings should be taken into account when considering blood transfusion and developing transfusion policies for patients undergoing lumbar spine procedures.

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

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

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

While abnormal loading is widely believed to cause cervical spine disc diseases, in vivo cervical disc deformation during dynamic neck motion has not been well delineated. This study investigated the range of cervical disc deformation during an in vivo functional flexion–extension of the neck. Ten asymptomatic human subjects were tested using a combined dual fluoroscopic imaging system (DFIS) and magnetic resonance imaging (MRI)-based three-dimensional (3D) modeling technique. Overall disc deformation was determined using the changes of the space geometry between upper and lower endplates of each intervertebral segment (C3/4, C4/5, C5/6, and C6/7). Five points (anterior, center, posterior, left, and right) of each disc were analyzed to examine the disc deformation distributions. The data indicated that between the functional maximum flexion and extension of the neck, the anterior points of the discs experienced large changes of distraction/compression deformation and shear deformation. The higher level discs experienced higher ranges of disc deformation. No significant difference was found in deformation ranges at posterior points of all the discs. The data indicated that the range of disc deformation is disc level dependent and the anterior region experienced larger changes of deformation than the center and posterior regions, except for the C6/7 disc. The data obtained from this study could serve as baseline knowledge for the understanding of the cervical spine disc biomechanics and for investigation of the biomechanical etiology of disc diseases. These data could also provide insights for development of motion preservation surgeries for cervical spine.

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

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

Study design Retrospective medical record review. Objective The purpose of this study was to determine whether a history of abdominal/pelvic surgery confers an increased risk of retroperitoneal anterior approach-related complications when undergoing anterior lumbar interbody fusion. Summary of background data As anterior lumbar interbody fusion gains popularity, both anterior retroperitoneal approach have become increasingly used. Methods The records of 263 patients, who underwent infraumbilical retroperitoneal approach to the anterior aspect of the lower lumbar spine for a degenerative spine condition between 2007 and 2011 were retrospectively reviewed. Patient's demographics, risk factors, preoperative diagnosis, surgical history, level of the anterior fusion, and perioperative complications were collected. Anterior retroperitoneal approach to the spine was carried out by a single general surgeon. Results Ninety-seven patients (37%) developed at least 1 complication. Forty-nine percent of patients with a history of abdominal surgery developed a postoperative complication compared with 28% of patients without such history (RR = 1.747, P≤ 0.001). After controlling for other factors such as age, sex, body mass index, diagnostic groups, and preoperative comorbidities (hypertension, diabetes, and smoking status), these differences remained statistically significant. When each type of complication was considered separately, there was a statistically significant difference in the incidence of general complications (RR = 2.384, P = 0.007), instrumentation-related complications (RR = 2.954, P = 0.010), and complications related to the anterior approach (RR = 1.797, P = 0.021). Conclusion Anterior lumbar interbody fusion via a midline incision and a retroperitoneal approach was associated with 37% overall rate of complication. Patients with a history of abdominal or pelvic surgery are at a higher risk of developing general, instrumentation, and anterior approach-related complications.

Many studies have reported on the segmental motion range of the lumbar spine using various in vitro and in vivo experimental designs. However, the in vivo weightbearing dynamic motion characteristics of the L4–5 and L5–S1 motion segments are still not clearly described in literature. This study investigated in vivo motion of the lumbar spine during a weight-lifting activity. Ten asymptomatic subjects (M/F: 5/5; age: 40–60 years) were recruited. The lumbar segment of each subject was MRI-scanned to construct 3D models of the L2–S1 vertebrae. The lumbar spine was then imaged using a dual fluoroscopic imaging system as the subject performed a weight-lifting activity from a lumbar flexion position (45°) to maximal extension position. The 3D vertebral models and the fluoroscopic images were used to reproduce the in vivo vertebral positions along the motion path. The relative translations and rotations of each motion segment were analyzed. All vertebral motion segments, L2–3, L3–4, L4–5 and L5–S1, rotated similarly during the lifting motion. L4–5 showed the largest anterior-posterior (AP) translation with 2.9 ± 1.5 mm and was significantly larger than L5–S1 (p

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

Knowledge of in vivo human lumbar loading is critical for understanding the lumbar function and for improving surgical treatments of lumbar pathology. Although numerous experimental measurements and computational simulations have been reported, non-invasive determination of in vivo spinal disc loads is still a challenge in biomedical engineering. The object of the study is to investigate the in vivo human lumbar disc loads using a subject-specific and kinematic driven finite element approach.Three dimensional lumbar spine models of three living subjects were created using MR images. Finite element model of the L3-4 disc was built for each subject. The endplate kinematics of the L3-4 segment of each subject during a dynamic weight lifting extension was determined using a dual fluoroscopic imaging technique. The endplate kinematics was used as displacement boundary conditions to calculate the in-vivo disc forces and moments during the weight lifting activity.During the weight lifting extension, the L3-4 disc experienced maximum shear load of about 230 N or 0.34 bodyweight at the flexion position and maximum compressive load of 1500 N or 2.28 bodyweight at the upright position. The disc experienced a primary flexion-extension moment during the motion which reached a maximum of 4.2 Nm at upright position with stretched arms holding the weight.This study provided quantitative data on in vivo disc loading that could help understand intrinsic biomechanics of the spine and improve surgical treatment of pathological discs using fusion or arthroplasty techniques.