The transcription factor LRF promotes integrin ß7 expression by and gut homing of CD8αα+ intraepithelial lymphocyte precursors.

While T cell receptor (TCR) αß+CD8α+CD8ß- intraepithelial lymphocytes (CD8αα+ IELs) differentiate from thymic IEL precursors (IELps) and contribute to gut homeostasis, the transcriptional control of their development remains poorly understood. In the present study we showed that mouse thymocytes deficient for the transcription factor leukemia/lymphoma-related factor (LRF) failed to generate TCRαß+CD8αα+ IELs and their CD8ß-expressing counterparts, despite giving rise to thymus and spleen CD8αß+ T cells. LRF-deficient IELps failed to migrate to the intestine and to protect against T cell-induced colitis, and had impaired expression of the gut-homing integrin α4ß7. Single-cell RNA-sequencing found that LRF was necessary for the expression of genes characteristic of the most mature IELps, including Itgb7, encoding the ß7 subunit of α4ß7. Chromatin immunoprecipitation and gene-regulatory network analyses both defined Itgb7 as an LRF target. Our study identifies LRF as an essential transcriptional regulator of IELp maturation in the thymus and subsequent migration to the intestinal epithelium.

A Thpok-Directed Transcriptional Circuitry Promotes Bcl6 and Maf Expression to Orchestrate T Follicular Helper Differentiation.

The generation of high-affinity neutralizing antibodies, the objective of most vaccine strategies, occurs in B cells within germinal centers (GCs) and requires rate-limiting "help" from follicular helper CD4+ T (Tfh) cells. Although Tfh differentiation is an attribute of MHC II-restricted CD4+ T cells, the transcription factors driving Tfh differentiation, notably Bcl6, are not restricted to CD4+ T cells. Here, we identified a requirement for the CD4+-specific transcription factor Thpok during Tfh cell differentiation, GC formation, and antibody maturation. Thpok promoted Bcl6 expression and bound to a Thpok-responsive region in the first intron of Bcl6. Thpok also promoted the expression of Bcl6-independent genes, including the transcription factor Maf, which cooperated with Bcl6 to mediate the effect of Thpok on Tfh cell differentiation. Our findings identify a transcriptional program that links the CD4+ lineage with Tfh differentiation, a limiting factor for efficient B cell responses, and suggest avenues to optimize vaccine generation.

A decade of diversity: using statistical indices to compare neurosurgery to other surgical specialties.

OBJECTIVE: Studies have demonstrated the benefits of diversity in neurosurgery. However, recruitment of minoritized groups within the neurosurgical workforce consistently lags other surgical specialties. While racial and gender demographics of neurosurgical residents are well documented, there has been minimal exploration into the multidimensional nature of diversity. The current study will evaluate the longitudinal diversity changes in neurosurgery residency programs compared with other surgical fields with validated diversity indices. METHODS: Nationwide reports including data about resident physicians were obtained from the American Medical Association and the Association of American Medical Colleges for the academic years 2008-2021. Self-reported race, biological sex, and medical school affiliation were recorded for surgical residents in the 10 commonly recognized surgical fields. The Gini-Simpson Diversity Index was used to calculate the effective counts (ECs) of races, sexes, and medical school types for each field. A Composite Diversity Index (CDI) comprising the aforementioned diversity traits was used to calculate the percentage of characteristics upon which two randomly selected residents within each specialty would differ. CDIs were calculated for each field in every year from 2008 to 2021. Median CDIs were compared between fields using Kruskal-Wallis testing, and p values < 0.05 were deemed statistically significant. RESULTS: Plastic surgery had the highest median sex EC (1.92, interquartile range [IQR] 1.78-1.95), indicating greater diversity, while neurosurgery had the third lowest sex EC (1.40, IQR 1.35-1.41). All surgical fields examined had fewer than 3 races effectively represented among their residents, despite there being 8 races present. Neurosurgery ranked among the top fields in effective racial diversity (EC 2.17, IQR 2.09-2.21) and medical school type diversity (EC 1.25, IQR 1.21-1.26). There were statistically significant differences in the sex, race, and school ECs between surgical specialties. While neurosurgery had a relatively low median overall diversity (CDI = 32.7, IQR 32.0-34.6), there was a consistent longitudinal increase in CDI from 2015 to 2021. CONCLUSIONS: Neurosurgery resident physicians have become increasingly diverse in the past decade but are more homogenous than residents in other surgical fields. The continued use of diversity indices to more accurately track diversity progress over time may better inform leaders in the field of how they may best focus their equity and inclusion efforts.

Hyperlipidemia, Obesity, and Diabetes, and Risk of Ossification of the Posterior Longitudinal Ligament.

BACKGROUND: Several risk factors of ossification of the posterior longitudinal ligament (OPLL) have been established, including diabetes and obesity. However, the relationship between hyperlipidemia (HLD) and OPLL is incompletely understood. METHODS: PearlDiver was queried to identify adults with (+) and without (-) HLD, diabetes, and obesity. Comparative analyses were performed on demographics, comorbidities, and OPLL rates before and after matching for age, sex, and comorbidities. Stepwise logistic regression modeling assessing the relationship between HLD and OPLL with the addition of predictor variables was also performed. RESULTS: In total, 31,677 cervical OPLL patients, as well as 170,467 HLD+ and 118,665 HLD-, 168,985 Diabetes+ and 137,966 Diabetes-, and 150,363 Obesity+ and 142,553 Obesity- patients, were examined. Mean age ranged 43.44-59.46 years, 54.94-63.12% were females, and mean Charlson Comorbidity Index ranged from 0.06 from 1.53, all higher in those with the comorbidity. Before matching, OPLL rates were higher in those with HLD (HLD+=0.05% vs. HLD-=0.03%, P = 0.005), diabetes (Diabetes+=0.06% vs. Diabetes-=0.02%, P < 0.001), and obesity (Obesity+=0.05% vs. Obesity-=0.02%, P = 0.001). However, after matching by age, sex, and Charlson Comorbidity Index, the associations between the studied comorbidities and OPLL were attenuated (all P > 0.05). Stepwise regression modeling revealed an association between HLD and cervical OPLL that was most impacted by the addition of age (OR=1.95, R2 = 0.029 to OR=1.38, R2 = 0.075) and obesity (OR=1.21, R2 = 0.086 to OR=1.07, R2 = 0.111) into the model. CONCLUSIONS: Cervical OPLL rates were higher in patients with HLD even after accounting for demographics and comorbidities. HLD may be an independent risk factor for OPLL development.

Same-Day Versus Staged Spinal Fusion: A Meta-analysis of Clinical Outcomes.

STUDY DESIGN: Meta-analysis. OBJECTIVE: This meta-analysis aims to compare same-day versus staged spine surgery, assessing their effects on patient care and health care system efficiency. BACKGROUND: In spinal surgery, the debate between whether same-day and staged surgeries are better for patients continues, as the decision may impact patient-related outcomes, health care resources, and overall costs. While some surgeons advocate for staged surgeries, citing reduced risks of complications, others proclaim same-day surgeries may minimize costs and length of hospital stays. METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) were searched up until February 2024. The studied outcomes were operative room (OR) time, estimated blood loss (EBL), length of hospital stay (LOS), overall complications, venous thromboembolism (VTE), death, operations, and nonhome discharge. RESULTS: Sixteen retrospective studies were included in this meta-analysis, representing a total of 2346 patients, of which 644 underwent staged spinal fusion surgeries and 1702 same-day surgeries. No statistically significant difference was observed in EBL between staged and same-day surgery groups. However, the staged group exhibited a statistically significant longer OR time ( P =0.05) and LOS ( P =0.004). A higher rate of overall complications ( P =0.002) and VTE ( P =0.0008) was significantly associated with the staged group. No significant differences were found in the rates of death, reoperations, and nonhome discharge between the 2 groups. CONCLUSIONS: Both staged and same-day spinal fusion surgeries showed comparable rates of death, operations, and nonhome discharges for patients undergoing spinal surgeries. However, given the increased OR time, LOS, and complications associated with staged spinal surgeries, this study supports same-day surgeries when possible to minimize the burden on healthcare resources and enhance efficiency.

Burst fracture treatment caudal to long posterior spinal fusion for adolescent idiopathic scoliosis utilizing temporary lumbo-pelvic fixation with restoration of lumbar mobility after instrumentation removal.

Background: Thoracolumbar burst fractures are common traumatic spinal fractures. The goals of treatment include stabilization, prevention of neurologic compromise or deformity, and preservation of mobility. The aim of this case report is to describe the occurrence and treatment of an L4 burst fracture caudal to long posterior fusion for adolescent idiopathic scoliosis (AIS). Case report: A 15-year-old girl patient underwent posterior spinal fusion from T3-L3. The patient tolerated the procedure well and there were no complications. Seven years postoperatively, the patient reported to the emergency department with lumbar pain after fall from height. A burst fracture at L4 was diagnosed and temporary posterior instrumentation to the pelvis was performed. One-year postinjury, the hardware was removed with fixation replaced only into the fractured segment. Flexion/extension radiographs revealed restored motion. Conclusions: Treatment of fractures adjacent to fusion constructs may be challenging. This case demonstrates that avoiding fusion may lead to satisfactory outcomes and restoration of mobility after instrumentation removal.

Lumbar Disc Replacement Versus Interbody Fusion: Meta-analysis of Complications and Clinical Outcomes.

Background: Lumbar spinal fusion is a commonly performed operation with relatively high complication and revision surgery rates. Lumbar disc replacement is less commonly performed but may have some benefits over spinal fusion. This meta-analysis aims to compare the outcomes of lumbar disc replacement (LDR) versus interbody fusion (IBF), assessing their comparative safety and effectiveness in treating lumbar DDD. Methods: PubMed, Cochrane, and Google Scholar (pages 1-2) were searched up until February 2024. The studied outcomes included operative room (OR) time, estimated blood loss (EBL), length of hospital stay (LOS), complications, reoperations, Oswestry Disability Index (ODI), back pain, and leg pain. Results: Ten studies were included in this meta-analysis, of which six were randomized controlled trials, three were retrospective studies, and one was a prospective study. A total of 1720 patients were included, with 1034 undergoing LDR and 686 undergoing IBF. No statistically significant differences were observed in OR time, EBL, or LOS between the LDR and IBF groups. The analysis also showed no significant differences in the rates of complications, reoperations, and leg pain between the two groups. However, the LDR group demonstrated a statistically significant reduction in mean back pain (p=0.04) compared to the IBF group. Conclusion: Both LDR and IBF procedures offer similar results in managing CLBP, considering OR time, EBL, LOS, complication rates, reoperations, and leg pain, with slight superiority of back pain improvement in LDR. This study supports the use of both procedures in managing degenerative spinal disease.

Laminoplasty Versus Laminectomy and Posterior Fusion for Cervical Myelopathy: A Meta-analysis of Radiographic and Clinical Outcomes.

STUDY DESIGN: Meta-analysis. OBJECTIVE: This meta-analysis investigates the outcomes of laminoplasty (LP) and laminectomy with fusion (LF) to guide effective patient selection for these two procedures. BACKGROUND: While LF traditionally offers the ability for excellent posterior decompression, it may alter cervical spine biomechanics and increase the risk of adjacent segment degeneration. LP aims to preserve the natural kinematics of the spine but has not been universally accepted, and may be associated with inadequate decompression, neck pain, and recurrent stenosis. METHODS: PubMed, Cochrane, and Google Scholar (Pages 1-20) were searched up until March 2024. The outcomes studied were surgery-related outcomes (operating room (OR) time, estimated blood loss (EBL), and length of stay (LOS)), adverse events (overall complications, C5 palsy, and reoperations), radiographic outcomes (cervical lordosis (CL), cervical sagittal vertical axis (cSVA), and T1 slope angle (T1SA)), and patient-reported outcome measures (PROMs) (Neck Disability Index (NDI), Visual Analog Scale (VAS) for neck pain, and Japanese Orthopaedic Association (JOA)). RESULTS: Twenty-two studies were included in this meta-analysis, of which 19 were retrospective studies, two were prospective non-randomized studies, and one was a randomized controlled trial. A total of 2,128 patients were included, with 1,025 undergoing LP and 1,103 undergoing LF. LP patients experienced significantly shorter OR time (P=0.009), less EBL (P=0.02), a lower rate of overall complications (P<0.00001) and C5 palsy (P=0.003), a lower T1SA (P=0.02), and a lower NDI (P=0.0004). No significant difference was observed in the remaining outcomes. CONCLUSION: This meta-analysis demonstrates that for cervical myelopathy, LP has the benefits of shorter OR time, less EBL, and reduced incidence of C5 palsy as well as overall complication rate. Given these findings, LP remains an important surgical option with a favorable complication profile in patients with cervical myelopathy, although careful patient selection is still paramount in choosing the right procedure for individual patients.

Preoperative Resilience and Improvement in Patient-Reported Outcomes After Lumbar Spinal Fusion.

BACKGROUND: It is incompletely understood how preoperative resilience affects 1-year postoperative outcomes after lumbar spinal fusion. METHODS: Patients undergoing open lumbar spinal fusion at a single-center institution were identified between November 2019 and September 2022. Preoperative resilience was assessed using the Brief Resilience Scale. Demographic data at baseline including age, gender, comorbidities, and body mass index (BMI) were extracted. Patient-reported outcome measures including Oswestry Disability Index, PROMIS (Patient-Reported Outcomes Measurement Information System) Global Physical Health, PROMIS Global Mental Health (GMH), and EuroQol5 scores were collected before the surgery and at 3 months and 1 year postoperatively. Bivariate correlation was conducted between Brief Resilience Scale scores and outcome measures at 3 months and 1 year postoperatively. RESULTS: Ninety-three patients had baseline and 1 year outcome data. Compared with patients with high resilience, patients in the low-resilience group had a higher percentage of females (69.4% vs. 43.9%; P = 0.02), a higher BMI (32.7 vs. 30.1; P = 0.03), and lower preoperative Global Physical Health (35.8 vs. 38.9; P = 0.045), GMH (42.2 vs. 49.2; P < 0.001), and EuroQol scores (0.56 vs. 0.61; P = 0.01). At 3 months postoperatively, resilience was moderately correlated with GMH (r = 0.39) and EuroQol (r = 0.32). Similarly, at 1 year postoperatively, resilience was moderately correlated with GMH (r = 0.33) and EuroQol (r = 0.34). Comparable results were seen in multivariable regression analysis controlling for age, gender, number of levels fused, BMI, Charlson Comorbidity Index, procedure, anxiety/depression, and complications. CONCLUSIONS: Low preoperative resilience can negatively affect patient-reported outcomes 1 year after lumbar spinal fusion. Resiliency is a potentially modifiable risk factor, and surgeons should consider targeted interventions for at-risk patient groups.

Assessing the Accuracy and Reliability of AI-Generated Responses to Patient Questions Regarding Spine Surgery.

BACKGROUND: In today's digital age, patients increasingly rely on online search engines for medical information. The integration of large language models such as GPT-4 into search engines such as Bing raises concerns over the potential transmission of misinformation when patients search for information online regarding spine surgery. METHODS: SearchResponse.io, a database that archives People Also Ask (PAA) data from Google, was utilized to determine the most popular patient questions regarding 4 specific spine surgery topics: anterior cervical discectomy and fusion, lumbar fusion, laminectomy, and spinal deformity. Bing's responses to these questions, along with the cited sources, were recorded for analysis. Two fellowship-trained spine surgeons assessed the accuracy of the answers on a 6-point scale and the completeness of the answers on a 3-point scale. Inaccurate answers were re-queried 2 weeks later. Cited sources were categorized and evaluated against Journal of the American Medical Association (JAMA) benchmark criteria. Interrater reliability was measured with use of the kappa statistic. A linear regression analysis was utilized to explore the relationship between answer accuracy and the type of source, number of sources, and mean JAMA benchmark score. RESULTS: Bing's responses to 71 PAA questions were analyzed. The average completeness score was 2.03 (standard deviation [SD], 0.36), and the average accuracy score was 4.49 (SD, 1.10). Among the question topics, spinal deformity had the lowest mean completeness score. Re-querying the questions that initially had answers with low accuracy scores resulted in responses with improved accuracy. Among the cited sources, commercial sources were the most prevalent. The JAMA benchmark score across all sources averaged 2.63. Government sources had the highest mean benchmark score (3.30), whereas social media had the lowest (1.75). CONCLUSIONS: Bing's answers were generally accurate and adequately complete, with incorrect responses rectified upon re-querying. The plurality of information was sourced from commercial websites. The type of source, number of sources, and mean JAMA benchmark score were not significantly correlated with answer accuracy. These findings underscore the importance of ongoing evaluation and improvement of large language models to ensure reliable and informative results for patients seeking information regarding spine surgery online amid the integration of these models in the search experience.

Management of traumatic spinal cord injury: A current concepts review of contemporary and future treatment.

Spinal Cord Injury (SCI) is a condition leading to inflammation, edema, and dysfunction of the spinal cord, most commonly due to trauma, tumor, infection, or vascular disturbance. Symptoms include sensory and motor loss starting at the level of injury; the extent of damage depends on injury severity as detailed in the ASIA score. In the acute setting, maintaining mean arterial pressure (MAP) higher than 85 mmHg for up to 7 days following injury is preferred; although caution must be exercised when using vasopressors such as phenylephrine due to serious side effects such as pulmonary edema and death. Decompression surgery (DS) may theoretically relieve edema and reduce intraspinal pressure, although timing of surgery remains a matter of debate. Methylprednisolone (MP) is currently used due to its ability to reduce inflammation but more recent studies question its clinical benefits, especially with inconsistency in recommending it nationally and internationally. The choice of MP is further complicated by conflicting evidence for optimal timing to initiate treatment, and by the reported observation that higher doses are correlated with increased risk of complications. Thyrotropin-releasing hormone may be beneficial in less severe injuries. Finally, this review discusses many options currently being researched and have shown promising pre-clinical results.

Cutibacterium acnes in spine surgery: pathophysiology, diagnosis, and treatment.

Cutibacterium acnes (C. acnes) previously named Propionibacterium acnes (P. acnes) has been increasingly recognized by spine surgeons as a cause of indolent post-surgical spinal infection. Patients infected with C. acnes may present with pseudarthrosis or nonspecific back pain. Currently, microbiological tissue cultures remain the gold standard in diagnosing C. acnes infection. Ongoing research into using genetic sequencing as a diagnostic method shows promising results and may be another future way of diagnosis. Optimized prophylaxis involves the use of targeted antibiotics, longer duration of antibiotic prophylaxis, antibacterial-coated spinal implants, and evidence-based sterile surgical techniques all of which decrease contamination. Antibiotics and implant replacement remain the mainstay of treatment, with longer durations of antibiotics proving to be more efficacious. Local guidelines must consider the surge of antimicrobial resistance worldwide when treating C. acnes.

Cortical Trajectory Versus Traditional Pedicle Screw Trajectory in Open Transforaminal Lumbar Interbody Fusion: Meta-analysis of Complications and Clinical Outcomes.

BACKGROUND: Lumbar degenerative disease imposes a substantial burden on global healthcare expenditures. Transforaminal lumbar interbody fusion (TLIF) utilizing either traditional trajectory (TT) pedicle screws or cortical bone trajectory (CT) pedicle screws have become increasingly common. This meta-analysis evaluates the outcomes and safety of open TLIF with TT compared to CT. METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) were explored until April 2024. The studied outcomes included complications, revision surgeries, operative room (OR) time, estimated blood loss (EBL), length of hospital stay (LOS), incision length, Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and the Japanese Orthopedic Association (JOA) score. RESULTS: Five studies were included in this meta-analysis. A total of 770 patients undergoing TLIF were included, with 415 in the CT group and 355 in the TT group. No statistically significant differences were found in the rate of overall complications, including specific complications, the rate of revision surgeries, PROMS scores, OR time, and EBL. However, the CT group demonstrated shorter LOS (p=0.05), and shorter incision lengths (p<.001) compared to the TT group. CONCLUSION: Both TT and CT techniques in TLIF procedures demonstrated comparable rates of complications, reoperations, and PROMs. Despite similar OR times and EBL, the CT group exhibited shorter incision lengths, and shorter LOS compared to the TT group. Both cortical and traditional trajectory pedicle screws are safe and effective options for TLIF. There are potential benefits to CT such as shorter incision and LOS, although TT remains an essential tool for spinal instrumentation techniques.

Sacroplasty for Sacral Insufficiency Fractures: Narrative Literature Review on Patient Selection, Technical Approaches, and Outcomes.

Sacral insufficiency fractures commonly affect elderly women with osteoporosis and can cause debilitating lower back pain. First line management is often with conservative measures such as early mobilization, multimodal pain management, and osteoporosis management. If non-operative management fails, sacroplasty is a minimally invasive intervention that may be pursued. Candidates for sacroplasty are patients with persistent pain, inability to tolerate immobilization, or patients with low bone mineral density. Before undergoing sacroplasty, patients' bone health should be optimized with pharmacotherapy. Anabolic agents prior to or in conjunction with sacroplasty have been shown to improve patient outcomes. Sacroplasty can be safely performed through a number of techniques: short-axis, long-axis, coaxial, transiliac, interpedicular, and balloon-assisted. The procedure has been demonstrated to rapidly and durably reduce pain and improve mobility, with little risk of complications. This article aims to provide a narrative literature review of sacroplasty including, patient selection and optimization, the various technical approaches, and short and long-term outcomes.

Variability in expenses related to spine oncology care: comparison of payer-negotiated rates at National Cancer Institute-Designated Cancer Centers.

BACKGROUND: As of 2021, the Centers for Medicare and Medicaid Services (CMS) requires all hospitals to publish their commercially negotiated prices. To our knowledge, price variation of spine oncology diagnosis and treatments has not been previously investigated. PURPOSE: The aim of this study is to characterize the availability and variation of prices for spinal oncology services among National Cancer Institute-Designated Cancer Centers (NCI-DCC). STUDY DESIGN: Cross-sectional analysis. METHODS: Cancer centers were identified; those that did not provide patient care or participate in Medicare's Inpatient Prospective System were excluded. A cross-sectional analysis was conducted to gather commercially negotiated prices by searching online for "[center name] price transparency OR machine-readable file OR chargemaster." Data obtained was queried using 44 current procedural terminology (CPT) codes for imaging, procedures, and surgeries relevant to spine oncology. Comparison of prices was achieved by normalizing the median price for each service at each center to the estimated 2022 Medicare reimbursement for the center's Medicare Administrator Contractor. The ratios between the lowest and highest median commercial negotiated price within a center and across all centers were defined as "within-center ratio" and "across-center ratio" respectively. RESULTS: In total, 49 centers disclosed commercial payer-negotiated rates. Mean rate (±SD) for cervical corpectomy was $9,134 (±$10,034), thoracic laminectomy for neoplasm excision was $5,382 (±$5502), superficial bone biopsy was $1,853 (±$1,717), and single-photon emission computerized tomography (SPECT) was $813 (±$232). Within-center ratios ranged from 5.0 (SPECT scan) to 17.8 (radiofrequency bone ablation). Across-center ratios (for codes with > 10 centers reporting) ranged from 9.0 (corpectomy, thoracic, lateral extra-cavitary) to 418.7 (anterior approach cervical corpectomy). CONCLUSIONS: Price transparency for spinal oncology remains elusive despite recent CMS regulatory oversight, with marked heterogeneity in the quality of published rates complicating patients' ability to "shop" for care. Additionally, there continues to be significant variation in commercial rates for spine oncology diagnosis and treatment. CLINICAL SIGNIFICANCE: Despite regulation by CMS, prices for spinal oncology services are not uniformly available to patients and vary between NCI-DCC. The findings of this manuscript present potential barriers for patients to compare and obtain affordable care.

Anterior cervical discectomy and fusion versus cervical disc arthroplasty: an epidemiological review of 433,660 surgical patients from 2011 to 2021.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are commonly performed operations to address cervical radiculopathy and myelopathy. Trends in utilization and revision surgery rates warrant investigation. PURPOSE: To explore the epidemiology, postoperative complications, and reoperation rates of ACDF and CDA DESIGN: Retrospective cohort study. PATIENT SAMPLE: A total of 433,660 patients who underwent ACDF or CDA between 2011 and 2021 were included in this study. OUTCOME MEASURES: The following data were observed for all cases: patient demographics, complications, and revisions. METHODS: The PearlDiver database was queried to identify patients who underwent ACDF and CDA between 2011 and 2021. Epidemiological analyses were performed to examine trends in cervical procedure utilization by age group and year. After matching by age, sex, Charlson Comorbidity Index (CCI), levels of operation, and reason for surgery, the early postoperative (2-week), short-term (2-year), and long-term (5-year) complications of both cervical procedures were examined. RESULTS: In total, 404,195 ACDF and 29,465 CDA patients were included. ACDF utilization rose by 25.25% between 2011 and 2014 while CDA utilization rose by 654.24% between 2011-2019 followed by relative plateauing in both procedures. Mann-Kendall trend test confirmed a significant but small rise in ACDF and large rise in CDA procedures from 2011 to 2021 (p<.001). After matching, ACDF and CDA had an overall complication rate of 12.20% and 8.77%, respectively, with the most common complications being subsequent anterior revision (4.96% and 3.35%) and dysphagia (3.70% and 2.98%). The ACDF cohort, especially multilevel ACDF patients, generally had more complications and higher revision rates than the CDA cohort (p<.05). CONCLUSIONS: While ACDF utilization has plateaued since 2014, CDA rates have risen by a staggering 654.24% over the past decade. ACDF and CDA complication and revision rates were relatively low in comparison to previously published values, with significantly lower rates in CDA. Although a lack of radiographic data in this study limits its power to recommend either procedure for individual patients with cervical radiculopathy or myelopathy, CDA may be associated with minor improvement in the complication and revision profile.

Cannabis use Disorder and Complications After Anterior Cervical Diskectomy and Fusion.

OBJECTIVE: The aim of this study, a retrospective database analysis, was to assess the impact of baseline cannabis use disorder (CUD) on perioperative complication outcomes in patients undergoing primary 1- to 2-level anterior cervical diskectomy and fusion (ACDF) surgery. METHODS: The PearlDiver Database was queried from January 2010 to December 2021 for patients who underwent primary 1- to 2-level ACDF surgery for degenerative spine disease. Patients with CUD diagnosis 6 months before the index ACDF surgery (i.e., CUD) were propensity matched with patients without CUD (i.e., control in a ratio of 1:1, employing age, gender, and Charlson Comorbidity Index as matching covariates). Univariate and multivariable analysis models with adjustment of confounding variables were used to evaluate the risk of CUD on perioperative complications between the propensity-matched cohorts. RESULTS: The 1:1 matched cohort included 838 patients in each group. Following multivariate analysis, CUD was demonstrated to be associated with an increased incidence of hospital readmission at 90 days (odds ratio [OR] = 2.64, 95% confidence interval: [1.19 to 6.78], [P = 0.027]) and revision surgery at 1 year postoperative (OR = 3.36, 95% confidence interval: [1.17 to 14.18], [P = 0.049]). CUD was additionally associated with reduced risk of overall medical complications at both 6 months and 1 year postoperative (OR = 0.55, [P = 0.021], and OR = 0.54, [P = 0.015], respectively). CONCLUSIONS: These findings indicate that isolated baseline CUD is associated with an increased risk of hospital readmission at 90 days postoperative and cervical spine reoperation at 1 year after primary 1- to 2-level ACDF surgery with a decrease in overall medical complications, cardiac arrhythmias, and acute renal failure.

Sagittal Alignment in the Degenerative Lumbar Spine: Surgical Planning.

➤ Sagittal alignment of the spine has gained attention in the field of spinal deformity surgery for decades. However, emerging data support the importance of restoring segmental lumbar lordosis and lumbar spinal shape according to the pelvic morphology when surgically addressing degenerative lumbar pathologies such as degenerative disc disease and spondylolisthesis.➤ The distribution of caudal lordosis (L4-S1) and cranial lordosis (L1-L4) as a percentage of global lordosis varies by pelvic incidence (PI), with cephalad lordosis increasing its contribution to total lordosis as PI increases.➤ Spinal fusion may lead to iatrogenic deformity if performed without attention to lordosis magnitude and location in the lumbar spine.➤ A solid foundation of knowledge with regard to optimal spinal sagittal alignment is beneficial when performing lumbar spinal surgery, and thoughtful planning and execution of lumbar fusions with a focus on alignment may improve patient outcomes.

Segmental Sagittal Alignment in Lumbar Spinal Fusion: A Review of Evidence-Based Evaluation of Preoperative Measurement, Surgical Planning, Intraoperative Execution, and Postoperative Evaluation.

BACKGROUND AND OBJECTIVES: Maintaining and restoring global and regional sagittal alignment is a well-established priority that improves patient outcomes in patients with adult spinal deformity. However, the benefit of restoring segmental (level-by-level) alignment in lumbar fusion for degenerative conditions is not widely agreed on. The purpose of this review was to summarize intraoperative techniques to achieve segmental fixation and the impact of segmental lordosis on patient-reported and surgical outcomes. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed, Embase, Cochrane, and Web of Science databases were queried for the literature reporting lumbar alignment for degenerative lumbar spinal pathology. Reports were assessed for data regarding the impact of intraoperative surgical factors on postoperative segmental sagittal alignment and patient-reported outcome measures. Included studies were further categorized into groups related to patient positioning, fusion and fixation, and interbody device (technique, material, angle, and augmentation). RESULTS: A total of 885 studies were screened, of which 43 met inclusion criteria examining segmental rather than regional or global alignment. Of these, 3 examined patient positioning, 8 examined fusion and fixation, 3 examined case parameters, 26 examined or compared different interbody fusion techniques, 5 examined postoperative patient-reported outcomes, and 3 examined the occurrence of adjacent segment disease. The data support a link between segmental alignment and patient positioning, surgical technique, and adjacent segment disease but have insufficient evidence to support a relationship with patient-reported outcomes, cage subsidence, or pseudoarthrosis. CONCLUSION: This review explores segmental correction's impact on short-segment lumbar fusion outcomes, finding the extent of correction to depend on patient positioning and choice of interbody cage. Notably, inadequate restoration of lumbar lordosis is associated with adjacent segment degeneration. Nevertheless, conclusive evidence linking segmental alignment to patient-reported outcomes, cage subsidence, or pseudoarthrosis remains limited, underscoring the need for future research.

Management of Thoracolumbar Vertebral Fractures and Dislocations in Patients with Ankylosing Conditions of the Spine.

Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are bone-forming spinal conditions which inherently increase spine rigidity and place patients at a higher risk for thoracolumbar fractures. Due to the long lever-arm associated with their pathology, these fractures are frequently unstable and may significantly displace leading to catastrophic neurologic consequences. Operative and non-operative management are considerations in these fractures. However conservative measures including immobilization and bracing are typically reserved for non-displaced or incomplete fractures, or in patients for whom surgery poses a high risk. Thus, first line treatment is often surgery which has historically been an open posterior spinal fusion. Recent techniques such as minimally invasive surgery (MIS) and robotic surgery have shown promising lower complication rates as compared to open techniques, however these methods need to be further validated.