The Importance of Alignment in the Management of Thoracolumbar Trauma.

Spinal injuries occur in 3% of all trauma patients, most commonly in males, and often due to high-velocity impact followed by abrupt deceleration. The most affected region following spinal trauma is the thoracolumbar junction due to the anterior center of gravity at T12-L1 vertebral level and the relatively stiff thoracic spine uniting with the mobile lumbar spine. Many classifications exist to guide the choice of operative versus non-operative management of traumatic injuries at this site. However, the current classifications do not consider the segmental alignment of the spine - an aspect which has been shown to improve quality of life in non-traumatic post-operative spinal patients. Ignoring this aspect of thoracolumbar management often contributes to the development of post-traumatic malalignment and other complications. This review recommends that a new or modified classification system accounts for sagittal segmental alignment factors, including the injured vertebra's level, the number of affected adjacent levels, imaging techniques with better specificity and sensitivity, and assessment for osteoporosis. Case studies are included to demonstrate the importance of segmental sagittal alignment and the vertebral level on patient outcomes.

Impact of Segmental Lordosis Restoration During Degenerative Spinal Fusion on Two-Year Adjacent Segment Disease and Revision Rates.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Assess the impact of inadequate correction of L4-S1 lordosis during transforaminal lumber interbody fusion (TLIF) on adjacent segment disease and revision rates. BACKGROUND: Restoring alignment is an important consideration in spinal fusions. Failure to correct to level-specific alignment goals could promote the development of adjacent segment disease. As such, it is crucial to investigate the role of sagittal segmental alignment on clinical outcomes following short segment lumbar fusion. METHODS: Patients who underwent 1- to 3-level transforaminal lumbar interbody fusion (TLIF) and had two-year outcomes data were included in this retrospective cohort study. Segmental lumbar lordosis was assessed in all patients with L3-L4, L4-L5, and L5-S1 constructs. Demographics, radiographic spinopelvic alignment, and complications were compared in a sub-group of patients fused at L4-S1 with adequate (i.e., within 35-45°) and inadequate (i.e., <35°) L4-S1 lordosis. RESULTS: Among the 168 included patients, mean age was 61.7 years, 56.0% were female, and mean follow-up was 32.3 months. Segmental lumbar lordosis did not change significantly after TLIF of L3-L4, L4-L5, or L5-S1 (P>0.05). Two-year postoperatively, 32.7% developed adjacent segment disease and 19.6% underwent revisions. After stratification by adequate (N=15) or inadequate (N=54) restoration of L4-S1 lordosis following initial TLIF surgery, adequately-restored patients had higher preoperative L4-S1 lordosis (Adequately-Restored=39.3° vs Inadequately-Restored=29.5°, P<0.001) and lower two-year postoperative adjacent segment disease (6.7% vs. 33.3%, P=0.032) and revision (5.7% vs. 25.9%, P=0.l33) rates. Adjacent segment disease patients had higher implant-related complications (Adjacent Segment Disease=36.8% vs No Adjacent Segment Disease=8.0%, P=0.008) and subsequent revisions (61.1% vs. 8.7%, P<0.001). CONCLUSIONS: Adjacent segment disease and revisions after degenerative lumbar spinal fusion are common. In this cohort, suboptimal restoration of L4-S1 lordosis was associated with higher rates of adjacent segment disease and subsequent revisions, thus highlighting the importance of restoring sagittal alignment in degenerative spine surgery. LEVEL OF EVIDENCE: III.

Epidemiology of Lumbar Spine Fractures: Twenty-Year Assessment of Nationwide Emergency Department Visit Data.

BACKGROUND: Lumbar spine fractures are common injuries associated with substantial morbidity for patients and socioeconomic burden. This study sought to epidemiologically analyze lumbar spine fractures by mechanism of injury and identify temporal trends in patient demographics and disposition, which few studies have previously evaluated. MATERIALS AND METHODS: A retrospective analysis was done of the US National Electronic Injury Surveillance System (NEISS) database between 2003 and 2022. The sample contained all patients 2 to 101 years old with product-related lumbar fractures presenting to participating institutions' emergency departments. A total of 15,196 unweighted injuries (642,979 weighted injuries) were recorded. RESULTS: Overall, there was a 20-year incidence rate of 10.14 cases per 100,000 person-years with a 2-fold increase in fracture incidence. Females were more prone to lumbar fracture than males (P=.032). Injuries primarily stemmed from a fall (76.6%). The incidence of lumbar fracture increased most significantly in older patients, with patients 80 years and older showing the greatest annual increase (ß=8.771, R2=0.7439, P<.001) and patients 60 to 69 years showing the greatest percent increase with a 3.24-fold increase in incidence. Most (58.9%) of the fractures occurred at home. Females were more often injured at home compared with males (P<.001), who more often sustained lumbar fractures during recreational or athletic activity (P<.001). All patients older than 40 years showed at least a doubling in incidence rate of lumbar fracture between 2003 and 2022. CONCLUSION: These data demonstrate the pressing need to address poor bone health in the aging population, shown here to have an increasing fracture burden. [Orthopedics. 202x;4x(x):xx-xx.].

Spinal deformity surgery in Scheuermann's kyphosis versus adolescent idiopathic scoliosis: meta-analysis of complications and clinical outcomes.

BACKGROUND: Surgical management of adolescent idiopathic scoliosis (AIS) and Scheuermann's kyphosis (SK) may be associated with several complications including extended length of stay and unplanned reoperations. Several studies have previously compared postoperative complications and functional outcomes for AIS and SK patients with mixed results. However, a meta-analysis compiling the literature on this topic is lacking. METHODS: Following the PRISMA guidelines, PubMed, Cochrane, and Google Scholar (pages 1-20) were accessed and explored until April 2024. The extracted data consisted of complications (overall and surgical-site infections [SSI]), readmissions, reoperations, and Scoliosis Research Society-22 (SRS-22) score. Mean differences (MD) with 95% CI were used for continuous data and odds ratio (OR) was utilized for dichotomous data were calculated across studies. RESULTS: Seven retrospective articles were included in the meta-analysis, including 4866 patients, with 399 in the SK group and 4467 in the AIS group. SK patients were found to have statistically significantly higher rates of overall complications (OR = 5.41; 95% CI 3.69-7.93, p < .001), SSI (OR = 11.30; 95% CI 6.14-20.82, p < .001), readmissions (OR = 2.81; 95% CI 1.21-6.53, p = 0.02), and reoperations (OR = 7.40; 95% CI 4.76-11.51, p < .001) than AIS patients. However, they had similar SRS-22 scores postoperatively (MD = -0.06; 95% CI -0.16 to 0.04, p = 0.26) despite the SK group having lower SRS-22 scores preoperatively (MD = -0.30; 95% CI -0.42 to -0.18, p < .001). CONCLUSION: In this meta-analysis of studies comparing spinal deformity surgery outcomes in AIS and SK patients, SK was associated with more complications, readmissions, and reoperations. SK did have equivalent SRS-22 scores postoperatively to AIS patients, highlighting the benefit of surgical treatment despite higher complication rates. This data may help inform healthcare institutions, payors, and quality monitoring organizations who examine outcomes of pediatric and adult spinal deformity surgery.

Postoperative Delirium Following Posterior Lumbar Spinal Fusion: Epidemiology, Risk Factors, and Associated Complications.

BACKGROUND: Postoperative delirium (POD) is frequently reported in the elderly after major surgery. Several risk factors have been identified, including age, surgical complexity, and comorbidities. METHODS: Posterior lumbar fusion patients were identified using PearlDiver and filtered into two cohorts based on presence or absence of POD within 7 days of surgery. Epidemiological analyses were performed to examine trends in POD by age and year. Comparative analyses were performed on patient demographics and baseline cognitive status. After matching by age, sex, and comorbidities, electrolyte disturbances and 90-day postoperative complications were analyzed. RESULTS: Among 476,482 no POD and 2,591 POD patients, mean age was 60.90 years, 57.6% were female, and mean CCI was 1.78. POD patients frequently had baseline cognitive impairment (p<0.001). Incidence of POD decreased from 0.7% in 2010 to 0.4% in 2022 (p<0.001) and increased with increasing patient age (p<0.001). POD patients had higher length of stay (12 vs 6 days, p<0.001) and 90-day costs ($20,605 vs $17,849, p<0.001). After matching, POD patients had higher hypernatremia (5.8% vs 3.5%, p=0.001) and hypocalcemia (5.0% vs 3.5%, p=0.026). POD patients had higher 90-day postoperative complications (p<0.05) than no POD patients. CONCLUSION: Nearly 0.5% of patients who underwent posterior spinal fusion between 2010-2022 developed delirium, although incidence rates have decreased over time. POD was common in elderly patients with electrolyte disturbances who underwent multi-level fusions. Patients suffering from POD had higher rates of 90-day postoperative complications. Ongoing efforts to deliver interventions to mitigate the consequences of POD among spine surgery patients are warranted.

Rheumatoid arthritis is associated with higher 90-day systemic complications compared to osteoarthritis after total shoulder arthroplasty: a cohort study.

BACKGROUND: Total shoulder arthroplasty (TSA) in patients with rheumatoid arthritis (RA) can present unique challenges. The aim of this study was to compare both systemic and joint-related postoperative complications in patients undergoing primary TSA with RA versus those with primary osteoarthritis (OA). METHODS: Using the TriNetX database, Current Procedural Terminology and International Classification of Diseases, 10th edition codes were used to identify patients who underwent primary TSA. Patients were categorized into two cohorts: RA and OA. After 1:1 propensity score matching, postoperative systemic complications within 90 days following primary TSA and joint-related complications within 5 years following anatomic TSA (aTSA) and reverse shoulder arthroplasty (RSA) were compared. RESULTS: After propensity score matching, the RA and OA cohorts each consisted of 8,523 patients. Within 90 days postoperation, RA patients had a significantly higher risk of total complications, deep surgical site infection, wound dehiscence, pneumonia, myocardial infarction, acute renal failure, urinary tract infection, mortality, and readmission compared to the OA cohort. RA patients had a significantly greater risk of periprosthetic joint infection and prosthetic dislocation within 5 years following aTSA and RSA, and a greater risk of scapular fractures following RSA. Among RA patients, RSA had a significantly higher risk of prosthetic dislocation, scapular fractures, and revision compared to aTSA. CONCLUSIONS: Following TSA, RA patients should be considered at higher risk of systemic and joint-related complications compared to patients with primary OA. Knowledge of the risk profile of RA patients undergoing TSA is essential for appropriate patient counseling and education. Level of evidence: III.

The impact of mental health on shoulder arthroplasty and rotator cuff repair: a meta-analysis.

BACKGROUND: The aim of this study was to evaluate the impact of mental health attributes, such as the presence of psychiatric comorbidities or psychological comorbidities (low resilience), on outcomes after rotator cuff repair (RCR) and total shoulder arthroplasty (TSA). METHODS: PubMed, Cochrane, and Google Scholar (results pages 1-20) were searched up to November 2023. Mental health problems of interest included the presence of psychiatric comorbidities (depression, anxiety) or indicators of poor psychological functioning, such as low resilience or the presence of distress. Patients were assigned to poor or good mental health groups in this study based on their grouping in the original study. RESULTS: Fourteen studies were included in the meta-analysis. Patients with good mental health had greater improvements in postoperative American Shoulder and Elbow Surgeons and Simple Shoulder Test scores in the TSA cohort (P=0.003 and P=0.01), RCR cohort (P<0.001), and the combined TSA and RCR cohort (P<0.001). No difference was found in visual analog scale score, satisfaction, external rotation, or flexion between the two mental health groups. Patients with poor mental health undergoing RCR experienced higher rates of adverse events and transfusions (P<0.001). Patients with poor mental health also had greater rates of revision and emergency department visits in the TSA cohort (P<0.001), RCR cohort (P=0.05 and P=0.03), and combined cohort (P<0.001). Patients with poor mental health undergoing TSA had a higher rate of re-admission (P<0.001). CONCLUSIONS: Patients with poor preoperative mental health showed inferior patient-reported outcome scores and increased rates of adverse events, revisions, and re-admissions. Level of evidence: III.

Patient-reported Physical and Mental Health Outcomes Following Lumbar Spinal Fusion versus Total Hip and Total Knee Replacement.

BACKGROUND: Total hip and knee arthroplasty (THA/TKA) are reliable surgical procedures for alleviating pain and optimizing function. Spinal fusion has also been shown to be beneficial, however the comparative benefit of THA/TKA to lumbar spinal fusion is incompletely understood. METHODS: This study analyzed a single-center database of patients who underwent primary lumbar spinal fusion, elective primary TKA, or THA. Patient-reported outcome measures (PROMs) included Veterans-Rand (VR12) Physical and Mental Component Score (PCS/MCS) for TKA/THA and PROMIS (Patient-Reported Outcomes Measurement Information System) Global Mental and Physical Health (GPH/GMH) for spinal fusion. RESULTS: A total of 356 patients who underwent TKA, 290 who underwent THA, and 125 who underwent spinal fusion were included. Joint replacement patients were older, with higher body mass index in the TKA group. Spine patients had a lower improvement in physical health than the joint patients (TKA: 9.4 ± 11.2, THA: 15.2 ± 11.2, Spine: 6.2 ± 8.7, P < 0.001) and a lower proportion of patients reaching the minimal clinically important difference (MCID). Spine patients had higher GMH improvements compared with TKA patients (TKA: -1.1 ± 10.7, THA: 1.1 ± 11.9, Spine: 1.8 ± 8.4, P = 0.009) and the highest proportion of patients reaching the MCID. CONCLUSIONS: Spinal fusion, total knee arthroplasty, and total hip arthroplasty all significantly improved PROMs at 1-year follow-up. At baseline, spinal fusion patients had better physical function scores and worse mental health scores compared with joint arthroplasty patients, while spinal fusion resulted in mean smaller gains in patient reported physical function and higher gains in patient reported mental health function compared with arthroplasty.

Hip Labral Repair versus Reconstruction: Meta-analysis.

The purpose of this meta-analysis is to compare the postoperative outcomes and complications of labral repair with those of labral reconstruction. An electronic search strategy was conducted from 1986 until August 2023 using the following databases: PubMed, Cochrane, and Google Scholar (pages 1-20). The primary objectives included the postoperative clinical outcomes determined by the number of patients who reached minimal clinical important difference (MCID) on the visual analog scale (VAS), modified Harris hip score (mHHS), Hip Outcome Score-Sports Subscale (HOS-SS), Hip Outcome Score-Activities of Daily Life (HOS-ADL), and International Hip Outcome Tool-12 (iHOT-12). In addition, analysis of the rate of revision arthroscopy, the rate of conversion to total hip arthroplasty (THA), the postoperative VAS, mHHS, HOS-SS, HOS-ADL, iHOT-12, nonarthritic hip score (NAHS), patient satisfaction, lower extremity function scale (LEFS), and the SF-12 (12-item shortform) was also performed. Any differences arising between the investigators were resolved by discussion. Seventeen studies were relevant to the inclusion criteria and were included in this meta-analysis. A higher rate of patients who reached MCID in the mHHS (P=0.02) as well as a higher rate of revision arthroscopy was observed for labral repair (P=0.03). The remaining studied outcomes were comparable. Despite the greater predictability of success in the reconstruction group, conduct of additional studies will be required for evaluation of the benefits of such findings. In addition, labral reconstruction is more technically demanding than a labral repair.

Lumbar Spondylolisthesis Grading: Current Standards and Important Factors to Consider for Management.

Spondylolisthesis is a common condition with a prevalence of 4-6% in childhood and 5-10% in adulthood. The Meyerding Classification, developed in 1932, assigns grades (I to V) based on the degree of slippage observed on standing, neutral lateral lumbar radiographs. Despite its historical significance and reliability, more factors should be evaluated to predict spondylolisthesis progression, especially in low-grade cases. The manuscript highlights areas for improvement in spondylolisthesis classification, emphasizing the need for considering factors beyond vertebral slippage. Factors such as global and segmental alignment, pelvic incidence, overhang, the number of affected levels, and the use of lateral flexion-extension radiographs to assess for stability using the kyphotic angle and slippage degree are identified as crucial in predicting progression and determining effective management strategies.

The role of vitamin D in shoulder health: a comprehensive review of its impact on rotator cuff tears and surgical results.

Vitamin D deficiency is highly prevalent in the general population and is associated with various chronic health conditions. In addition to its role in bone mineralization, Vitamin D has various physiological effects that may impact the pathogenesis of shoulder pathologies. Vitamin D deficiency may also affect outcomes after shoulder surgeries, such as rotator cuff repair and total shoulder arthroplasty. Vitamin D plays a role in tissue healing, bone growth, and maintenance of homeostasis in skeletal muscle cells. Vitamin D also has anti-inflammatory effects that are important to rotator cuff health. Vitamin D deficiency is highly prevalent in patients with rotator cuff tears, suggesting its role as a potential risk factor. Vitamin D deficiency has been associated with decreased preoperative shoulder strength as well as increased re-tear rates, postoperative stiffness, and the need for revision surgery in patients who underwent rotator cuff repair. Studies have also demonstrated a potential association between vitamin D deficiency and increased risk of revision after total shoulder arthroplasty. Further research is necessary to elucidate the direct role of vitamin D in the pathogenesis of rotator cuff tears and its impact on clinical outcomes after rotator cuff surgery and total shoulder arthroplasty.

Reverse Versus Anatomic Total Shoulder Arthroplasty for Glenohumeral Osteoarthritis with Intact Cuff: A Meta-Analysis of Clinical Outcomes.

BACKGROUND: Anatomic and reverse shoulder arthroplasty (TSA, RSA) have surged in popularity in recent years. While RSA is Food and Drug Administration (FDA) approved for cases of rotator cuff tear arthropathy, indications have expanded to include, among others, primary glenohumeral osteoarthritis (GHOA). METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) were queried through November 2023. Inclusion criteria consisted of studies that compared the utility of TSA to that of RSA for the treatment of GHOA with intact rotator cuff with respect to adverse events, patient-reported outcomes, and range of motion. The ROBINS-I tool was used to assess the risk of bias in the included non-randomized studies, and Review Manager 5.4 was used for statistical analysis. P-values <0.05 were deemed significant. RESULTS: Fourteen studies met the above inclusion criteria. Twelve studies reported adverse outcomes, with the RSA group having a lower rate of complications (odds-ratio=0.54, p=0.004) and reoperations (odds-ratio=0.31, p<.001) relative to TSA at an average follow-up of 3.4 years. Four studies reported SPADI and UCLA scores, while five reported SST scores. These studies showed superior SPADI (p=0.040), UCLA(p=0.006), and SST(p=0.040) scores among the RSA group. No significant differences were seen with regards to other patient reported outcomes. Ten studies reported on range of motion, and the RSA group had a significantly lower external rotation relative to the TSA group (p<.001) while other range of motion parameters did not show statistically significant differences. CONCLUSION: The present study provides support for RSA as a reasonable surgical option for patients with GHOA and an intact rotator cuff, with lower rates of adverse events and better outcomes relative to TSA, although at the expense of decreased external rotation. Patient education and counseling is key in order to decide optimal treatment as part of a shared decision-making process, as well as setting appropriate expectations.

ChatGPT: A concise Google alternative for people seeking accurate and comprehensive carpal tunnel syndrome information.

Popular artificial intelligence systems, like ChatGPT, may be used by anyone to generate humanlike answers to questions. This study assessed whether ChatGPT version 3.5 (ChatGPTv3.5) or the first five results from a Google search provide more accurate, complete, and concise answers to the most common questions patients have about carpal tunnel syndrome. Three orthopedic hand surgeons blindly graded the answers using Likert scales to assess accuracy, completeness, and conciseness. ChatGPTv3.5 and the first five Google results provide answers to carpal tunnel syndrome questions that are similar in accuracy and completeness, but ChatGPTv3.5 answers are more concise. ChatGPTv3.5, being freely accessible to the public, is therefore a good resource for patients seeking concise, Google-equivalent answers to specific medical questions regarding carpal tunnel syndrome. ChatGPTv3.5, given its lack of updated sourcing and risk of presenting false information, should not replace frequently updated academic websites as the primary online medical resource for patients.

Impact of Prior Cervical Fusion on Patients Undergoing Thoracolumbar Deformity Correction.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: Evaluate the impact of prior cervical constructs on upper instrumented vertebrae (UIV) selection and postoperative outcomes among patients undergoing thoracolumbar deformity correction. BACKGROUND: Surgical planning for adult spinal deformity (ASD) patients involves consideration of spinal alignment and existing fusion constructs. METHODS: ASD patients with (ANTERIOR or POSTERIOR) and without (NONE) prior cervical fusion who underwent thoracolumbar fusion were included. Demographics, radiographic alignment, patient-reported outcome measures (PROMs), and complications were compared. Univariate and multivariate analyses were performed on POSTERIOR patients to identify parameters predictive of UIV choice and to evaluate postoperative outcomes impacted by UIV selection. RESULTS: Among 542 patients, with 446 NONE, 72 ANTERIOR, and 24 POSTERIOR patients, mean age was 64.4 years and 432 (80%) were female. Cervical fusion patients had worse preoperative cervical and lumbosacral deformity, and PROMs (P<0.05). In the POSTERIOR cohort, preoperative LIV was frequently below the cervicothoracic junction (54%) and uncommonly (13%) connected to the thoracolumbar UIV. Multivariate analyses revealed that higher preoperative cervical SVA (coeff=-0.22, 95%CI=-0.43--0.01, P=0.038) and C2SPi (coeff=-0.72, 95%CI=-1.36--0.07, P=0.031), and lower preoperative thoracic kyphosis (coeff=0.14, 95%CI=0.01-0.28, P=0.040) and thoracolumbar lordosis (coeff=0.22, 95%CI=0.10-0.33, P=0.001) were predictive of cranial UIV. Two-year postoperatively, cervical patients continued to have worse cervical deformity and PROMs (P<0.05) but had comparable postoperative complications. Choice of thoracolumbar UIV below or above T6, as well as the number of unfused levels between constructs, did not affect patient outcomes. CONCLUSIONS: Among patients who underwent thoracolumbar deformity correction, prior cervical fusion was associated with more severe spinopelvic deformity and PROMs preoperatively. The choice of thoracolumbar UIV was strongly predicted by their baseline cervical and thoracolumbar alignment. Despite their poor preoperative condition, these patients still experienced significant improvements in their thoracolumbar alignment and PROMs after surgery, irrespective of UIV selection. LEVEL OF EVIDENCE: IV.

Enamel Deproteinization or Sandblasting for Enamel Reconditioning Before Acid Etching to Enhance the Shear Bond Strength of Metallic Brackets in a Third Bonding: An In Vitro Study.

BACKGROUND: Enamel conditioning with 37% phosphoric acid is the most common technique during orthodontic bracket bonding procedures. However, due to the repeated de-bonding of the orthodontic brackets during treatment, other methods were needed to condition the enamel surface and increase the bond strength. This study aimed to compare the effect of conditioning the enamel surface by sandblasting with aluminum oxide particles or 5.25% sodium hypochlorite gel in combination with acid etching compared to acid etching alone on shear bond strength (SBS). MATERIAL AND METHODS: One hundred eight extracted upper premolars were randomly divided into three groups according to the conditioning enamel surface method. After the first and second bonding of metal brackets, new metal brackets were bonded with a total-etching adhesive after enamel conditioning using different methods: acid etching only (37% phosphoric acid for 30 seconds) (AE group), sodium hypochlorite associated with acid etching (5.25% NaOCl gel for 60 seconds and then acid etching for 30 seconds) (NaOCl-AE group), and sandblasting associated with acid etching (sandblasting for five seconds and then acid etching for 30 seconds) (SB-AE group). The shear bond strengths of the brackets were tested with a universal testing machine. One-way analysis of variance (ANOVA) and Tukey's honestly significant difference (HSD) tests were used to detect significant differences in shear bond strength among groups at the third bonding. Repeated-measure ANOVA and Bonferroni's tests were used to detect significant differences in shear bond strength among the bonding attempts within each group. RESULTS: 5.25% sodium hypochlorite associated with the acid etching method produced significantly greater shear bond strength than sandblasting associated with acid etching and acid etching only methods at the third bonding (16.40 ± 5.80 MPa, 13.60.47 ± 6.40 MPa, and 9.90 ± 4.40 MPa, respectively; P < 0.001). However, there was no significant difference between the AE and SB-AE groups (P = 0.247). In addition, we found a significant decrease in the shear bond strength within each group after each bonding attempt. CONCLUSION: Conditioning the enamel surface with 5.25% sodium hypochlorite associated with acid etching produced greater bond strength than conditioning by sandblasting associated with acid etching and acid etching only at the third bonding. The bond strength of the metal bracket decreased with increasing bonding attempts, even with the application of enamel surface conditioning methods.

Crossing the Cervicothoracic Junction: A Biomechanical Investigation of C7 vs T1 Caudal Selection's Effect on Adjacent Segment Motion in Posterior Cervical Fusion.

STUDY DESIGN: Biomechanical Study. OBJECTIVE: This study aims to evaluate the biomechanical adjacent segment effects of multi-level posterior cervical fusion constructs that terminate at C7 compared to those that terminate at T1 in cadaveric specimens. BACKGROUND: The cervicothoracic junction poses unique challenges for spine surgeons. Deciding to terminate multi-level posterior cervical fusion constructs at C7 or extend them across the cervicothoracic junction remains a controversial issue. METHODS: Six cadaveric specimens underwent biomechanical testing in the intact state and after instrumentation with constructs from C3 and terminating at either C7 or T1. Range of motion (ROM) was assessed in flexion-extension, lateral bending, and axial rotation globally and at cranial and caudal adjacent segments. RESULTS: There was a significant decrease in overall flexion/extension by both C7 (-35.5°, P=0.002) and T1 (-39.8°, P=0.002) instrumentation compared to the intact spine. T1 instrumentation had significantly lower (-4.3°, P=0.008) flexion/extension ROM compared to C7 instrumentation. There were significant decreases in axial rotation by both C7 (-31.4°, P=0.009) and T1 (-36.8°, P=0.009) instrumentation compared to the intact spine, but no significant differences were observed between the two. There were also significant decreases in lateral bending by both C7 (-27.9°, P=0.022) and T1 (-33.7°, P=0.022) instrumentation compared to the intact spine, but no significant differences were observed between the two. No significant differences were observed in ROM at cranial or caudal adjacent segments between constructs terminating at C7 and those extending to T1. CONCLUSION: This biomechanical investigation demonstrates that constructs that cross the cervicothoracic junction experience less overall spinal motion in flexion-extension compared to those that terminate at C7. However, contrary to prior studies there is no difference in cranial and caudal adjacent segment motion. Surgeons should make clinical decisions regarding the caudal extent of fusion in multi-level posterior cervical fusions without major concerns about adjacent segment motion.

Sagittal spinal alignment measurements and evaluation: Historical perspective.

Spinal alignment analysis play an important role in evaluating patients and planning surgical corrections for adult spinal deformity. The history of these parameters is relatively short with the first parameter, the Cobb angle, introduced in 1948 as part of an effort to improve scoliosis evaluation. New developments in the field were limited for nearly 30 years before better imaging technology encouraged new theories and later data about spinal alignment and the relationship between the spine and pelvis. These efforts would ultimately contribute to the creation of foundational spinal alignment parameters, including pelvic incidence, pelvic tilt, and sacral slope. By the 1990s, spinal alignment had become a sustained area of investigation for spinal surgeons and researchers. Novel alignment parameters have since been introduced as our knowledge has evolved and has allowed for valuable research that demonstrates the clinical and surgical value of alignment measurement. This manuscript will explore the history of spinal alignment analysis over the decades.

Untwining the intertwined: a comprehensive review on differentiating pathologies of the shoulder and spine.

Background: The anatomic interplay and overlap between the cervical spine and the shoulder constitutes a challenge for shoulder and spine surgeons, as symptoms of spine and shoulder pathologies are often similar and may lead to entity misdiagnosis. Methods: PubMed, Cochrane, and Google Scholar (page 1-20) searches were updated to October 2023 in search of the qualified papers. Boolean Operators were used with a combination of the keywords "spine" OR "neck" And "Shoulder". Furthermore, reference lists from papers were also searched to find literature. Results: It is of pivotal importance to conduct comprehensive preoperative clinical investigation to appropriately evaluate and assess the source of the pathology and the leading causes behind it. Certain markers can help guide surgeons towards etiologies, and these include areas of pain and physical exam findings with the arm squeeze test having the highest sensitivity and specificity for diagnosing cervical radiculopathy. As for the shoulder, despite its low sensitivity, the Yergason test had the highest specificity for diagnosing subacromial impingement. Local anesthetic injection can help as well in the diagnostic approach. Moreover, the interplay between these anatomic locations is not solely related to preoperative diagnosis. Studies have shown that previous surgery for cervical spine pathology may negatively affect the outcomes of shoulder procedures like arthroplasties. Conclusion: Shoulder and spine surgeons should be wary and vigilant of accurately diagnosing the etiology of the presenting symptoms to ensure proper management and optimize prognosis.

Antegrade vs Retrograde Intra-Medullary Nailing in Femoral Shaft Fractures: A Systematic Review and Meta-Analysis.

Objectives: Femoral shaft fractures are one of the most prevalent fractures found in clinical practice. Numerous operative and non-operative options are readily available for the treatment of such fractures with intra-medullary nailing being the gold standard. To date, no consensus has been reached favoring one approach over the other. Thus, this meta-analysis aims to compare the outcomes between an antegrade and retrograde intra-medullary nailing for the treatment of femoral shaft fractures. Methods: PubMed, Cochrane, Google Scholar (page 1-20), and Embase were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, reoperations, hip and knee pain, and surgery-related parameters. Results: Higher rates of hip pain, and heterotopic ossification (p=0.0003, and p=0.0002 respectively) was observed with antegrade nailing. However, a higher rate of knee pain (p=0.02) was appreciated in retrograde nailing. There was no statistically significant difference in the remaining analyzed outcomes such as operative time, reoperation rate or other complications. Conclusion: Despite a higher rate of heterotopic ossification using the antegrade nailing technique, both the antegrade and retrograde nailing techniques yield overall similar outcomes. Therefore, the decision to choose one or the other should be based on patient-related factors, and the surgeon's experience and preference.