Be a Lighthouse for Your Medical Students: How to Help Them Navigate During Changing Times to a Successful Match.

The transition between medical school and residency is a complex, multifaceted process that is commonly a time of stress and uncertainty for medical students. Occupying most of a student's final year of medical school, the residency application includes a primary Electronic Residency Application Service application, a variable number of program-specific secondary applications, and interviews. The application process culminates with The Match. Orthopaedic surgery is among the more competitive specialties; thus, it is critical that all involved parties understand the complexity of the process and the numerous variables that play into such a critical decision point in the career trajectory of a future physician. It is important to provide a mentor with an overview of the residency application process, specifically with respect to orthopaedic surgery, so that they may be best prepared to guide their medical student mentee through the process and help them find success.

Pharmacotherapies to prevent epidural fibrosis after laminectomy: a systematic review of in vitro and in vivo animal models.

BACKGROUND CONTEXT: Excessive production of epidural fibrosis in the nerve root can be a pain source after laminectomy. Pharmacotherapy is a minimally invasive treatment option to attenuate epidural fibrosis by suppressing proliferation and activation of fibroblasts, inflammation, and angiogenesis, and inducing apoptosis. PURPOSE: We reviewed and tabulated pharmaceuticals with their respective signaling axes implicated in reducing epidural fibrosis. Additionally, we summarized current literature for the feasibility of novel biologics and microRNA to lessen epidural fibrosis. STUDY DESIGN/SETTING: Systematic Review. METHODS: According to the PRISMA guidelines, we systematically reviewed the literature in October 2022. The exclusion criteria included duplicates, nonrelevant articles, and insufficient detail of drug mechanism. RESULTS: We obtained a total of 2,499 articles from PubMed and Embase databases. After screening the articles, 74 articles were finally selected for the systematic review and classified based on the functions of drugs and microRNAs which included inhibition of fibroblast proliferation and activation, pro-apoptosis, anti-inflammation, and antiangiogenesis. In addition, we summarized various pathways to prevent epidural fibrosis. CONCLUSION: This study allows a comprehensive review of pharmacotherapies to prevent epidural fibrosis during laminectomy. CLINICAL SIGNIFICANCE: We expect that our review would enable researchers and clinicians to better understand the mechanism of anti-fibrosis drugs for the clinical application of epidural fibrosis therapies.

Chemoprophylaxis Timing Is Not Associated With Postoperative Bleeding After Spinal Trauma Surgery.

BACKGROUND: Little is known regarding appropriate timing for chemical venous thromboembolism (VTE) prophylaxis initiation in operative traumatic spinal injuries. We hypothesized that the incidence of post-operative bleeding leading to neurological decline or re-operation would not increase in patients who received early VTE prophylaxis (≤2 days post-surgery) as compared to those who received late VTE prophylaxis (≥ 3 days post-surgery). METHODS: This is a retrospective cohort study. Spine trauma patients who underwent spinal surgery, defined as anterior cervical discectomy and fusion, posterior cervical spinal fusion, anterior or posterior thoracic/lumbar spinal fusion, or vertebral percutaneous fixation from July 2015 to July 2020 were included. Demographics, pre-injury anti-thrombotics, operative characteristics, pre- and post-operative VTE prophylaxis, and post-operative complications, including spinal bleeding, and VTE were collected. Univariate analysis was performed, comparing baseline characteristics, VTE prophylaxis timing, and complications between the early and late groups. RESULTS: Two-hundred-eighty-two patients were included; 189 were in the early group (1.7 ± 0.5 days), and 93 were in the late (4.4 ± 2.1 days) group. The late group received enoxaparin more often than patients in the early group (41.9 % vs. 19 %, p < 0.001). Baseline characteristics, hospital course, and surgical management were similar between the groups. The rate of post-operative complications, including hematoma and VTE was similar between the groups. None of the patients in the early group had post-operative bleeding. CONCLUSION: In this retrospective cohort study, VTE prophylaxis timing was not associated with clinically significant post-operative spinal bleeding and VTE in trauma patients.

Risk factors for delirium in elderly patients after lumbar spinal fusion.

OBJECTIVE: To identify perioperative risk factors for postoperative delirium (POD) in patients aged 65 or older undergoing lumbar spinal fusion procedures. PATIENTS AND METHODS: A retrospective cohort analysis was performed on patients undergoing lumbar spinal fusion over an approximately three-year period at a single institution. Demographic and perioperative data were obtained from electronic medical records. The primary outcome was the presence of postoperative delirium assayed by the Delirium Observation Screening Scale (DOSS) and Confusion Assessment Method for the ICU (CAM-ICU). Univariate and multivariate analyses were performed on the data. RESULTS: Of the 702 patients included in the study, 173 (24.6%) developed POD. Our analysis revealed that older age (p < 0.001), lower preoperative hemoglobin (p < 0.001), and higher ASA status (p < 0.001), were significant preoperative risk factors for developing POD. The only significant intraoperative risk factor was a higher number of spinal levels that were instrumented (p < 0.001). Higher pain scores on postoperative day 1 (p < 0.001), and lower postoperative hemoglobin (p < 0.001) were associated with increased POD; as were ICU admission (p < 0.001) and increased length of ICU stay (p < 0.001). Patients who developed POD had a longer hospital stay (p < 0.001) with lower rates of discharge to home as opposed to an inpatient facility (p < 0.001). CONCLUSION: Risk factors for POD in older adults undergoing lumbar spinal fusion surgery include advanced age, diabetes, lower preoperative and postoperative hemoglobin, higher ASA grade, greater extent of surgery, and higher postoperative pain scores. Patients with delirium had a higher incidence of postoperative ICU admission, increased length of stay, decreased likelihood of discharge to home and increased mortality, all consistent with prior studies. Further studies may determine whether adequate management of anemia and pain lead to a reduction in the incidence of postoperative delirium in these patients.

Patient specific predictive factors of vertebral artery injury following blunt cervical spine trauma.

OBJECTIVE: Determine patient and injury characteristics predictive of vascular injury (VAI) in blunt cervical spine (BCS) trauma to identify high-risk patients and propose an alternative screening protocol. METHODS: Patients presenting between 2014 and 2018 with BCS injury and cervical spine CT imaging were included. Demographics and injury characteristics of BCS injuries were collected. Univariate and multivariate analyses to determine risk factors for VAI were performed. Once factors associated with greater odds of VAI were identified, this information was used to create an alternative protocol for indicating CTA in patients who sustained BCS injury. RESULTS: A total of 475 patients were included. CTA of the neck was performed in 55.5% patients. In patients who received CTA, 18.2% had a contraindication to receiving anti-platelet therapy, and 25% were already receiving anti-coagulation therapy as an outpatient medication. VAI was found in 13.2% patients. In patients with VAI, 48.5% were already receiving anti-coagulation as outpatient medication. Acute kidney injury was found in 10.5% patients who had received CTA. Factors associated with greater odds of having VAI included transverse foramen involvement(p = 0.0001), subluxation/displacement/dislocation of fracture(p = 0.03), high energy mechanism(p = 0.02), SLIC score > 4(p = 0.04), and concomitant lumbar spine injury(p = 0.03). Using Modified Hawkeye Protocol, 40.2% of patients were indicated to receive a CTA, and 17 VAI were identified. Compared to Denver Criteria, CTAs were performed in 73 less patients(p = 0.04). CONCLUSIONS: Updated protocols utilizing evidence-based clinical parameters to predict chance of VAI may avoid unnecessary advanced imaging and contrast load to patients in the setting of BCS trauma.

Intraoperative Spinal Cord Monitoring Does Not Decrease New Postoperative Neurological Deficits in Patients With Cervical Radiculopathy or Spondylotic Myelopathy Undergoing One or Two Level Anterior Cervical Discectomy And Fusion.

BACKGROUND: Intraoperative neurological monitoring (IONM) is commonly used in spine surgery. However, the utility of IONM in anterior cervical decompression and fusion (ACDF) remains a topic of debate. The purpose of the study was to investigate the utility and cost of IONM (both Somatosensory evoked potentials (SSEPs) and Motor Evoked Potentials (Tc-MEPs)) in reducing postoperative neurological deficits in myelopathic and non-myelopathic patients undergoing ACDF. METHODS: Retrospective chart review was performed to include only patients with cervical radiculopathy or myelopathy undergoing one or two level ACDF over a 7-year period at a busy academic center. SSEP and Tc-MEP tracings were reviewed for all monitored patients and significant changes and inconsistencies were noted. IONM billing codes (SSEP/Tc-MEP) were reviewed and summed to evaluate the average procedural cost. Medical records were reviewed for preoperative physical exam and for new postoperative neurological deficits on postoperative day one and again at six weeks and matched to the monitored tracings. RESULTS: There were 249 total patients (48 Non-monitored, 201 monitored). There was no difference in gender, age, or BMI between monitored and non-monitored groups. There was no difference in new neurological deficits in monitored compared with non-monitored patients with radiculopathy (p=0.1935) or myelopathy (p=0.1977). However, when radiculopathy and myelopathy patients were combined, there was an increased incidence of new neurologic deficits in monitored patients (8.0%) versus non-monitored patients (0%) (p=0.0830). All new neurological deficits occurred in patients with normal IONM tracings. There were no new neurologic deficits in the non-monitored radiculopathy or myelopathy groups. The average IONM procedure charge was $6500. CONCLUSION: Our results indicate that intraoperative spinal cord monitoring did not reduce new neurological deficits in our cohort of patients. The higher incidence in new neurological deficits despite no IONM changes in our monitored group suggests a lack of utility of IONM in ACDF. Furthermore, at an average of $6500 per IONM procedure, the present study underlines the importance of prudence when choosing to use IONM in the era of cost containment.Level of Evidence: III.

Complete spinal cord injury following computed tomography-guided biopsy of the thoracic spine: A case report.

Computed tomography-guided spine biopsy is a routine procedure in diagnosing vertebral infection or tumor. Following a thoracic intervertebral disc biopsy for presumed osteodiscitis, a patient immediately presented with flaccid paralysis and loss of temperature and pinprick sensation below biopsy level, followed rapidly by complete sensation loss. There was no evidence of direct injury during the biopsy, and emergent post-biopsy magnetic resonance imaging revealed no cord signal abnormality or compression. Later magnetic resonance imaging demonstrated corresponding-level cord edema, presumed secondary to transient cord ischemia during the procedures. Despite frequent utility, authors recommend caution in utilization of computed tomography-guided spine biopsy.