Disparities in Surgical Intervention and Health-Related Quality of Life Among Racial/Ethnic Groups With Degenerative Lumbar Spondylolisthesis.

BACKGROUND AND OBJECTIVES: Racial and socioeconomic disparities in spine surgery for degenerative lumbar spondylolisthesis persist in the United States, potentially contributing to unequal health-related quality of life (HRQoL) outcomes. This is important as lumbar spondylolisthesis is one of the most common causes of surgical low back pain, and low back pain is the largest disabler of individuals worldwide. Our objective was to assess the relationship between race, socioeconomic factors, treatment utilization, and outcomes in patients with lumbar spondylolisthesis. METHODS: This cohort study analyzed prospectively collected data from 9941 patients diagnosed with lumbar spondylolisthesis between 2015 and 2020 at 5 academic hospitals. Exposures were race, socioeconomic status, health coverage, and HRQoL measures. Main outcomes and measures included treatment utilization rates between racial groups and the association between race and treatment outcomes using logistic regression, adjusting for patient characteristics, socioeconomic status, health coverage, and HRQoL measures. RESULTS: Of the 9941 patients included (mean [SD] age, 67.37 [12.40] years; 63% female; 1101 [11.1%] Black, Indigenous, and People of Color [BIPOC]), BIPOC patients were significantly less likely to use surgery than White patients (odds ratio [OR] = 0.68; 95% CI, 0.62-0.75). Furthermore, BIPOC race was associated with significantly lower odds of reaching the minimum clinically important difference for physical function (OR = 0.74; 95% CI, 0.60; 0.91) and pain interference (OR = 0.77; 95% CI, 0.62-0.97). Medicaid beneficiaries were significantly less likely (OR = 0.65; 95% CI, 0.46-0.92) to reach a clinically important improvement in HRQoL when accounting for race. CONCLUSION: This study found that BIPOC patients were less likely to use spine surgery for degenerative lumbar spondylolisthesis despite reporting higher pain interference, suggesting an association between race and surgical utilization. These disparities may contribute to unequal HRQoL outcomes for patients with lumbar spondylolisthesis and warrant further investigation to address and reduce treatment disparities.

Defining the Post-Operative Progression of Degenerative Scoliosis: An Analysis of Cases without Instrument Failure.

OBJECTIVE: The expected post-operative changes in radiographic alignment over time remain poorly defined in patients surgically treated for degenerative scoliosis without instrument failure. Here we aim to describe the optimal natural progression of radiographic degenerative scoliosis at multiple timepoints in patients treated with a transforaminal lumbar interbody fusion (TLIF). METHODS: We identified an initial retrospective cohort of 114 patients treated with a TLIF for degenerative scoliosis between 2018 and 2022, with 39 patients ultimately meeting the imaging inclusion criteria. Patients who completed a primary or revision procedure with no evidence of instrument failure, proximal junctional kyphosis, or proximal junctional failure at last follow-up were included. Radiographic measurements of spinopelvic alignment were manually extracted from X-Ray scoliosis films. RESULTS: Thirty-nine patients (mean age 62.6 ± 8.7, mean follow-up 2.9 years), of which 23 underwent a primary TLIF (Primary) and 16 a revision procedure (Revision), were analyzed. Patients in the Primary group experienced a durable improvement in Thoracolumbar Cobb angle (-25° ± 15°), Thoracic Kyphosis (10° ± 13°), and Pelvic Incidence/lumbar lordosis mismatch (PI/LL) (-19° ± 19°) through the first year of follow-up. In the Revision group, at one year follow-up, all measures of spinopelvic alignment except PI/LL mismatch had reverted to pre-operative levels. Thoracolumbar Cobb angle decreased to a significantly greater degree in the Primary group compared to the Revision group. CONCLUSION: Primary TLIF operations without instrument failure consistently improve radiographic outcomes in three key measures through the first year. For revision procedures, there appears to be modest radiographic benefit at follow-up.

Advances and Evolving Challenges in Spinal Deformity Surgery.

BACKGROUND: Surgical intervention is a critical tool to address adult spinal deformity (ASD). Given the evolution of spinal surgical techniques, we sought to characterize developments in ASD correction and barriers impacting clinical outcomes. METHODS: We conducted a literature review utilizing PubMed, Embase, Web of Science, and Google Scholar to examine advances in ASD surgical correction and ongoing challenges from patient and clinician perspectives. ASD procedures were examined across pre-, intra-, and post-operative phases. RESULTS: Several factors influence the effectiveness of ASD correction. Standardized radiographic parameters and three-dimensional modeling have been used to guide operative planning. Complex minimally invasive procedures, targeted corrections, and staged procedures can tailor surgical approaches while minimizing operative time. Further, improvements in osteotomy technique, intraoperative navigation, and enhanced hardware have increased patient safety. However, challenges remain. Variability in patient selection and deformity undercorrection have resulted in heterogenous clinical responses. Surgical complications, including blood loss, infection, hardware failure, proximal junction kyphosis/failure, and pseudarthroses, pose barriers. Although minimally invasive approaches are being utilized more often, clinical validation is needed. CONCLUSIONS: The growing prevalence of ASD requires surgical solutions that can lead to sustained symptom resolution. Leveraging computational and imaging advances will be necessary as we seek to provide comprehensive treatment plans for patients.

Utility of Expandable Interbody Cages in Open Transforaminal Interbody Fusions: A Comparison With Static Cages.

Background Expandable interbody cages, while popular in minimally invasive fusions due to their slim profile and increased ease of insertion, have not been widely explored in open surgery. The benefits of expandable cages may also extend to open fusions through their potential to achieve a greater restoration of lumbar lordosis while minimizing intraoperative complications. To highlight these benefits, we present a case series of adult spinal deformity (ASD) patients treated with an open transforaminal lumbar interbody fusion (TLIF) using expandable cages and compare outcomes to those of patients treated with static cages from the literature. Methods A retrospective cohort study of patients who underwent a deformity correction procedure and TLIF with expandable interbody cages at Brigham and Women's Hospital between 2018 and 2022 was conducted. Patient demographics, complications, and pre- and postoperative radiographic parameters of spinopelvic alignment were collected. A literature search was completed to identify studies employing static cages. T-tests were performed to compare postoperative changes in radiographic parameters by cage type. Results Forty-five patients (mean age of 62.6 years) with an average of 2.1 cages placed met the inclusion criteria. Patients experienced five intraoperative complications and 23 neurologic deficits (from minor to major), while nine patients required a revision operation. Lumbar lordosis increased by 9.8° ± 14.5° (p < 0.0001), the sagittal vertical axis (SVA) decreased by 25.5 mm ± 56.7 mm (p = 0.0048), and pelvic incidence-lumbar lordosis mismatch decreased by 13.3° ± 17.5° (p < 0.0001) with the use of expandable cages. Expandable cages yielded similar changes in lumbar lordosis to 15° and 8° cages but improved the lumbar lordosis generated from rectangular and 4° cages. When compared to static cages, expandable cages mildly reduced intraoperative complications. Conclusions Expandable interbody cages are an effective means of restoring spinopelvic alignment in ASD that have the potential to improve patient outcomes in open fusions compared to standard static cages. Especially when compared to rectangular and 4° static cages, expandable cages provide a clear benefit in the correction of lumbar lordosis. The impact of open spinal fusions with expandable cages on outcomes should continue to be explored in other cohorts.

Spinal Metastases from Colorectal Cancer at Mass General Brigham: A Twenty-Year Case Series With Literature Review.

OBJECTIVE: We present an institutional case series of patients treated for colorectal carcinoma (CRC) spinal metastases to investigate the outcomes between no treatment, radiation, surgery, and surgery/radiation. METHODS: A retrospective cohort of patients with CRC spinal metastases presenting to affiliated institutions between 2001 and 2021 wereidentified. Information related to patient demographics, treatment modality, treatment outcomes, symptom improvement, and survival was collected by chart review. Overall survival (OS) was compared between treatments by log-rank significance testing. A literature review was conducted to identify other cases series of CRC patients with spinal metastases. RESULTS: Eighty-nine patients (mean age 58.5) with CRC spinal metastases across a mean of 3.3 levels met inclusion criteria: 14 (15.7%) received no treatment, 11 (12.4%) received surgery alone, 37 (41.6%) received radiation alone, and 27 (30.3%) received both radiation and surgery. Patients treated with combination therapy had the longest median OS of 24.7 months (range 0.6-85.9), which did not significantly differ from the median OS of 8.9 months (range 0.2-42.6) observed in patients who received no treatment (P = 0.075). Combination therapy provided objectively longer survival time in comparison to other treatment modalities but failed to reach statistical significance. The majority of patients that received treatment (n = 51/75, 68.0%) experienced some degree of symptomatic or functional improvement. CONCLUSIONS: Therapeutic intervention has the potential to improve the quality of life in patients with CRC spinal metastases. We demonstrate that surgery and radiation are useful options for these patients, despite their lack of objective improvement in OS.

Gross total resection of spinal chondrosarcoma is associated with improved locoregional relapse-free survival and overall survival.

BACKGROUND: Spinal chondrosarcomas are rare malignant osseous tumors. The low incidence of spinal chondrosarcomas and the complexity of spine anatomy have led to heterogeneous treatment strategies with varying curative and survival rates. The goal of this study is to investigate prognostic factors for locoregional recurrence-free survival (LRFS) and overall survival (OS) comparing en bloc vs. piecemeal resection for the management of spinal chondrosarcoma. METHODS: We retrospectively identified patients who underwent curative-intent resection of primary and metastatic spinal chondrosarcoma over a 25-year period. Univariate and multivariate survival analyses were conducted with LRFS as primary endpoint and OS as secondary endpoint. LRFS and OS were modeled using the Kaplan-Meier method and assessed using Cox regression analysis. RESULTS: For 72 patients who underwent first resection, the median follow-up time was 5.1 years (95% CI 2.2-7.0). Thirty-three patients (45.8%) had en bloc resection, and 39 (54.2%) had piecemeal resection. Of the 68 patients for whom extent of resection was known, 44 patients had gross total resection (GTR) and 24 patients had subtotal resection. In survival analyses, both LRFS and OS showed statistically significant difference based on the extent of resection (p = 0.001; p = 0.04, respectively). However, only LRFS showed statistically significant difference when assessing the type of resection (p = 0.02). In addition, higher tumor grade and more invasive disease were associated with worse LRFS and OS rates. CONCLUSION: Although in our study en bloc and GTR were associated with improved survival, heterogenous and complex spinal presentations may limit total resection. Therefore, the surgical management should be tailored individually to ensure the best local control and maximum preservation of function.

The Relationship Among Surgeon Experience, Complications, and Radiographic Outcomes in Spine Deformity Surgery: The Experience of a Junior Surgeon.

OBJECTIVE: To examine complication rates and radiographic outcomes in patients undergoing surgery for adult spinal deformity (ASD) by a junior surgeon. METHODS: A study was conducted of a retrospective cohort of patients who underwent an open posterior interbody fusion of the thoracic and/or lumbar regions by a single surgeon for ASD between 2018 and 2022. Patient characteristics, complications, and common radiographic parameters of spinopelvic alignment were collated. RESULTS: A total of 112 patients with an average of 4.2 comorbidities underwent surgical correction of ASD. Thirty-seven patients (33.0%) experienced 52 major complications and 50 patients (44.6%) experienced 66 minor complications. Twenty-three patients (20.5%) required a revision operation. Both sagittal vertical axis (P < 10-14) and pelvic incidence-lumbar lordosis mismatch (P < 10-7) significantly improved postoperatively. Number of levels (P < 0.05), operative time >650 minutes (P < 0.01), estimated blood loss >1500 mL (P < 0.01), length of intensive care unit stay >1 day (P < 0.05), and hospitalization length >5 days (P < 0.05) all significantly increased the risk of a major complication. No patient factors significantly increased the risk of minor complications or revision surgery. CONCLUSIONS: Observed complication and revision rates in this cohort were consistent with rates reported in the literature. No preoperative patient risk factors significantly increased risk of complications or need for revision, suggesting that no patient population is at increased risk undergoing surgery by a junior surgeon. The relatively high rate of complications observed in this cohort may be a result of high baseline morbidity.

Spinal level and cord involvement in the prediction of sepsis development after vertebral fracture repair for traumatic spinal injury.

OBJECTIVE: Despite understanding the associated adverse outcomes, identifying hospitalized patients at risk for sepsis is challenging. The authors aimed to characterize the epidemiology and clinical risk of sepsis in patients who underwent vertebral fracture repair for traumatic spinal injury (TSI). METHODS: The authors conducted a retrospective cohort analysis of adults undergoing vertebral fracture repair during initial hospitalization after TSI who were registered in the National Trauma Data Bank from 2011 to 2014. RESULTS: Of the 29,050 eligible patients undergoing vertebral fracture repair, 317 developed sepsis during initial hospitalization. Of these patients, most presented after a motor vehicle accident (63%) or fall (28%). Patients in whom sepsis developed had greater odds of being male (adjusted OR [aOR] 1.5, 95% CI 1.1-1.9), having diabetes mellitus (aOR 1.5, 95% CI 1.11-2.1), and being obese (aOR 1.9, 95% CI 1.4-2.5). Additionally, they had greater odds of presenting with moderate (aOR 2.7, 95% CI 1.8-4.2) or severe (aOR 3.9, 95% CI 2.9-5.2) Glasgow Coma Scale scores and of having concomitant abdominal injuries (aOR 1.9, 95% CI 1.5-2.5) but not cranial, thoracic, or lower-extremity injuries. Interestingly, cervical spine injury was significantly associated with developing sepsis (OR 1.4, 95% CI 1.1-1.8), but thoracic and lumbar spine injuries were not. Spinal cord injury (OR 1.9, 95% CI 1.5-2.5) was also associated with sepsis regardless of level. Patients with sepsis were hospitalized approximately 16 days longer. They had greater odds of being discharged to rehabilitative care or home with rehabilitative care (OR 2.4, 95% CI 1.8-3.2) and greater odds of death or discharge to hospice (OR 6.0, 95% CI 4.4-8.1). CONCLUSIONS: Among patients undergoing vertebral fracture repair, those with cervical spine fractures, spinal cord injuries, preexisting comorbidities, and severe concomitant injuries are at highest risk for developing postoperative sepsis and experiencing adverse hospital disposition.

Appropriate Telemedicine Utilization in Spine Surgery: Results From a Delphi Study.

STUDY DESIGN: Delphi expert panel consensus. OBJECTIVE: To obtain expert consensus on best practices for appropriate telemedicine utilization in spine surgery. SUMMARY OF BACKGROUND DATA: Several studies have shown high patient satisfaction associated with telemedicine during the COVID-19 peak pandemic period as well as after easing of restrictions. As this technology will most likely continue to be employed, there is a need to define appropriate utilization. METHODS: An expert panel consisting of 27 spine surgeons from various countries was assembled in February 2021. A two-round consensus-based Delphi method was used to generate consensus statements on various aspects of telemedicine (separated as video visits or audio visits) including themes, such as patient location and impact of patient diagnosis, on assessment of new patients. Topics with ≥75% agreement were categorized as having achieved a consensus. RESULTS: The expert panel reviewed a total of 59 statements. Of these, 32 achieved consensus. The panel had consensus that video visits could be utilized regardless of patient location and that video visits are appropriate for evaluating as well as indicating for surgery multiple common spine pathologies, such as lumbar stenosis, lumbar radiculopathy, and cervical radiculopathy. Finally, the panel had consensus that video visits could be appropriate for a variety of visit types including early, midterm, longer term postoperative follow-up, follow-up for imaging review, and follow-up after an intervention (i.e., physical therapy, injection). CONCLUSION: Although telemedicine was initially introduced out of necessity, this technology most likely will remain due to evidence of high patient satisfaction and significant cost savings. This study was able to provide a framework for appropriate telemedicine utilization in spine surgery from a panel of experts. However, several questions remain for future research, such as whether or not an in-person consultation is necessary prior to surgery and which physical exam maneuvers are appropriate for telemedicine.Level of Evidence: 4.

Association of venous thromboembolism following pediatric traumatic spinal injuries with injury severity and longer hospital stays.

OBJECTIVE: Venous thromboembolism (VTE) can cause significant morbidity and mortality in hospitalized patients, and may disproportionately occur in patients with limited mobility following spinal trauma. The authors aimed to characterize the epidemiology and clinical predictors of VTE in pediatric patients following traumatic spinal injuries (TSIs). METHODS: The authors conducted a retrospective cohort analysis of children who experienced TSI, including spinal fractures and spinal cord injuries, encoded within the National Trauma Data Bank from 2011 to 2014. RESULTS: Of the 22,752 pediatric patients with TSI, 192 (0.8%) experienced VTE during initial hospitalization. Proportionally, more patients in the VTE group (77%) than in the non-VTE group (68%) presented following a motor vehicle accident. Patients developing VTE had greater odds of presenting with moderate (adjusted odds ratio [aOR] 2.6, 95% confidence interval [CI] 1.4-4.8) or severe Glasgow Coma Scale scores (aOR 4.3, 95% CI 3.0-6.1), epidural hematoma (aOR 2.8, 95% CI 1.4-5.7), and concomitant abdominal (aOR 2.4, 95% CI 1.8-3.3) and/or lower extremity (aOR 1.5, 95% CI 1.1-2.0) injuries. They also had greater odds of being obese (aOR 2.9, 95% CI 1.6-5.5). Neither cervical, thoracic, nor lumbar spine injuries were significantly associated with VTE. However, involvement of more than one spinal level was predictive of VTE (aOR 1.3, 95% CI 1.0-1.7). Spinal cord injury at any level was also significantly associated with developing VTE (aOR 2.5, 95% CI 1.8-3.5). Patients with VTE stayed in the hospital an adjusted average of 19 days longer than non-VTE patients. They also had greater odds of discharge to a rehabilitative facility or home with rehabilitative services (aOR 2.6, 95% CI 1.8-3.6). CONCLUSIONS: VTE occurs in a low percentage of hospitalized pediatric patients with TSI. Injury severity is broadly associated with increased odds of developing VTE; specific risk factors include concomitant injuries such as cranial epidural hematoma, spinal cord injury, and lower extremity injury. Patients with VTE also require hospital-based and rehabilitative care at greater rates than other patients with TSI.

Predictors of thoracic and lumbar spine injuries in patients with TBI: A nationwide analysis.

OBJECTIVE: Cervical spine injury screening is common practice for traumatic brain injury (TBI) patients. However, risk factors for concomitant thoracolumbar trauma remain unknown. We characterized epidemiology and clinical risk for concomitant thoracolumbar trauma in TBI. METHODS: We conducted a multi-center, retrospective cohort analysis of TBI patients in the National Trauma Data Bank from 2011-2014 using multivariable logistic regression. RESULTS: Out of 768,718 TBIs, 46,654 (6.1%) and 42,810 (5.6%) patients were diagnosed with thoracic and lumbar spine fractures, respectively. Only 11% of thoracic and 7% of lumbar spine fracture patients had an accompanying spinal cord injury at any level. The most common mechanism of injury was motor vehicle accident (67% of thoracic and 71% and lumbar fractures). Predictors for both thoracic and lumbar fractures included moderate (thoracic: OR 1.26, 95%CI 1.21-1.31; lumbar: OR 1.13, 95%CI 1.08-1.18) and severe Glasgow Coma Scale (GCS) score (OR 1.71, 95%CI 1.67-1.75; OR 1.17, 95%CI 1.13-1.20) compared to mild; epidural hematoma (OR 1.36, 95%CI 1.28-1.44; OR 1.1, 95%CI 1.04-1.19); lower extremity injury (OR 1.38, 95%CI 1.35-1.41; OR 2.50, 95%CI 2.45-2.55); upper extremity injury (OR 2.19, 95%CI 2.14-2.23; OR 1.15, 95%CI 1.13-1.18); smoking (OR 1.09, 95%CI 1.06-1.12; OR 1.12, 95%CI 1.09-1.15); and obesity (OR 1.39, 95%CI 1.34-1.45; OR 1.29, 95%CI 1.24-1.35). Thoracic injuries (OR 4.45; 95% CI 4.35-4.55) predicted lumbar fractures, while abdominal injuries (OR 2.02; 95% CI 1.97-2.07) predicted thoracic fractures. CONCLUSIONS: We identified GCS, smoking, upper and lower extremity injuries, and obesity as common risk factors for thoracic and lumbar spinal fractures in TBI.

Deep Learning for Adjacent Segment Disease at Preoperative MRI for Cervical Radiculopathy.

Background Patients who undergo surgery for cervical radiculopathy are at risk for developing adjacent segment disease (ASD). Identifying patients who will develop ASD remains challenging for clinicians. Purpose To develop and validate a deep learning algorithm capable of predicting ASD by using only preoperative cervical MRI in patients undergoing single-level anterior cervical diskectomy and fusion (ACDF). Materials and Methods In this Health Insurance Portability and Accountability Act-compliant study, retrospective chart review was performed for 1244 patients undergoing single-level ACDF in two tertiary care centers. After application of inclusion and exclusion criteria, 344 patients were included, of whom 60% (n = 208) were used for training and 40% for validation (n = 43) and testing (n = 93). A deep learning-based prediction model with 48 convolutional layers was designed and trained by using preoperative T2-sagittal cervical MRI. To validate model performance, a neuroradiologist and neurosurgeon independently provided ASD predictions for the test set. Validation metrics included accuracy, areas under the curve, and F1 scores. The difference in proportion of wrongful predictions between the model and clinician was statistically tested by using the McNemar test. Results A total of 344 patients (median age, 48 years; interquartile range, 41-58 years; 182 women) were evaluated. The model predicted ASD on the 93 test images with an accuracy of 88 of 93 (95%; 95% CI: 90, 99), sensitivity of 12 of 15 (80%; 95% CI: 60, 100), and specificity of 76 of 78 (97%; 95% CI: 94, 100). The neuroradiologist and neurosurgeon provided predictions with lower accuracy (54 of 93; 58%; 95% CI: 48, 68), sensitivity (nine of 15; 60%; 95% CI: 35, 85), and specificity (45 of 78; 58%; 95% CI: 56, 77) compared with the algorithm. The McNemar test on the contingency table demonstrated that the proportion of wrongful predictions was significantly lower by the model (test statistic, 2.000; P < .001). Conclusion A deep learning algorithm that used only preoperative cervical T2-weighted MRI outperformed clinical experts at predicting adjacent segment disease in patients undergoing surgery for cervical radiculopathy. © RSNA, 2021 An earlier incorrect version appeared online. This article was corrected on September 22, 2021.

Expandable Versus Static Cages in Minimally Invasive Lumbar Interbody Fusion: A Systematic Review and Meta-Analysis.

BACKGROUND: Expandable cages for interbody fusion allow for in situ expansion optimizing fit while mitigating endplate damage. Studies comparing outcomes after using expandable or static cages have been conflicting. METHODS: This was a meta-analysis A systematic search was performed in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines identifying studies reporting outcomes among patients who underwent minimally invasive lumbar interbody fusion (MIS-LIF). RESULTS: Fourteen articles with 1129 patients met inclusion criteria. Compared with MIS-LIFs performed with static cages, those with expandable cages had a significantly lower incidence of graft subsidence (expandable: incidence 0.03, I2 22.50%; static: incidence 0.27, I2 51.03%, P interaction <0.001), length of hospital stay (expandable: mean difference [MD] 3.55 days, I2 97%; static: MD 7.1 days, I2 97%, P interaction <0.01), and a greater increase in disc height (expandable: MD -4.41 mm, I2 99.56%; static: MD -0.79 mm, I2 99.17%, P interaction = 0.02). There was no statistically significant difference among Oswestry Disability Index (expandable: MD -22.75, I2 98.17%; static: MD -17.11, I2 95.26%, P interaction = 0.15), fusion rate (expandable: incidence 0.94, I2 0%; static incidence 0.92, I2 0%, P interaction = 0.44), overall change in lumbar lordosis (expandable: MD 3.48 degrees, I2 59.29%; static: MD 3.67 degrees, I2 0.00%, P interaction 0.88), blood loss (expandable: MD 228.9 mL, I2 100%; static: MD 261.1 mL, I2 94%, P interaction = 0.69) and operative time (expandable: MD 184 minutes, I2 95.32%; static: MD 150.4 minutes, I2 91%, P interaction = 0.56). CONCLUSIONS: Expandable interbody cages in MIS-LIF were associated with a decrease in subsidence rate, operative time and greater in increase in disc height.

Association of Spinal Alignment Correction With Patient-Reported Outcomes in Adult Cervical Deformity: Review of the Literature.

OBJECTIVE: Adult cervical deformity (ACD) is a debilitating spinal condition that causes significant pain, neurologic dysfunction, and functional impairment. Surgery is often performed to correct cervical alignment, but the optimal amount of correction required to improve patient-reported outcomes (PROs) are not yet well-defined. METHODS: A review of the literature was performed and Fisher z-transformation (Zr) was used to pool the correlation coefficients between alignment parameters and PROs. The strength of correlation was defined according to the following: poor (0 < r ≤ 0.3), fair (0.3 < r ≤ 0.5), moderate (0.5 < r ≤ 0.8), and strong (0.8 < r ≤ 1). RESULTS: Increased C2-7 sagittal vertical axis was fairly associated with increased Neck Disability Index (NDI) (pooled Zr = 0.31; 95% confidence interval [CI], -0.03 to 0.58). Changes in T1 slope minus cervical lordosis poorly correlated with NDI (pooled Zr = -0.04; 95% CI, -0.23 to 0.30). Increased C7-S1 was poorly associated with worse EuroQoL 5-Dimension (pooled Zr = -0.22; 95% CI, -0.36 to -0.06). Correction of horizontal gaze did not correlate with legacy metrics. Modified Japanese Orthopedic Association correlated with C2-slope, C7-S1, and C2-S1. CONCLUSION: Spinal alignment parameters variably correlated with improved health-related quality of life and myelopathy after corrective surgery for ACD. Further studies evaluating legacy PROs, Patient-Reported Outcomes Measurement System, and ACD specific instruments are needed for further validation.

Adult sports-related traumatic spinal injuries: do different activities predispose to certain injuries?

OBJECTIVE: Sports injuries are known to present a high risk of spinal trauma. The authors hypothesized that different sports predispose participants to different injuries and injury severities. METHODS: The authors conducted a retrospective cohort analysis of adult patients who experienced a sports-related traumatic spinal injury (TSI), including spinal fractures and spinal cord injuries (SCIs), encoded within the National Trauma Data Bank from 2011 through 2014. Multiple imputation was used for missing data, and multivariable linear and logistic regression models were estimated. RESULTS: The authors included 12,031 cases of TSI, which represented 15% of all sports-related trauma. The majority of patients with TSI were male (82%), and the median age was 48 years (interquartile range 32-57 years). The most frequent mechanisms of injury in this database were cycling injuries (81%), skiing and snowboarding accidents (12%), aquatic sports injuries (3%), and contact sports (3%). Spinal surgery was required during initial hospitalization for 9.1% of patients with TSI. Compared to non-TSI sports-related trauma, TSIs were associated with an average 2.3-day increase in length of stay (95% CI 2.1-2.4; p < 0.001) and discharge to or with rehabilitative services (adjusted OR 2.6, 95% CI 2.4-2.7; p < 0.001). Among sports injuries, TSIs were the cause of discharge to or with rehabilitative services in 32% of cases. SCI was present in 15% of cases with TSI. Within sports-related TSIs, the rate of SCI was 13% for cycling injuries compared to 41% and 49% for contact sports and aquatic sports injuries, respectively. Patients experiencing SCI had a longer length of stay (7.0 days longer; 95% CI 6.7-7.3) and a higher likelihood of adverse discharge disposition (adjusted OR 9.69, 95% CI 8.72-10.77) compared to patients with TSI but without SCI. CONCLUSIONS: Of patients with sports-related trauma discharged to rehabilitation, one-third had TSIs. Cycling injuries were the most common cause, suggesting that policies to make cycling safer may reduce TSI.

Single- versus Dual-Attending Surgeon Approach for Spine Deformity: A Systematic Review and Meta-Analysis.

BACKGROUND: Surgical management of spine deformity is associated with significant morbidity. Recent literature has inconsistently demonstrated better outcomes after utilizing 2 attending surgeons for spine deformity. OBJECTIVE: To conduct a systematic review and meta-analysis on studies reporting outcomes following single- vs dual-attending surgeons for spine deformity. METHODS: MEDLINE, Embase, Web of science, and Cochrane databases were last searched on July 16, 2020. A total of 1013 records were identified excluding duplicates. After screening, 10 studies (4 cohort, 6 case series) were included in the meta-analysis. Random-effect models were used to pool the effect estimates by study design. When feasible, further subgroup analysis by deformity type was conducted. RESULTS: A total of 953 patients were analyzed. Pooled results from propensity score-matched cohort studies revealed that the single-surgeon approach was unfavorably associated with a nonstatistically significant higher blood loss (mean difference = 421.0 mL; 95% CI: -28.2, 870.2), a statistically significant higher operative time (mean difference = 94.3 min; 95% CI: 54.9, 133), length of stay (mean difference = 0.84 d; 95% CI: 0.46, 1.22), and an increased risk of complications (Mantel-Haenszel risk ratio = 2.93; 95% CI: 1.12, 7.66). Data from pooled case series demonstrated similar results for all outcomes. Moreover, these results did not differ significantly between deformity types (adolescent idiopathic scoliosis and adult spinal deformity). CONCLUSION: Dual-attending surgeon approach appeared to be associated with reduced operative time, shorter hospital stays, and reduced risk of complications. These findings may potentially improve outcomes in surgical treatment of spine deformity.