Adolescent idiopathic scoliosis in adulthood.

Adolescent idiopathic scoliosis (AIS) is an abnormal coronal curvature of the spine that most commonly presents in adolescence. While it may be asymptomatic, AIS can cause pain, cosmetic deformity, and physical and psychological disability with curve progression. As adolescents with AIS enter adulthood, condition outcomes vary with some experiencing curve stabilization and others noting further curve progression, chronic pain, osteoporosis/fractures, declines in pulmonary and functional capacity, among others. Regular monitoring and individualized management by healthcare professionals are crucial to address the diverse challenges and provide appropriate support for a fulfilling adult life with AIS. This review examines the prevalence, risk factors, presenting symptoms, diagnosis, management, and complications of AIS in the adult population, informing targeted interventions by clinicians caring for adult patients with AIS.

Hip Osteoarthritis in Patients Undergoing Surgery for Severe Adult Spinal Deformity: Prevalence and Impact on Spine Surgery Outcomes.

BACKGROUND: Hip osteoarthritis (OA) is common in patients with adult spinal deformity (ASD). Limited data exist on the prevalence of hip OA in patients with ASD, or on its impact on baseline and postoperative alignment and patient-reported outcome measures (PROMs). Therefore, this paper will assess the prevalence and impact of hip OA on alignment and PROMs. METHODS: Patients with ASD who underwent L1-pelvis or longer fusions were included. Two independent reviewers graded hip OA with the Kellgren-Lawrence (KL) classification and stratified it by severity into non-severe (KL grade 1 or 2) and severe (KL grade 3 or 4). Radiographic parameters and PROMs were compared among 3 patient groups: Hip-Spine (hip KL grade 3 or 4 bilaterally), Unilateral (UL)-Hip (hip KL grade 3 or 4 unilaterally), or Spine (hip KL grade 1 or 2 bilaterally). RESULTS: Of 520 patients with ASD who met inclusion criteria for an OA prevalence analysis, 34% (177 of 520) had severe bilateral hip OA and unilateral or bilateral hip arthroplasty had been performed in 8.7% (45 of 520). A subset of 165 patients had all data components and were examined: 68 Hip-Spine, 32 UL-Hip, and 65 Spine. Hip-Spine patients were older (67.9 ± 9.5 years, versus 59.6 ± 10.1 years for Spine and 65.8 ± 7.5 years for UL-Hip; p < 0.001) and had a higher frailty index (4.3 ± 2.6, versus 2.7 ± 2.0 for UL-Hip and 2.9 ± 2.0 for Spine; p < 0.001). At 1 year, the groups had similar lumbar lordosis, yet the Hip-Spine patients had a worse sagittal vertebral axis (SVA) measurement (45.9 ± 45.5 mm, versus 25.1 ± 37.1 mm for UL-Hip and 19.0 ± 39.3 mm for Spine; p = 0.001). Hip-Spine patients also had worse Veterans RAND-12 Physical Component Summary scores at baseline (25.7 ± 9.3, versus 28.7 ± 9.8 for UL-Hip and 31.3 ± 10.5 for Spine; p = 0.005) and 1 year postoperatively (34.5 ± 11.4, versus 40.3 ± 10.4 for UL-Hip and 40.1 ± 10.9 for Spine; p = 0.006). CONCLUSIONS: This study of operatively treated ASD revealed that 1 in 3 patients had severe hip OA bilaterally. Such patients with severe bilateral hip OA had worse baseline SVA and PROMs that persisted 1 year following ASD surgery, despite correction of lordosis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Restoring L4-S1 Lordosis Shape in Severe Sagittal Deformity: Impact of Correction Techniques on Alignment and Complication Profile.

BACKGROUND: Severe sagittal plane deformity with loss of L4-S1 lordosis is disabling and can be improved through various surgical techniques. However, data are limited on the differing ability of anterior lumbar interbody fusion (ALIF), pedicle subtraction osteotomy (PSO), and transforaminal lumbar interbody fusion (TLIF) to achieve alignment goals in severely malaligned patients. METHODS: Severe adult spinal deformity patients with preoperative PI-LL >20°, L4-S1 lordosis <30°, and full body radiographs and PROMs at baseline and 6-week postoperative visit were included. Patients were grouped into ALIF (1-2 level ALIF at L4-S1), PSO (L4/L5 PSO), and TLIF (1-2 level TLIF at L4-S1). Comparative analyses were performed on demographics, radiographic spinopelvic parameters, complications, and PROMs. RESULTS: Among the 96 included patients, 40 underwent ALIF, 27 underwent PSO, and 29 underwent TLIF. At baseline, cohorts had comparable age, sex, race, Edmonton frailty scores, and radiographic spinopelvic parameters (P > 0.05). However, PSO was performed more often in revision cases (P < 0.001). Following surgery, L4-S1 lordosis correction (P = 0.001) was comparable among ALIF and PSO patients and caudal lordotic apex migration (P = 0.044) was highest among ALIF patients. PSO patients had higher intraoperative estimated blood loss (P < 0.001) and motor deficits (P = 0.049), and in-hospital ICU admission (P = 0.022) and blood products given (P = 0.004), but were otherwise comparable in terms of length of stay, blood transfusion given, and postoperative admission to rehab. Likewise, 90-day postoperative complication profiles and 6-week PROMs were comparable as well. CONCLUSIONS: ALIF can restore L4-S1 sagittal alignment as powerfully as PSO, with fewer intraoperative and in-hospital complications. When feasible, ALIF is a suitable alternative to PSO and likely superior to TLIF for correcting L4-S1 lordosis among patients with severe sagittal malalignment.

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.

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.

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.

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.

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.

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.

Impact of Self-Reported Loss of Balance and Gait Disturbance on Outcomes following Adult Spinal Deformity Surgery.

Background: The objective of this study was to evaluate if imbalance influences complication rates, radiological outcomes, and patient-reported outcomes (PROMs) following adult spinal deformity (ASD) surgery. Methods: ASD patients with baseline and 2-year radiographic and PROMs were included. Patients were grouped according to whether they answered yes or no to a recent history of pre-operative loss of balance. The groups were propensity-matched by age, pelvic incidence-lumbar lordosis (PI-LL), and surgical invasiveness score. Results: In total, 212 patients were examined (106 in each group). Patients with gait imbalance had worse baseline PROM measures, including Oswestry disability index (45.2 vs. 36.6), SF-36 mental component score (44 vs. 51.8), and SF-36 physical component score (p < 0.001 for all). After 2 years, patients with gait imbalance had less pelvic tilt correction (-1.2 vs. -3.6°, p = 0.039) for a comparable PI-LL correction (-11.9 vs. -15.1°, p = 0.144). Gait imbalance patients had higher rates of radiographic proximal junctional kyphosis (PJK) (26.4% vs. 14.2%) and implant-related complications (47.2% vs. 34.0%). After controlling for age, baseline sagittal parameters, PI-LL correction, and comorbidities, patients with imbalance had 2.2-times-increased odds of PJK after 2 years. Conclusions: Patients with a self-reported loss of balance/unsteady gait have significantly worse PROMs and higher risk of PJK.

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.

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.

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.

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.

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.

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.

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.

Impact of Hip and Knee Osteoarthritis on Full Body Sagittal Alignment and Compensation for Sagittal Spinal Deformity.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To investigate the effect of lower extremity osteoarthritis on sagittal alignment and compensatory mechanisms in adult spinal deformity (ASD). BACKGROUND: Spine, hip, and knee pathologies often overlap in ASD patients. Limited data exists on how lower extremity osteoarthritis impacts sagittal alignment and compensatory mechanisms in ASD. PATIENTS AND METHODS: In total, 527 preoperative ASD patients with full body radiographs were included. Patients were grouped by Kellgren-Lawrence grade of bilateral hips and knees and stratified by quartile of T1-Pelvic Angle (T1PA) severity into low-, mid-, high-, and severe-T1PA. Full-body alignment and compensation were compared across quartiles. Regression analysis examined the incremental impact of hip and knee osteoarthritis severity on compensation. RESULTS: The mean T1PA for low-, mid-, high-, and severe-T1PA groups was 7.3°, 19.5°, 27.8°, and 41.6°, respectively. Mid-T1PA patients with severe hip osteoarthritis had an increased sagittal vertical axis and global sagittal alignment ( P <0.001). Increasing hip osteoarthritis severity resulted in decreased pelvic tilt ( P =0.001) and sacrofemoral angle ( P <0.001), but increased knee flexion ( P =0.012). Regression analysis revealed that with increasing T1PA, pelvic tilt correlated inversely with hip osteoarthritis and positively with knee osteoarthritis ( r2 =0.812). Hip osteoarthritis decreased compensation through sacrofemoral angle (ß-coefficient=-0.206). Knee and hip osteoarthritis contributed to greater knee flexion (ß-coefficients=0.215, 0.101; respectively). For pelvic shift, only hip osteoarthritis significantly contributed to the model (ß-coefficient=0.100). CONCLUSIONS: For the same magnitude of spinal deformity, increased hip osteoarthritis severity was associated with worse truncal and full body alignment with posterior translation of the pelvis. Patients with severe hip and knee osteoarthritis exhibited decreased hip extension and pelvic tilt but increased knee flexion. This examines sagittal alignment and compensation in ASD patients with hip and knee arthritis and may help delineate whether hip and knee flexion is due to spinal deformity compensation or lower extremity osteoarthritis.