CT based bone mineral density as a predictor of proximal junctional fractures.

Background: Proximal junctional fractures (PJFr) can be a catastrophic complication associated with adult spinal deformity surgery. Osteoporosis can be a major risk factor for the cause of PJFr. Recent studies suggest using surrogate computed tomography (CT) scans in place of spinal dual-energy x-ray absorptiometry (DEXA) scores for bone mineral density (BMD). Investigate the feasibility of using preoperative CT based bone mineral density at upper instrumented vertebrae (UIV) and one level proximally (UIV+1) and distally (UIV-1) to predict the possibility of PJFr risk. Methods: Retrospective two-academic center case-controlled study, reviewed consecutive adult spinal deformity surgeries; included constructs encompassing at least five fusion levels and fusions to pelvis. Examined demographic, surgical, and radiographic data preoperatively, postoperatively, and final follow-up. Formed groups based on type of proximal junctional deformity (PJD): Control (no PJD), proximal junctional kyphosis (PJK) and PJFr. Preoperative CT BMD values measured in Hounsfield units (HU) for sagittal and axial planes at UIV, UIV+1, and UIV-1 and compared between groups. Results: N=92 patients. Preoperative CT scan BMD values were significantly lower in PJFr vs. control at: UIV+1 in sagittal (p=0.007), axial (p=0.02) planes; UIV sagittal (p=0.04) and axial (p=0.03) planes; and UIV-1 sagittal (p=0.05) plane. Similarly, lower CT scan BMD values noted in PJFr vs. PJK at: UIV+1 in sagittal (p=0.04) and axial (p=0.03) planes. Trend seen with lower CT scan BMD values at UIV+1 level in PJFr vs. PJK in sagittal (p=0.12) and axial (p=0.10) planes. Preoperative global sagittal imbalance measurements significantly lower in control, but comparable between PJK and PJFr. Conclusions: Higher preoperative global sagittal imbalance with lower preoperative CT BMD values at UIV and UIV+1 vertebral body may increase the risk of proximal junctional fractures after adult spine deformity surgery. Proximal junctional hooks may supplement the pathogenesis. Readers should note the small sample size.Level of Evidence: 3.

Comparison of operative implications between adolescent and young adult idiopathic scoliosis patients from scoliosis research society mortality and morbidity database.

PURPOSE: To compare the operative implications between adolescent idiopathic scoliosis patients (10-18 years) and young adult idiopathic scoliosis (YAdIS) patients (19-30 years). METHODS: This was a retrospective study querying the SRS M&M database for AIS (10-18 years) and YAdIS (19-30 years) cases enrolled between 2009 and 2015. Demographic and surgical parameters (Lenke curve classification, preoperative curve magnitude, approach type, osteotomy type, estimated blood volume (EBV), levels of fusion and ASA scores) were evaluated and compared between groups. RESULTS: N = 690: AIS (n = 607) and YAdIS (n = 83). Lenke curve classification distributions in AIS and YAdIS cases were: main thoracic, 293 vs. 34; double thoracic, 42 vs. 5; double major, 159 vs. 15; triple major, 15 vs. 5; thoracolumbar, 85 vs. 17; and lumbar, 5 vs. 6, respectively. Patients with a coronal curve > 90° were significantly greater in YAdIS vs. AIS patients, p = 0.008. Anterior and combined surgery rates were significantly higher in YAdIS, p = 0.028. Two-staged surgeries were significantly higher for YAdIS cohort, p = 0.01. Osteotomy rate was similar between groups, p = 0.42, but proportion of 3-column osteotomies was significantly higher for YAdIS, p < 0.001. ASA (severe systemic disease and some functional limitation) score 3 patients' rate was higher in YAdIS cohort, p = 0.01. EBV was significantly higher in YAdIS, p = 0.01. Average number of levels of fusions between cohorts was not significant, p = 0.87. CONCLUSIONS: The operative implications observed with young adult idiopathic scoliosis patients may potentially result in more complex surgical procedures and operative-associated complications than their adolescent counterparts. Further studies are required and should include a larger number of cases, be prospective in nature and verifiable data. LEVEL OF EVIDENCE: II.

The Reliability of CT Scan Measurements of Pelvic Incidence in the Evaluation of Adult Spondylolisthesis.

BACKGROUND:  Pelvic incidence (PI) has been described as a parameter that may be a risk factor for lumbar spondylolisthesis (SPL). Studies have reported PI measurement is more precise in CT scans. Very limited studies have measured PI using CT scans to evaluate SPL. We analyzed the reliability of CT scans to measure PI to evaluate SPL and compared it to patients without SPL. METHODS:  A retrospective, cross-sectional study of PI in a consecutive cohort of patients' pelvic/abdominal CT scans from an emergency room visit at a Level 1 trauma center between 2013 and 2016. Inclusion criteria was >18 years and had no lumbar or pelvis fracture. A total of 361 patients met the criteria for our study. We documented age, average PI, and SPL (type, grading, and location). Sagittal CT scans were used to measure PI (between hip axis to an orthogonal line originating at the center of superior end plate axis of first sacral vertebra). Patients were categorized: with SPL (n=45) and without SPL (n=316). Subgroups were comprised based on the location of SPL (L4/L5 and L5/S1) and type of SPL. Analysis of variance (ANOVA) and chi-square tests used; p≤0.05 considered statistically significant. RESULTS:  Patients with SPL were significantly older versus patients without SPL, p=0.006. There were no statistical differences in PI between patients with and without SPL (p=0.29); between subgroups of patients with SPL at L4/L5 and without SPL (p=0.52); between subgroups with type of SPL at L4/L5 and without SPL (p=0.47); and between SPL patients at L5/S1 and without SPL (p=0.40). Patients with isthmic SPL at L5/S1 had nearly significant higher PIs (p=0.06) compared to those without SPL or with degenerative SPL at L5/S1. There was a trend towards higher PI in Grade 2 SPL patients at L5/S1, p=0.18. CONCLUSIONS: Patients with SPL were significantly older than patients without SPL. The two trends observed were that PI was higher in patients with isthmic SPL at L5/S1 and an increased PI with Grade 2 isthmic SPL at L5/S1. Our reported CT PI measurements correlated with reported PI measured using standard radiographs in patients with SPL. CT scans may be a reliable modality to evaluate adult SPL.

Evaluation of shoulder balance in early onset scoliosis after definitive fusion and comparison with adolescent idiopathic scoliosis shoulder balance.

STUDY DESIGN: The Children Spine Study Group registry was queried for early onset scoliosis (EOS) patients who had final definitive spinal fusion after their scoliosis was managed with either growing rods or VEPTR. The Harms Study Group registry was queried for adolescent idiopathic scoliosis (AIS) patients who had definitive fusion OBJECTIVE: The goal is to assess shoulder alignment in EOS patients after a definitive fusion and how these radiographic outcomes relate to the more familiar situation of post-definitive fusions shoulder alignment in AIS patients. BACKGROUND: EOS is a challenging pathology to manage. Numerous components are important in the success of spinal surgery for this population. Shoulder balance is a one of the components that is easily seen by the patient. Recently, the importance of its relationship to patient satisfaction has received greater attention. METHODS: Sample size: n = 145 (EOS (n = 34) and AIS (n = 111)). Shoulder balance parameters (SBP) of clavicular angle (CA), coracoid height difference (CHD), clavicular tilt angle difference (CTAD), and clavicle-rib cage intersection difference (CRID) measurements were measured from the reviewed radiographs and documented pre-definitive, post-definitive and 2-year follow-up measures. Shoulder balance parameters were compared between EOS and AIS cohorts at documented intervals. RESULTS: EOS mean pre-definitive fusion SBPs (CA, CTAD, CRID, CHD) were significantly higher compared to AIS, p = 0.004, 0.003, < 0.001, < 0.001, respectively. Significant post-definitive fusion corrections were noticed for CTAD (0.01), CHD (0.01), nearly significant CA (0.07), non-significant CRID in EOS patients. In AIS patients, no significant corrections were noticed for CA, CTAD, CHD and but significant for CRID (0.02). At post-definitive and 2-year follow-up, CA, CRID, CHD were not significant between cohorts, but CTAD (< 0.01) was significantly higher in EOS cohort at final follow-up. CONCLUSION: Post-definitive and 2-year follow-up shoulder balance for EOS patients was not significantly different from AIS patients. LEVEL OF EVIDENCE: III.

Impact of liberal intraoperative allogeneic blood transfusion on postoperative morbidity and mortality in major thoracic and lumbar posterior spine instrumentation surgeries.

PURPOSE: To investigate the impact of intraoperative blood transfusion on outcomes in patients who had major thoracic and lumber posterior spine instrumentation surgery. METHODS: Retrospective study included patients who underwent major spine surgery between 2013 and 2017. Patients' demographics, surgical charts, anesthesia charts, discharge charts and follow-up outpatient charts were reviewed. Data collection included: age, gender, BMI, Charlson Co-morbidity Index (CCI) scores, American Society of Anesthesiologists (ASA) scores, amount of estimated blood loss [% estimated blood volume (%EBV)], amount of blood transfused during surgery and post-surgery before discharge, number of fusion levels, pre- and postoperative hemoglobin (Hb) levels, and length of hospital stay. Also collected in-hospital postoperative complications (cardiovascular, pulmonary, infections and deaths). Patients' postoperative intubation status data documented. Reviewed follow-up charts to document any complications. RESULTS: Sample size = 289; No transfusion = 92; transfusion = 197. Transfused patients were significantly older, p < 0.001, higher average BMIs (p < 0.001); ASA scores (p < 0.001); CCI scores (p < 0.001), mean postoperative Hb level (p = 0.004), average intraoperative %EBV loss (p < 0.001), longer hospital stays (p = 0.003). Non-transfusion cohort had significantly higher proportion of patients (p < 0.001) extubated immediately after surgery. Seventeen patients had at least one in-hospital complication, p = 0.05. Complications were not significant among groups. CONCLUSION: Intraoperative blood transfusions and high volume intraoperative allogeneic blood transfusions did not increase risk for in-hospital complications or surgical site infections. Delayed extubations noticed in patients who received higher volumes of intraoperative allogeneic blood transfusions. High-volume intraoperative blood transfusions increased length of hospital stays. High post-hospital surgical infections associated with high volume intraoperative blood transfusions. Results should be interpreted cautiously due to small sample size.

Is it safe to stop at C7 during multilevel posterior cervical decompression and fusion? - multicenter analysis.

BACKGROUND CONTEXT: Despite a number of studies addressing the anatomical and biomechanical challenges of long segment, posterior cervical fusion surgery, recommendations for appropriate caudal "end level" vary widely. PURPOSE: Compare revision rates, patient reported outcomes and radiographic outcomes in patients in whom 3+ level posterior fusions ended in the cervical spine versus those in whom the fusion was extended into the thoracic spine. STUDY DESIGN: Multicenter retrospective analysis. OUTCOME MEASURES: Visual analog scale (VAS), Oswestry disability index (ODI), cervical lordosis, C2-C7 sagittal plumbline, T1 slope, and revision rate. METHODS: We assembled a radiographic and clinical database of patients that had undergone three or more level posterior cervical fusions for degenerative disease from January 2013 to May 2015 at one of four busy spine centers. Only those patients with at least 2 years of postoperative (postop) follow-up were included. Patients were divided into two groups: group I (fusion ending at C6 or C7) and group II (fusion extending into the thoracic spine). All radiographic measurements (cervical lordosis, T1 slope, and C2-C7 sagittal plumbline) were performed by an independent experienced clinical researcher. RESULTS: Two hundred and sixty-four patient cases were reviewed and sorted into the two outlined groups, Group I (n=168) and Group II (n=96). Demographically, mean age, percentage of females, non-smokers and anterior support were greater in Group II than in Groups I (p<.05). Mean estimated blood loss (EBL), operative time (OR) and length of hospital stay (LOS) were significantly higher in Group II (p<.05). Rate of revision was not clinically or statistically significantly different (p>.05) between Group I (11.1%) and Group II (9.4%). The majority of the revision surgeries occurred between 2 to 5 years postop. A greater number of subjacent degeneration/spondylolisthesis events were noted in Group I compared with Group II (3.6% vs. 1.2%). There were significant improvements in mean clinical outcomes (ie, VAS and ODI) at two years postop in both groups, but there were no statistically significant differences between the groups (p>.05). Mean cervical lordosis at 2 years postop improved in all groups (12.8° vs. 14.1°); however, there was no significant statistical difference in change for mean cervical lordosis (2 weeks vs. 2 year postop) between the two groups. Similary, there were no significant statistical differences in change for mean C2-C7 sagittal plumbline and T1 slope (2 weeks vs. 2 year postop) between the two groups(p>.05). CONCLUSIONS: Caudal end level did not significantly affect revision rates, patient reported outcomes or radiographic outcomes. Higher EBL, OR, and LOS in group II suggest that, absent focal C7-T1 pathology, extension of posterior cervical fusions into the thoracic spine may not be necessary. Extension of posterior cervical fusions into the thoracic spine may be recommended for higher risk patients with limitations to strong C7 bone anchorage. In others, it is safe to stop at C7.

Comparison of adverse events between cervical disc arthroplasty and anterior cervical discectomy and fusion: a 10-year follow-up.

BACKGROUND CONTEXT: Cervical disc arthroplasty (CDA) has been advocated as an alternative to anterior cervical discectomy and fusion (ACDF) with the added potential to reduce the risk of adjacent level disc degeneration and segmental instability. However, the long-term adverse events of arthroplasty have yet to be fully reported. PURPOSE: To investigate the 10-year follow-up adverse events rates between CDA and ACDF. STUDY DESIGN/SETTING: The study was a randomized, prospective, multicenter Investigational Device Exemption (IDE) trial and its continued follow-up as a postapproval study (PAS). Single level surgeries were performed for cervical disc pathologies between May 2002 and October 2004. PATIENT SAMPLE: n=463 patients. OUTCOME MEASURES: Adverse events comparison of CDA and ACDF from self-reported and physiologic measures. METHODS: At each evaluation time point, subjects were queried for adverse events since their last visit; and all adverse events were documented, regardless of whether or not they appeared related to the surgery or device. Adverse events were recorded, categorized, and assessed for severity and relationship to the study device and/or surgical procedure. The 10-year cumulative rates for each type of adverse events were summarized using a life-table method for the time-to-event analysis. A log-rank test was used to compare the two treatment groups. RESULTS: A total of 242 patients received CDA and 221 patients received ACDF. At 10-year follow-up, 54% (130/242) of CDA patients and 47% (104/221) of the ACDF subjects were evaluated. At up to 10-year follow-up, 231 patients in the CDA group (cumulative rate 98.4%) and 199 patients in the ACDF group (cumulative rate 98.7%) had at least one adverse event. Overall, the difference in the cumulative rate of all adverse events over 10 years was not statistically different (p=0.166). The cumulative rates of the following adverse events were not different between the two groups for cancer, cardiovascular, death, dysphonia/dysphagia, gastrointestinal, infection, urogenital, respiratory, implant displacement/loosening, implant malposition, neck and arm pain, neurological, other pain, spinal events, and intraoperative vascular injury. However, there were more adverse events in the CDA group resulting from trauma (p=.012) and more spinal events at the index level (p=.006). The ACDF group had significantly more nonunion events (p=.019), and nonunion outcome pending (p=.034), adjacent level spinal events (p=.033), and events that fell into the "other" category (p=.015). CONCLUSIONS: The cumulative rates of patients who had any adverse events were not different between the artificial cervical disc and the anterior cervical arthrodesis groups. In addition, the cumulative rates were not different between the two groups for the majority of categories as well.

Outcomes of Negative Pressure Wound Therapies in the Management of Spine Surgical Site Wound Infections.

BACKGROUND: Many studies report benefits using negative pressure wound therapy (NPWT) in surgical site infections (SSIs). We measured and compared efficacy and complications associated with NPWT for traditional versus suprafascial vacuum-assisted closures (VACs). METHODS: This is a retrospective chart review of consecutive SSIs managed with negative wound therapy after spinal procedures between 2012 and 2015 from a single, academic center. Patients were collected through International Classification of Diseases, Ninth Revision, procedure codes. Inclusion criteria were patients with spine SSIs managed by irrigation and debridement with a VAC device; infection occurring after spinal surgeries; and age over 18. A total of 23 consecutive patients met the criteria. We reviewed demographic data, surgical data, infectious disease data, discharge summaries, and postoperative follow-up charts. We compared and analyzed demographics, duration of VAC therapy, and reoperation rates between VAC groups. Statistical analysis was completed using analysis of variance and χ2 tests; P ≤ 0.05 was considered statistically significant. RESULTS: A total of 7 patients had traditional VACs (Group 1), and 16 patients had suprafascial VACs (Group 2). Average blood loss and number of levels involved during index surgery were not statistically significant between groups. Locations of infection occurrence were cervical spine = 3, thoracic spine = 1, and lumbar spine = 19. Reoperation rate after initial wound VAC placement was 34%, with rates significantly higher for Group 1 (71%) than Group 2 (16%), P = 0.02. Average duration of wound therapy was longer in Group 1 (77 days) than Group 2 (33 days), P = 0.08. Average number of operating room visits after initial wound VAC implantation were 0.7 for Group 1 and 0.3 for Group 2, P = 0.26, before obtaining a clean wound closure. CONCLUSIONS: Small sample size and retrospective nature were limitations. Negative pressure wound therapy may be useful for managing spinal infections, and suprafascial VAC had less time duration, lower risk of sponge fragment retainment, and fewer procedures to ultimately achieve wound closure. LEVEL OF EVIDENCE: 3.

Nerve Root Sedimentation Sign: Can It Predict the Success for Surgical Intervention in Patients With Symptomatic Lumbar Spinal Stenosis?

INTRODUCTION:  The use of interspinous process devices are less invasive surgical methods designed to manage mild to moderate lumbar spinal stenosis symptoms. Symptomatic relief may not be seen in all patients undergoing this procedure. Magnetic resonance imaging (MRI) parameters have been used to predict the success of clinical outcomes in patients with symptomatic lumbar spinal stenosis for decompressive surgeries. The purpose of this study was to determine the feasibility of using nerve root sedimentation sign to predict mid- to long-term clinical outcomes of patients treated with interspinous spacers for lumbar spinal stenosis. METHODS: This was a retrospective study using prospective multicenter Food and Drug Administration Investigational Device Exemption (FDA IDE) trial (Superion™ and X-STOP®) data. Inclusion criteria were patients treated with interspinous spacers, aged 45 or older with lumbar spinal stenosis at one or more contiguous levels from L1 to L5 and symptoms of neurogenic claudication. Preoperative axial T2 weighted MRI images were used to determine nerve root sedimentation sign. Preoperative, six-week, one- and two-year postoperative clinical outcomes were measured using Oswestry Disability Index (ODI) scores. Clinical outcomes were compared between positive and negative nerve root sedimentation sign groups; p ≤0.05 was considered significant. RESULTS: This study included n=374 patients; 40 excluded; 334 included (113=positive nerve root sedimentation sign (NRSS) (34%) and 221=negative NRSS (66%)). At six weeks, significant postoperative ODI correction was noted in both groups (p<0.001). No significant differences in ODI scores were identified between groups. A subgroup analysis with MRI image quality grade 3 and certainty determination grade 5, six-week postoperative ODI correction was significant in both groups. Six-week, one- and two-year postoperative ODI scores were greater by 6 points in the positive nerve root sedimentation sign group compared to the negative nerve root sedimentation sign group. CONCLUSIONS:  Although satisfactory postoperative improvement occurred in both groups, there were statistically significant differences noted in certain sub-categories. The subgroup analysis indicated MRI image quality and nerve root sedimentation sign certainty of determination may be factors that may aid with planning the surgical management of lumbar spinal stenosis.

Clinical Outcomes of Idiopathic Scoliosis Surgery: Is There a Difference Between Young Adult Patients and Adolescent Patients?

Background Surgical outcomes of adolescent idiopathic scoliosis (AIS) patients have been well studied. However, few studies have examined the surgical outcomes of young adult idiopathic scoliosis (YAdIS) patients. This study analyzed and compared the surgical outcomes of young adult (19-30 years) and adolescent (10-18 years) idiopathic scoliosis patients. Methods This is a retrospective, comparative two-center study. Reviewed data of consecutive AIS and YAdIS patients who had undergone posterior spinal deformity surgery (n=56) by two spine surgeons from 2010 to 2014. Inclusion criteria were age between 10 to 30 years and preoperative coronal Cobb angle >40o. We excluded patients with previous correction surgery. Demographic data (age at time of surgery, gender, body mass index (BMI)), surgical data (preoperative diagnosis, number of levels fused, blood loss, duration of surgery, peri- and postoperative complications, duration of surgery, length of stay, revision surgery, and final follow-up) and radiographic data collected, reviewed, and analyzed. The groups were divided as AIS (n=29) and YAdIS (n=27). Results Patients' gender, BMI, average preoperative main coronal curve (YAdIS 53o vs. AIS 570), and follow-up intervals were not statistically different between groups. Statistically significant for YAdIS patients were more levels fused (10.6 vs. 8.9, p=0.02) and more intraoperative blood loss (872 ml vs. 564 ml, p=0.02) were statistically significant. Not significant between the groups were duration of surgery (p>0.05), perioperative complications (p=0.14), and length of stay (p=0.11). At mean 21 months follow-up, patients in both groups had a significant correction of their main coronal curve (YAdIS 21o vs. 53o, p<0.001, and AIS, 19o vs. 57o, p<0.01). YAdIS had a lower percentage correction of their curves (61% vs. 68%, p=0.03). Three YAdIS (11.1%) and no AIS (0%) patients had additional surgery, p=0.07. YAdIS had more distal fusion levels at L4 or below. Conclusions YAdIS patients had a greater number of levels fused, higher blood losses, and lower major Cobb correction versus AIS patients.

Employment Status for the First Decade Following Randomization to Cervical Disc Arthroplasty Versus Fusion.

STUDY DESIGN: An analysis of employment status data up to 10 years following the Federal Drug Administration (FDA) Investigational Device Exemption (IDE) randomized trial and extension as post-approval study comparing BRYAN cervical disc (Medtronic, Minneapolis, MN) arthroplasty (CDA) versus single-level anterior cervical discectomy and fusion (ACDF) was performed. OBJECTIVE: Ten-year experience with the BRYAN disc arthroplasty trial provides opportunity to report patient employment data. SUMMARY OF BACKGROUND DATA: The long-term consequences of arthroplasty remain incomplete, including the occurrence of occupational compromise. METHODS: Patients' employment status were measured at regular intervals in both groups up to 10 years. RESULTS: The preoperative employment status proportion was comparable between investigational (BRYAN CDA) and control (ACDF) groups. In the investigational group, 49.2% returned to work at 6 weeks compared with 39.4% of the control group (P = 0.046). At 6 months and 2 years postoperatively, there was a similar likelihood of active employment in both groups. After 2 years at all time points, 10% drop-off seen in control group employment, but not in investigational group. At 10 years, 76.2% CDA patients were employed to 64.1% ACDF patients (P = 0.057). Preoperative variables influencing work status at 10 years following CDA included: preoperative work status, age, and SF-36 Mental Component Score (SF-36 MCS); whereas, no significant preoperative factor identified with ACDF. Time to return to work was influenced in both groups by preoperative work status; and in the ACDF group: reaching age 65 at 10-year visit, preoperative arm pain and NDI score had significant influences. CONCLUSION: More patients returned to work at 6 weeks after CDA compared with ACDF, although there was no difference by 6 months. After 2 years, a nonsignificant trend toward higher employment rates in the arthroplasty group was evident, but this difference could not be validated due to the very high rate of loss of patients to the follow-up. LEVEL OF EVIDENCE: 2.

A Comparison of Complications and Union Rates in Intramedullary Nailing of Femoral Shaft Fractures Treated With Open Versus Closed Reduction.

Intramedullary rod fixation is a common technique for treatment of femoral shaft fractures, with both open and closed reduction techniques described. The purpose of this study was to assess union and complication rates among patients treated with open vs closed reduction and intramedullary nailing of closed femoral shaft fractures. A total of 107 patients undergoing intramedullary fixation of nonpathologic femoral shaft fractures (AO/OTA type 32) between January 2012 and June 2017 were retrospectively studied. Those undergoing open reduction prior to intramedullary nailing were compared with those undergoing closed reduction. The primary outcome analyzed was union rate. Secondary outcomes were time to union, complications necessitating return to the operating room, and operative times. Mean follow-up was 14 months in both groups (range, 6-48 months). Of the 107 patients, 34.6% (n=37) underwent open reduction and 65.4% (n=70) underwent closed reduction. Patients in the open reduction group had rates of union (89.1%, 33 of 37) similar to those of patients in the closed reduction group (92.9%, 65 of 70; P=.378). Patients in the open reduction group who had union did so in a mean of 6.2 months (range, 3-12 months) vs a mean of 5.4 months (range, 2-11 months) in the closed reduction group (P=.13). Six patients (16.2%) in the open reduction group and 6 patients (8.6%) in the closed reduction group had a postoperative complication requiring return to the operating room (P=.18). Open reduction and intramedullary nailing results in rates of union, time to union, and rates of significant complications similar to those of closed reduction and intramedullary nailing. [Orthopedics. 2020; 43(2): 103-107.].

Increased lactic acid content associated with extracellular matrix depletion in a porcine disc degeneration induced by superficial annular lesion.

BACKGROUND: Degenerative intervertebral disc (IVD) disease can cause lower back pain. However, the change of lactic acid content during disc degeneration process still unclear. The objective of this study was to investigate whether the change of the content of lactic acid is associated with depletion of degenerative intervertebral disc extracellular matrix. METHODS: A total of 18 miniature pigs were equally divided into annular lesion surgery (AL) and sham group. The lateral superficial annulus fibrosus (AF) of T12-L4 discs in AL group were penetrated by 3.5 mm trepan with the depth of 3 mm, the same IVD were only exposed without any injury in the sham group. At 4, 8 and 12 weeks after surgery, the degree of intervertebral disc degeneration was evaluated by magnetic resonance, histological and biochemical analysis. RESULTS: No obvious degeneration was found in sham group. However, disc degeneration was found and gradually worsened in AL group after surgery. Histological analysis showed that the AF was rupture and disorder, the number of cells in nucleus pulposus (NP) was decreased in AL group. Compared with the sham group, the extent of type II collagen (Col-II) and aggrecan in NP tissue was dramatically decreased in AL group, consistent with the results of Col -II immunohistochemistry staining and quantitative reverse transcription polymerase chain reaction (qRT-PCR). Besides, the gene expression of matrix metallopeptidase 3 and 13 also continuous increased in AL group. The amount of lactic acid and nerve growth factor in NP tissue was gradually increased after operation in AL group. CONCLUSIONS: The content of lactic acid gradually increased after annular lesion, associated with the damage of AF structural and the decrease of Col -II and aggrecan in NP tissue, which leading to the disc degeneration. Depletion of extracellular matrix is consistent with lactic acid accumulation inside of IVD.

The Mobi-C® cervical disc and other devices for two-level disc replacement: overview of its safety and efficacy.

INTRODUCTION: Cervical disc arthroplasty (CDA) has become an acceptable alternative for anterior cervical discectomy and fusion (ACDF) for a significant patient population with cervical radiculopathy and/or myelopathy secondary to degenerative changes in the cervical spine. There are sufficient mid- and long-term data supporting performance and safety of one-level CDA. With the success of single-level cervical CDA, considerable interest exists about CDA use for multilevel cervical degenerative disc disease (DDD). This review analyzes the safety and efficacy of two-level CDA for treatment of symptomatic cervical DDD with focus on the Mobi-C® Cervical Disc. AREAS COVERED: This review summarizes previously published articles in a literature search using keywords: 'two-level-anterior cervical arthrodesis; two-level anterior cervical decompression and fusion (ACDF); two-level cervical disc arthroplasty (CDA); two-level cervical total disc replacement; two-level symptomatic degenerative disc disease (DDD); Mobi-C® disc'. EXPERT OPINION: Two-level CDA with the Mobi-C® device demonstrated equivalent, and in certain aspects, favorable outcomes compared to ACDF for treatment of symptomatic cervical 2-level degenerative disc disease (DDD) indicating a satisfactory safety and efficacy profile.

Perioperative Intravenous Corticosteroids and Radiographic Prevertebral Soft Tissue Swelling in Anterior Cervical Fusion for Degenerative Disease.

OBJECTIVE: Prevertebral soft tissue swelling (PSTS) is a known complication of anterior cervical fusion (ACF). Prior studies have shown that perioperative steroids may reduce PSTS after ACF. We retrospectively evaluated the role of perioperative intravenous (IV) corticosteroid administration in minimizing radiographic PSTS measurements in patients undergoing ACF for degenerative disease. METHODS: Records of 100 consecutive patients undergoing ACF for degenerative disease (Current Procedural Terminology code 63075) from January 2010 through December 2012 by 2 orthopedic spine fellowship-trained surgeons at a single institution were retrospectively reviewed. Patients were included on the basis of specific criteria. They were then separated into comparison and IV steroid groups. Demographic and surgical data were collected. Last, measurements of PSTS, which included PSTS ratio and PSTS index (PSTSI), were obtained from plain radiographs preoperatively and at 3 postoperative time points. RESULTS: Eighty patients were included; 26 received IV steroids at the surgeon's discretion (12 intraoperatively, 11 postoperatively and 3 at both time periods). With the exception of a history of prior anterior cervical spine surgery (3.70% comparison vs. 23.08% IV steroid, P = 0.01), there was no statistically significant demographic characteristic. Furthermore, there was no statistically significant surgical characteristic. Last, there was no statistically significant difference between groups at any time point for either PSTS ratio at any level or PSTSI. CONCLUSIONS: There does not appear to be a role for perioperative IV steroid administration in minimizing radiographic PSTS in patients undergoing ACF for degenerative disease. The relationship between perioperative IV steroid administration and PSTS requires further investigation.

Surgical treatment of early-onset idiopathic scoliosis in the United States: a trend analysis of 15 years (1997-2012).

BACKGROUND CONTEXT: Early-onset scoliosis is a challenging problem that is defined as a curvature of the spine of more than 10 degrees identified in a child less than 10 years. Early-onset idiopathic scoliosis (EOIS) can cause substantial morbidity and may require surgical intervention. PURPOSE: The aim of the present study was to identify the trends of EOIS type of surgeries, length of hospital stay, in-hospital complications, and total inpatient admission charges over a 15-year study period in the United States from 1997 to 2012. STUDY DESIGN/SETTING: This retrospective study used the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes from the Healthcare Cost and Utilization Project (HCUP) Kids Inpatient's Database (KID) for a 15-year period (1997-2012). PATIENT SAMPLE: We identified a total of 897 patients with EOIS over the 15-year study period. OUTCOME MEASURES: The present study determines the current trends for EOIS surgeries. METHODS: The present study had no funding sources or any potential conflicts of interest associated biases. Idiopathic scoliosis patients with ages between 0 and <10 years were identified from the Kids' Inpatient Database with ICD-9-CM code 737.30. Posterior, anterior, and combined spinal surgeries were identified in EOIS through the procedure codes. Patients' gender, discharge diagnosis (comorbidities), hospital length of stay (LOS), mortality rates, hospital charges, and in-hospital complication rate data were collected between 1997 and 2012. The primary grouping variable of the study was the type of surgery (posterior, anterior, and combined). The trends of each variable (female gender, mortality rates, in-hospital complications rates, discharge diagnosis, LOS, and total hospital charges) were assessed for each surgical group separately. Cost inflation of hospital charges was adjusted for the year 2012. An analysis of variance test was used to analyze continuous variables and a chi-square test was used for categorical variables. A linear regression test was used to assess the trend of changes. p≤.05 was considered statistically significant. RESULTS: The study identified 897 patients, with 546 (61%) of them requiring surgery. Spine deformity surgery rates significantly decreased in patients with EOIS over time from 75% in 1997 to 47% in 2012, p=.019. In the surgery cohort, the male to female distribution was 37% and 63%, respectively. The overall mortality rate was 0.1%. The average length of hospital stay was 8 days and the average number of discharge diagnosis was 5.3. Aggregated complications were seen in 6% of the patients. The total mean hospital charge (per 2012 US dollars) was $119,613, which increased significantly for all types of surgeries. Over the 15-year study period, 62% (n=342) of the patients had posterior surgeries, 13% (n=71) of the patients had anterior surgeries, and 24% (n=133) of the patients had combined (anterior and posterior) surgeries. Posterior surgeries increased significantly from 33% in 1997 to 91% in 2012 (p<.004). Combined surgeries saw a significant decline from 50% to 4.3% (0<0.001). Anterior surgeries also decreased from 17% to 4.3% (p<.126), but this did not reach statistical significance. CONCLUSIONS: From 1997 to 2012 (15 years) study period of patients with EOIS, posterior-based surgeries significantly increased. The overall surgery rate has significantly decreased for these patients. A significant increase in hospital charges were noticed in posterior, anterior, and combined surgeries.

Assessment of Inter- and Intraobserver Reliability and Accuracy to Evaluate Apical Vertebral Rotation Using Four Methods: An Experimental Study Using a Saw Bone Model.

STUDY DESIGN: After placing a thoracic three-vertebra segment saw bones model on a standardized turntable, a series of anteroposterior (AP) radiographs were obtained and then set in increments to 90° rotation. Then the specimen was instrumented with 35-mm pedicle screws bilaterally and the rotation process and image acquisition were repeated. OBJECTIVE: Assess reliability and accuracy of spine surgeons evaluating apical vertebral rotation (AVR) through surgeon's visual x-ray estimation, Nash-Moe system, Upasani trigonometric method, and Upasani grading system. BACKGROUND CONTEXT: Accurate assessment of AVR is one measure surgeons can evaluate the success of intervention and potential loss of correction in scoliotic deformities. METHODS: Eighty-four representative images of uninstrumented and instrumented vertebral segments were blinded. AVR was estimated by five experienced spinal deformity surgeons using the four techniques. The surgeons' grading, estimates, and errors compared to actual rotation were calculated. Inter- and intraobserver reliability were calculated using interclass correlation (ICC). RESULTS: Each surgeon's error for simple visual estimation for uninstrumented segments was 8.7° to 17.4° (average error = 12.4°), and for instrumented segments it was 7.7° to 11.3° (average error = 9.5°). Error for the Upasani trigonometric method was -6.7° to 11.6° (average error = 0.9°). There was relatively poor accuracy for Nash-Moe system (38.2%-53.9%) compared with the Upasani grading system (76.74%-80.23%). Interobserver reliability using the Nash-Moe method was good (0.844), with intraobserver reliability from fair to excellent (0.684-0.949). Interobserver reliability for the Upasani grading method was good (0.829), with intraobserver reliability from fair to good (0.751-0.869). We found excellent interobserver reliability for Upasani trigonometric classification (0.935) with fair to excellent intraobserver reliability (0.775-0.991). The interobserver reliability of surgeons' visual estimates was good (0.898) and the intraobserver reliability from good to excellent (0.866-0.99) without pedicle screws, and interobserver reliability was excellent (0.948) and intraobserver reliability also excellent (0.959-0.986) with pedicle screws. CONCLUSIONS: We confirm that both techniques described by Upasani have good reliability and accuracy, appearing more accurate than surgeon's visual estimates or Nash-Moe system. LEVEL OF EVIDENCE: Level III.

The Effect of Kyphoplasty on Mortality in Symptomatic Vertebral Compression Fractures: A Review.

BACKGROUND: Vertebral compression fractures (VCFs) are common comorbidities encountered in the elderly, and they are on the rise. Kyphoplasty may be superior in VCF management compared with conservative management. A comprehensive review of literature was conducted, focusing on the effect of kyphoplasty on mortality and overall survivorship in patients with a diagnosis of symptomatic VCFs. METHODS: A comprehensive literature search was conducted to find recently published literature on kyphoplasty effects on mortality using the following keywords: "kyphoplasty," "mortality," "morbidity," "vertebral compression fractures," and "survivorship." We only included articles that listed one of their primary or secondary outcomes as morbidity and mortality after a kyphoplasty procedure in VCF patients. RESULTS: Of 27 articles, only 6 articles met the inclusion criteria. Studies have reported that surgical procedures have decreased the mortality rate in symptomatic VCF patients. Four studies concluded that the mortality rate was lower after kyphoplasty compared with vertebroplasty and nonoperative treatments. One study reported there was no significant difference between kyphoplasty and nonoperative management. One study summarized that the mortality rate was not significantly different between kyphoplasty and vertebroplasty. CONCLUSIONS: Multicenter prospective and randomized control studies are required to fully evaluate the decreasing trend of mortality rates after a kyphoplasty procedure.

The relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery: a multicenter retrospective study.

OBJECTIVEUse of surgical site drains following posterior cervical spine surgery is variable, and its impact on outcomes remains controversial. Studies of drain use in the lumbar spine have suggested that drains are not associated with reduction of reoperations for wound infection or hematoma. There is a paucity of studies examining this relationship in the cervical spine, where hematomas and infections can have severe consequences. This study aims to examine the relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery.METHODSThis study is a multicenter retrospective review of 1799 consecutive patients who underwent posterior cervical decompression with instrumentation at 4 tertiary care centers between 2004 and 2016. Demographic and perioperative data were analyzed for associations with drain placement and return to the operating room.RESULTSOf 1799 patients, 1180 (65.6%) had a drain placed. Multivariate logistic regression analysis identified history of diabetes (OR 1.37, p = 0.03) and total number of levels operated (OR 1.32, p < 0.001) as independent predictors of drain placement. Rates of reoperation for any surgical site complication were not different between the drain and no-drain groups (4.07% vs 3.88%, p = 0.85). Similarly, rates of reoperation for surgical site infection (1.61% vs 2.58%, p = 0.16) and hematoma (0.68% vs 0.48%, p = 0.62) were not different between the drain and no-drain groups. However, after adjusting for history of diabetes and the number of operative levels, patients with drains had significantly lower odds of returning to the operating room for surgical site infection (OR 0.48, p = 0.04) but not for hematoma (OR 1.22, p = 0.77).CONCLUSIONSThis large study characterizes current practice patterns in the utilization of surgical site drains during posterior cervical decompression and instrumentation. Patients with drains placed did not have lower odds of returning to the operating room for postoperative hematoma. However, the authors' data suggest that patients with drains may be less likely to return to the operating room for surgical site infection, although the absolute number of infections in the entire population was small, limiting the analysis.

Assessment of Coronal Spinal Alignment for Adult Spine Deformity Cases After Intraoperative T Square Shaped Use.

STUDY DESIGN: Retrospectively reviewed surgeries between 2011 and 2015 of patients who underwent posterior spinal deformity instrumentation with constructs involving fusions to pelvis and encompassing at least five levels. OBJECTIVE: Measure the radiographic outcomes of coronal malalignment (CM) after use of an intraoperative T square shaped instrument in posterior spinal deformity surgeries with at least five levels of fusion and extension to pelvis. BACKGROUND: Neuromuscular children found to benefit from intraoperative T square technique to help achieve proper coronal spinal balance with extensive fusions. This intraoperative technique used in our posterior spine deformity instrumentation surgeries with the aforementioned parameters. METHODS: There were 50 patients: n = 16 with intraoperative T square and n = 34 no-T square shaped device. Subgroups divided based on greater than 20 mm displacement and greater than 40 mm displacement of the C7 plumb line to the central sacral vertical line on either side in preoperative radiographs. We analyzed the demographics and the pre- and postoperative radiographic parameters of standing films: standing CM (displacement of C7 plumb line to central sacral vertical line), and major coronal Cobb angles in total sample and subgroups and compared T square shaped device with no-T square shaped device use by analysis of variance. A p value ≤.05 is statistically significant. RESULTS: In the total sample, though postoperative CM mean was not statistically different, we observed greater CM corrections in patients where a T square shaped device was used (70%) versus no-T square shaped device used (18%). In >20 mm and >40 mm subgroups, the postoperative mean CM values were statistically lower for the patients where a T square shaped device was used, p = .016 and p = .003, respectively. Cobb corrections were statistically higher for T square shaped device use in both >20 mm and >40 mm subgroups, 68%, respectively. CONCLUSION: The intraoperative T square shaped device technique had a positive effect on the amount of spine coronal malalignment correction after its use and for lumbar and thoracic coronal Cobb angles. LEVEL OF EVIDENCE: Level III.