Liposomal bupivacaine nerve block provides better pain control post-total shoulder arthroplasty than continuous indwelling catheter.

BACKGROUND: Pain control is essential to successful total shoulder arthroplasty (TSA). MATERIALS AND METHODS: This non-blinded, randomized clinical trial compared shoulder pain, narcotic use, interscalene (IS) block application time, and costs in 76 subjects who were randomly assigned to receive either a single injection IS nerve block of 10 cc (133 mg) liposomal bupivacaine mixed with 10 cc of 0.5% bupivacaine (Group 1), or 20 cc of 0.5% ropivacaine direct injection combined with an indwelling IS nerve block catheter delivering 0.2% ropivacaine at a continual 4 cc/h infusion for the initial 3 post-operative days (Group 2). Surgical time, local anesthesia duration, hospital stay length, morphine milligram equivalents (MME) consumed, worst shoulder pain at 24, 48 and 72 h, and complications were recorded. Patient reported function, pain and activity level surveys were completed before, and 6-week post-TSA (P < 0.05). RESULTS: Group 1 had less pain 24-h (0.72 ± 0.8 vs. 3.4 ± 2.9, p < 0.0001) and 48-h (2.5 ± 2.2 vs. 4.8 ± 2.6, p = 0.005) post-TSA. At 24-h post-TSA, MME consumption was similar (Group 1 = 4.5 ± 6.4 vs. Group 2 = 3.7 ± 3.8, p = 0.54), but was lower for Group 1 at 48 h (0.0 ± 0.0 vs. 0.64 ± 0.99, p = 0.001). Group 2 had longer IS block application time (10.00 ± 4.6 min vs. 4.84 ± 2.7 min, p < 0.0001). Only group 2 had a strong relationship between MME consumption over the first 24-h post-TSA and pain 24-h post-TSA (r = 0.76, p < 0.0001), a moderate relationship with pain 48-h post-TSA (r = 0.59, P = 0.001), and a weak relationship with pain 72-h post-TSA (r = 0.44, P = 0.02). Significant relationships for these variables were not observed for Group 1 (r ≤ 0.30, p ≥ 0.23). Group 1 IS block costs were less/patient than Group 2 ($190.17 vs. $357.12 USD). CONCLUSION: A single shot, liposomal bupivacaine interscalene nerve block provided better post-TSA pain control with less narcotic consumption, less time for administration and less healthcare system cost compared to interscalene nerve block using a continuous indwelling catheter. LEVEL OF EVIDENCE: Level I, Prospective, Randomized.

The Scoli-RISK 1 results of lower extremity motor function 5 years after complex adult spinal deformity surgery.

INTRODUCTION: Neurologic complications after complex adult spinal deformity (ASD) surgery are important, yet outcomes are heterogeneously reported, and long-term follow-up of actual lower extremity motor function is unknown. OBJECTIVE: To prospectively evaluate lower extremity motor function scores (LEMS) before and at 5 years after surgical correction of complex ASD. DESIGN: Retrospective analysis of a prospective, multicenter, international observational study. METHODS: The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers around the world. Inclusion criteria were Cobb angle of > 80°, corrective osteotomy for congenital or revision deformity and/or 3-column osteotomy. Among patients with 5-year follow-up, comparisons of LEMS to baseline and within each follow-up period were made via documented neurologic exams on each patient. RESULTS: Seventy-seven (28.3%) patients had 5-year follow-up. Among these 77 patients with 5-year follow-up, rates of postoperative LEMS deterioration were: 14.3% hospital discharge, 10.7% at 6 weeks, 6.5% at 6 months, 9.5% at 2 years and 9.3% at 5 years postoperative. During the 2-5 year window, while mean LEMS did not change significantly (-0.5, p = 0.442), eight (11.1%) patients deteriorated (of which 3 were ≥ 4 motor points), and six (8.3%) patients improved (of which 2 were ≥ 4 points). Of the 14 neurologic complications, four (28.6%) were surgery-related, three of which required reoperation. While mean LEMS were not impacted in patients with a major surgery-related complication, mean LEMS were significantly lower in patients with neurologic surgery-related complications at discharge (p = 0.041) and 6 months (p = 0.008) between the two groups as well as the change from baseline to 5 years (p = 0.041). CONCLUSIONS: In 77 patients undergoing complex ASD surgery with 5-year follow-up, while mean LEMS did not change from 2 to 5 years, subtle neurologic changes occurred in approximately 1 in 5 patients (11.1% deteriorated; 8.3% improved). Major surgery-related complication did not result in decreased LEMS; however, those with neurologic surgery-related complications continued to have decreased lower extremity motor function at 5 years postoperative. These results underscore the importance of long-term follow-up to 5 years, using individual motor scores rather than group averages, and comparing outcomes to both baseline and last follow-up.

Are Higher Global Alignment and Proportion Scores Associated With Increased Risks of Mechanical Complications After Adult Spinal Deformity Surgery? An External Validation.

BACKGROUND: The Global Alignment and Proportion (GAP) score, based on pelvic incidence-based proportional parameters, was recently developed to predict mechanical complications after surgery for spinal deformities in adults. However, this score has not been validated in an independent external dataset. QUESTIONS/PURPOSES: After adult spinal deformity surgery, is a higher GAP score associated with (1) an increased risk of mechanical complications, defined as rod fractures, implant-related complications, proximal or distal junctional kyphosis or failure; (2) a higher likelihood of undergoing revision surgery to treat a mechanical complication; and (3) is a lower (more proportioned) GAP score category associated with better validated outcomes scores using the Oswestry Disability Index (ODI), Scoliosis Research Society-22 (SRS-22) and the Short Form-36 questionnaires? METHODS: A total of 272 patients who had undergone corrective surgeries for complex spinal deformities were enrolled in the Scoli-RISK-1 prospective trial. Patients were included in this secondary analysis if they fulfilled the original inclusion criteria by Yilgor et al. From the original 272 patients, 14% (39) did not satisfy the radiographic inclusion criteria, the GAP score could not be calculated in 14% (37), and 24% (64) did not have radiographic assessment at postoperative 2 years, leaving 59% (159) for analysis in this review of data from the original trial. A total of 159 patients were included in this study,with a mean age of 58 ± 14 years at the time of surgery. Most patients were female (72%, 115 of 159), the mean number of levels involved in surgery was 12 ± 4, and three-column osteotomy was performed in 76% (120 of 159) of patients. The GAP score was calculated using parameters from early postoperative radiographs (between 3 and 12 weeks) including pelvic incidence, sacral slope, lumbar lordosis, lower arc lordosis and global tilt, which were independently obtained from a computer software based on centralized patient radiographs. The GAP score was categorized as proportional (scores of 0 to 2), moderately disproportional (scores of 3 to 6), or severely disproportional (scores higher than 7 to 13). Receiver operating characteristic area under curve (AUC) was used to assess associations between GAP score and risk of mechanical complications and risk of revision surgery. An AUC of 0.5 to 0.7 was classified as "no or low associative power", 0.7 to 0.9 as "moderate" and greater than 0.9 as "high". We analyzed differences in validated outcome scores between the GAP categories using Wilcoxon rank sum test. RESULTS: At a minimum of 2 years' follow-up, a higher GAP score was not associated with increased risks of mechanical complications (AUC = 0.60 [95% CI 0.50 to 0.70]). A higher GAP score was not associated with a higher likelihood of undergoing a revision surgery to treat a mechanical complication (AUC = 0.66 [95% 0.53 to 0.78]). However, a moderately disproportioned GAP score category was associated with better SF-36 physical component summary score (36 ± 10 versus 40 ± 11; p = 0.047), better SF-36 mental component summary score (46 ± 13 versus 51 ± 12; p = 0.01), better SRS-22 total score (3.4 ± 0.8 versus 3.7 ± 0.7, p = 0.02) and better ODI score (35 ± 21 versus 25 ± 20; p = 0.003) than severely disproportioned GAP score category. CONCLUSION: Based on the findings of this external validation study, we found that alignment targets based on the GAP score alone were not associated with increased risks of mechanical complications and mechanical revisions in patients with complex adult spinal disorders. Parameters not included in the original GAP score needed to be considered to reduce the likelihood of mechanical complications. LEVEL OF EVIDENCE: Level III, diagnostic study.

Surgical Outcomes of Obese Patients With Adolescent Idiopathic Scoliosis From Endemic Areas of Obesity in the United States.

BACKGROUND: Obesity rates continue to rise among children and adolescents across the globe. A multicenter research consortium composed of institutions in the Southern US, located in states endemic for childhood obesity, was formed to evaluate the effect of obesity on pediatric musculoskeletal disorders. This study evaluates the effect of body mass index (BMI) percentile and socioeconomic status (SES) on surgical site infections (SSIs) and perioperative complications in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF). METHODS: Eleven centers in the Southern US retrospectively reviewed postoperative AIS patients after PSF between 2011 and 2017. Each center contributed data to a centralized database from patients in the following BMI-for-age groups: normal weight (NW, 5th to <85th percentile), overweight (OW, 85th to <95th percentile), and obese (OB, ≥95th percentile). The primary outcome variable was the occurrence of an SSI. SES was measured by the Area Deprivation Index (ADI), with higher scores indicating a lower SES. RESULTS: Seven hundred fifty-one patients were included in this study (256 NW, 235 OW, and 260 OB). OB and OW patients presented with significantly higher ADIs indicating a lower SES (P<0.001). In addition, SSI rates were significantly different between BMI groups (0.8% NW, 4.3% OW, and 5.4% OB, P=0.012). Further analysis showed that superficial and not deep SSIs were significantly different between BMI groups. These differences in SSI rates persisted even while controlling for ADI. Wound dehiscence and readmission rates were significantly different between groups (P=0.004 and 0.03, respectively), with OB patients demonstrating the highest rates. EBL and cell saver return were significantly higher in overweight patients (P=0.007 and 0.002, respectively). CONCLUSION: OB and OW AIS patients have significantly greater superficial SSI rates than NW patients, even after controlling for SES. LEVEL OF EVIDENCE: Level III.

Correction to: Providence nighttime bracing is effective in treatment for adolescent idiopathic scoliosis even in curves larger than 35°.

SpineTech should correctly been written as Spinal Technology, inc.

Returning to Work Within Two Years After First-Time, Single-Level, Simple Lumbar Discectomy: A Multifactorial, Predictive Model.

Purpose Continued inability to work has societal and individual consequences. Thus, the factors associated with sustained return to work after lumbar discectomy should be identified. Prior studies of the biopsychosocial factors associated with sustained RTW were primarily based on patient-reported outcome data and have shown conflicting results because of small study samples. In patients undergoing first-time, single-level, simple lumbar discectomy, we describe the time to sustained return to work within 2 years after surgery using outcome data from a national database and identify the pre- and peri-operative factors associated with sustained return to work within 2 years by developing and validating a predictive multivariable model. Methods The time to a sustained return to work within the study period was described using a Kaplan-Meier plot. A temporal validated Cox proportional hazards model examined associations between biopsychosocial factors and return to work. Results In the derivation cohort made up by 351 operated patients who were on sick-leave for more than 3 weeks around the time of surgery, 62% returned to work (median 15 weeks). The probability of sustained return to work was associated with a high education level, positive expectations towards future labor market attachment, pre-operative stable labor market attachment, pre-operative higher physical quality of life, and less disability. Conclusions Through the development and validation of a predictive model, this study identifies a number of patient-related factors associated with sustained return to work after lumbar discectomy, while revealing that most disease-related clinical findings were not associated with the outcome.

Providence nighttime bracing is effective in treatment for adolescent idiopathic scoliosis even in curves larger than 35°.

Since 2006, the Providence nighttime brace has been used for a conservative treatment for scoliosis. Previous studies comparing the outcomes after full-time bracing and nighttime bracing have reported a comparable outcome with curves < 35°. The aim of this study was to report the outcome after treatment in a cohort of adolescent idiopathic scoliosis patients, with curves between 20° and 45°. METHODS: One hundred and twenty-four patients with adolescent idiopathic scoliosis were included in this study with Cobb > 20°, remaining growth potential and no previous scoliosis treatment. Providence nighttime treatment, 8 h nightly, was initiated. Treatment was continued until 2 years post-menarcheal for females and until 6-month growth arrest for males. The patients were evaluated using standing radiographs during treatment and 6 and 12 months after termination of bracing. RESULTS: One hundred and twenty-four patients were included; 80 patients terminated brace treatment and were available for follow-up. Mean in-brace correction was 82%, and curve progression was observed in 9 patients. Brace treatment was success full in 89% of the patients, 88% of the patients braced with curves 20°-29°, 93% of the patients braced with 30°-39° and 77% of the patients braced with curves 40°-45°. Five of the 80 AIS patients were referred to surgery: 4 due to progression and 1 due to cosmetic concerns. CONCLUSIONS: Providence nighttime braces are an effective treatment for adolescent idiopathic scoliosis patients. This study reports a success rate of 89%, and the results are comparable to full-time treatment with the Boston brace. In-brace correction is crucial in part-time bracing, and we recommend at least 70% curve correction, if part-time bracing should be considered. These slides can be retrieved under Electronic Supplementary Material.

Non-neurologic adverse events after complex adult spinal deformity surgery: results from the prospective, multicenter Scoli-RISK-1 study.

PURPOSE: Accurate information regarding the expected complications of complex adult spinal deformity (ASD) is important for shared decision making and informed consent. The purpose of the present study was to investigate the rate and types of non-neurologic adverse events after complex ASD surgeries, and to identify risk factors that affect their occurrence. METHODS: The details and occurrence of all non-neurologic adverse events were reviewed in a prospective cohort of 272 patients after complex ASD surgical correction in a mulitcentre database of the Scoli-RISK-1 study with a planned follow-up of 2 years. Logistic regression analyses were used to identify potential risk factors for non-neurologic adverse events. RESULTS: Of the 272 patients, 184 experienced a total of 515 non-neurologic adverse events for an incidence of 67.6%. 121 (44.5%) patients suffered from more than one adverse event. The most frequent non-neurologic adverse events were surgically related (27.6%), of which implant failure and dural tear were most common. In the unadjusted analyses, significant factors for non-neurologic adverse events were age, previous spine surgery performed, number of documented non-neurologic comorbidities and ASA grade. On multivariable logistic regression analysis, previous spine surgery was the only independent risk factor for non-neurologic adverse events. CONCLUSIONS: The incidence of non-neurologic adverse events for patients undergoing corrective surgeries for ASD was 67.6%. Previous spinal surgery was the only independent risk factor predicting the occurrence of non-neurologic adverse events. These findings complement the earlier report of neurologic complications after ASD surgeries from the Scoli-RISK-1 study. These slides can be retrieved under Electronic Supplementary Material.

Shared decision making when patients consider surgery for lumbar herniated disc: development and test of a patient decision aid.

BACKGROUND: Shared decision making (SDM) is a systematic approach aimed at improving patient involvement in preference-sensitive health care decisions. Choosing between surgical or non-surgical treatment for lumbar disc herniation, can be difficult as the evidence of a superior treatment is unclear, which makes it a preference-sensitive decision. The objectives of this study was therefore to assess the degree of SDM and afterwards to develop and test a patient decision aid (PtDA) to support SDM during the clinical encounter between surgeon and patient, when patients choose between surgical and non-surgical treatment for Lumbar disc herniation (LDH). METHODS: The study was conducted in four steps. 1) Assessment of the extent to which SDM was practiced in the spine clinic. 2) Development of a PtDA to support SDM. 3) Testing its usability and acceptability amongst potential users (patients). 4) Pilot-test of its usability in the clinical setting. RESULTS: Results from our small baseline study (n = 40) showed that between a third and two-thirds of the patients reported not being fully engaged in a shared decision. A pre-designed template (BESLUTNINGSHJÆLPER™) was adapted to support the decision about whether or not to have surgery for LDH. Testing the prototype with patients led to minor refinements. A subsequent pilot test of its usability in a clinical setting achieved positive responses from both patients and clinicians. CONCLUSION: Our baseline study demonstrated that SDM was not universally practiced in the clinic. The PtDA we have developed was rated as acceptable and usable by both patients and clinicians for helping those with LDH choose between surgical or non- surgical treatment. This tool now requires further testing to assess its effectiveness.

Differences in lumbar and pelvic parameters among African American, Caucasian and Asian populations.

PURPOSE: Ethnic differences in spino-pelvic parameters among a healthy population are poorly defined in the literature. The purpose of this study was to document sagittal spino-pelvic parameters in a sample of African Americans and to compare them with previously reported data for Caucasians and Asians. METHODS: African American individuals without spine pathology who had standing lateral radiographs were identified. Radiographs were measured to determine the following parameters: lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS). Data of adult subjects were compared with those previously published for Caucasians (n = 709) and Asians (n = 312). RESULTS: These measurements (LL, PI, PT, and SS) obtained for the 36 African American subjects aged 18 years or older [15 men and 21 women; mean age 26.6 ± 8.7 range (18-53)] The mean LL, PI, PT and SS values were 57.2°, 57.7°, 15.9° and 41.4°, respectively. A comparative analysis showed the means values for PI was greater in the African American than in Caucasian (57.7° vs. 52.6°, p = 0.007), and than in Asian (57.7° vs. 48.7°, p < 0.001). The linear regression model for the LL as a function of PI were "predict LL = 0.41 × PI + 33.7" in African American, "predict LL = 0.58 × PI + 24.3" in Caucasian, and "predict LL = 0.54 × PI + 22.0" in Asian, respectively. CONCLUSION: Significant differences in sagittal spino-pelvic parameters among races were seen. These differences should be considered when planning surgical reconstruction for spinal surgery. These slides can be retrieved under Electronic Supplementary Material.

External validation of the adult spinal deformity (ASD) frailty index (ASD-FI).

PURPOSE: To assess the ability of the recently developed adult spinal deformity frailty index (ASD-FI) to predict odds of perioperative complications, odds of reoperation, and length of hospital stay after adult spinal deformity (ASD) surgery using a database other than the one used to create the index. METHODS: We used the ASD-FI to calculate frailty scores for 266 ASD patients who had minimum postoperative follow-up of 2 years in the European Spine Study Group (ESSG) database. Patients were enrolled from 2012 through 2013. Using ASD-FI scores, we categorized patients as not frail (NF) (< 0.3 points), frail (0.3-0.5 points), or severely frail (SF) (> 0.5 points). Multivariable logistic regression, adjusted for preoperative and surgical factors such as operative time and blood loss, was performed to determine the relationship between ASD-FI category and odds of major complications, odds of reoperation, and length of hospital stay. RESULTS: We categorized 135 patients (51%) as NF, 90 patients (34%) as frail, and 41 patients (15%) as SF. Overall mean ASD-FI score was 0.29 (range 0-0.8). The adjusted odds of experiencing a major intraoperative or postoperative complication (OR 4.5, 95% CI 2.0-10) or having a reoperation (OR 3.9, 95% CI 1.7-8.9) were higher for SF patients compared with NF patients. Mean hospital stay was 2.1 times longer (95% CI 1.8-2.4) for SF patients compared with NF patients. CONCLUSIONS: Greater patient frailty, as measured by the ASD-FI, is associated with longer hospital stays and greater odds of major complications and reoperation. These slides can be retrieved under Electronic Supplementary Material.

Management of Unstable Fracture-Dislocations of the Spine in Polytrauma Patients.

A multidisciplinary and systematic approach is required for the treatment of polytrauma patients with a thoracolumbar fracture-dislocation to provide timely care and prevent iatrogenic injury. Thoracolumbar fracture-dislocations frequently occur in patients who sustain a high-energy mechanism of injury; therefore, they are associated with other orthopaedic and visceral injuries that need to be identified via a systematic protocol. Orthopaedic surgeons must obtain a thorough patient history, perform an appropriate physical examination, and obtain adequate imaging studies to expeditiously treat polytrauma patients with a thoracolumbar fracture-dislocation.

Which Malpositioned Pedicle Screws Should Be Revised?

BACKGROUND: Up to 10% of free-hand pedicle screws are malpositioned, and 1 in 300 patients may undergo return to surgery for revision of malpositioned screws. The indications for revision of asymptomatic malpositioned screws have not been carefully examined in the literature. We sought to evaluate the threshold among spinal deformity surgeons for revision of malpositioned screws. METHODS: Twelve experienced spine surgeons reviewed x-ray and computed tomographic images of 32 malpositioned pedicle screws with variable degrees of anterior, medial, and lateral breeches. The surgeons were asked whether based on the image they would revise the screw: (1) intraoperatively before rod placement; (2) intraoperatively after rod placement; (3) in clinic with an asymptomatic patient. For each scenario, we assumed stable neuromonitoring and no neurological changes. Agreement and multirater κ was calculated. RESULTS: There was good agreement as to which screws were malpositioned (80% agreement, κ=0.703). After the rod was placed or postoperatively (scenarios 2 and 3), surgeons less frequently recommended screw revision, and there was greater variability among the surgeons' recommendations. For return to surgery from clinic for asymptomatic screw revision, % agreement was only 65% (κ=0.477). The majority recommended revision surgery for screws which approached the dura (10/12) or the aorta (7/12 surgeons). Half of the surgeons recommended revision surgery for an asymptomatic screw if the entire screw diameter was in the canal. Revision surgery was not recommended for asymptomatic patients with screws partially violating the canal (<½ the screw diameter), malpositioned laterally in the rib head, or with small anterior cortical violations remote from a vascular structure. CONCLUSIONS: There is significant variability of opinion among surgeons regarding which malpositioned screws can be safely observed in an asymptomatic patient. Given the frequency of malpositioned screws and morbidity of surgical return to surgery, more long-term data are needed to develop practice guidelines for determining which screws require revision surgery. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Age variation in the minimum clinically important difference in SRS-22r after surgical treatment for adult spinal deformity - A single institution analysis in Japan.

BACKGROUND: The Scoliosis Research Society-22r (SRS-22r) has been shown to be reliable, valid and responsive to change in patients with adult spinal deformity (ASD) undergoing surgery. The minimum clinically important difference (MCID) quantifies a threshold value of improvement that is clinically relevant to the patient. Health-related quality of life scores depend on age. The purpose of this study was to assess MCID threshold values stratified by age for SRS-22r domains in patients with ASD undergoing surgical correction. METHODS: We identified a consecutive series of 184 Japanese ASD patients who completed the SRS-22r and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) preoperatively and 1 year postoperatively. Effectiveness as measured on the JOABPEQ was used as the anchor to determine MCID for the Function, Pain, and Mental health domains using receiver-operating-characteristic (ROC) curve analysis. We performed MCID analysis stratified by age (<70 or ≥70). RESULTS: Mean preoperative SRS-22r Function score was 2.69 improving to 3.23 at postoperatively (p < 0.001). Mean preoperative SRS-22r Pain score was 3.04 improving to 3.78 at postoperatively (p < 0.001). Mean preoperative SRS-22r Mental health score was 2.72 improving to 3.25 at postoperatively (p < 0.001). There was a statistically difference in change in domain score between "not effective" and "effective" (p < 0.001). The ROC curve analysis methods yielded MCID values of 0.58 for Function, 0.55 for Pain, and 0.70 for Mental health domains. There was difference of MCID value for Function and Mental health domain between aged <70 and ≥70; 0.78 and 0.55 for Function; 0.70 and 0.48 for Mental health. CONCLUSION: Results of this study showed that MCID threshold values for SRS-22 Function and Mental health domains in older than 70 was lower than in younger than 70, potentially implying that older patients have lower expectation.

Management of a 3-year-old with an unstable C6-C7 diastasis without quadriplegia.

BACKGROUND: Caring for pediatric spine trauma patients places spine surgeons in situations that require unique solutions for complex problems. Recent case reports have highlighted a specific injury pattern to the lower cervical spine in very young children that is frequently associated with complete spinal cord injury. METHODS: This report describes the presentation and treatment of a C6-C7 dislocation in a 3-year-old patient with an incomplete spinal cord injury. The highly unstable cervical injury and the need to prevent neurologic decline added complexity to the case. RESULTS: A multi-surgeon team allowed for ample manpower to position the patient; with individuals with the requisite training and experience to safely move a patient with a highly unstable cervical spine. Initial closed reduction under close neurophysiologic monitoring, posterior fusion and immediate anterior stabilization lead to a successful patient outcome with preserved neurologic function. A traumatic cerebrospinal fluid leak, while a concern early on during the procedure, resolved without direct dural repair and did not complicate the patient's fusion healing. Additional anterior stabilization and fusion allowed long-term stability with bone healing that may not be achievable with posterior fixation and/or soft tissue healing alone. CONCLUSIONS: Familiarity with the challenges and solutions presented in the case may be useful to surgeons who could face a similar challenge in the future.

Communicating hydrocephalus, a long-term complication of dural tear during lumbar spine surgery.

PURPOSE: Iatrogenic dural tears during lumbar spine surgery are not uncommon and may have multiple long-term sequelae if not managed promptly and definitively. Sequelae include pseudomeningocoeles due to a persistent cerebrospinal fluid leak, which may result in a subarachnoid hemorrhage or subdural hematoma. These, in turn, can lead to adult communicating hydrocephalus. The purpose of this study is to describe a case of an intraoperative iatrogenic dural tear leading to the formation of a pseudomeningocoele and progressing to hydrocephalus. METHODS: We present a case of a 62-year-old female who had an iatrogenic dural tear during a lumbar decompression and instrumented fusion. Attempts at closure were unsuccessful, which led to the formation of a pseudomeningocoele and an ascending subdural hygroma, progressing into a communicating hydrocephalus which was treated with a ventriculoperitoneal shunt. RESULTS: Imaging studies and clinical follow up after the incidental durotomy demonstrate complications arising from the persistent cerebrospinal fluid leak, beginning with the formation of the pseudomeningocoele and progression to hydrocephalus. Based on these imaging studies, it was possible to illustrate the development of each of the complications. CONCLUSION: The need for prompt recognition and proper management of iatrogenic dural tears are emphasized in order to avoid future complications that may arise from inadequate or proper treatment.

Incidence of cancer in adolescent idiopathic scoliosis patients treated 25 years previously.

PURPOSE: To report the incidence of cancer in a cohort of adolescent idiopathic scoliosis (AIS) patients treated 25 years previously. METHODS: 215 consecutive AIS patients treated between 1983 and 1990 were identified and requested to return for clinical and radiographic examination. The incidence of cancer was determined through chart review and follow-up interviews. Using the original radiographic log file that included patient position, mAs, kV and the total number of X-rays taken, a radiation physicist calculated the total radiation dose during treatment and follow-up adjusted for BMI and sex. RESULTS: From the original cohort of 215 consecutive AIS patients, radiation information was available in 211 of the patients, and medical charts were available in 209 AIS patients. 170 (83 %) of the 205 AIS patients participated in the follow-up study with questionnaires. The calculated mean total radiation exposure was 0.8-1.4 mSV per examination and 2.4-5.6 mSv/year. An average of 16 radiographs were taken during the treatment period. Nine AIS patients developed cancer, mostly breast (3) and endometrial (4). The AIS patients had a relative risk of 4.8 (CI 2.3-5.8, p < 0.000) for developing cancer compared to the normal Danish population. CONCLUSIONS: The overall cancer rate in this AIS cohort was 4.3 % which is five times higher than compared to the age-matched Danish population, and endometrial and breast cancer was most frequent. The radiation dose applied to the patients in this study, is comparable to modern equipment. This is to our knowledge the first study to report increased rates of endometrial cancers in a cohort of AIS patients, and future attention is needed to reduce the radiation dose distributed to the AIS patients both pre-operatively and during surgery.

Periarticular Injection After Total Knee Arthroplasty Using Liposomal Bupivacaine vs a Modified Ranawat Suspension: A Prospective, Randomized Study.

BACKGROUND: The purpose of this study is to compare liposomal bupivacaine to a modified (Ranawat) local injection for total knee arthroplasty (TKA). METHODS: This is a prospective, randomized study of 105 consecutive patients undergoing primary TKA. Group A patients received a periarticular injection with liposomal bupivacaine and group B with a mixture of ropivacaine, epinephrine, ketorolac, and clonidine. There were 54 patients in the group A (liposomal bupivacaine) and 51 in group B. RESULTS: There were no differences in the groups with respect to age, sex, and preoperative knee scores. There were no differences with respect to postoperative narcotic usage and knee range of motion. CONCLUSION: Liposomal bupivacaine as a periarticular injection after TKA demonstrated similar pain levels, narcotic usage, and range of motion compared to a modified Ranawat suspension but improved walking distance.

Evaluation of complications and neurological deficits with three-column spine reconstructions for complex spinal deformity: a retrospective Scoli-RISK-1 study.

OBJECT: The goal in this study was to evaluate the risk factors for complications, including new neurological deficits, in the largest cohort of patients with adult spinal deformity to date. METHODS: The Scoli-RISK-1 inclusion criteria were used to identify eligible patients from 5 centers who were treated between June 1, 2009, and June 1, 2011. Records were reviewed for patient demographic information, surgical data, and reports of perioperative complications. Neurological deficits were recorded as preexisting or as new deficits. Patients who underwent 3-column osteotomies (3COs) were compared with those who did not (posterior spinal fusion [PSF]). Between-group comparisons were performed using independent samples t-tests and chi-square analyses. RESULTS: Two hundred seven patients were identified-75 who underwent PSF and 132 treated with 3CO. In the latter group, patients were older (58.9 vs 49.4 years, p < 0.001), had a higher body mass index (29.0 vs 25.8, p = 0.029), smaller preoperative coronal Cobb measurements (33.8° vs 56.4°, p < 0.001), more preoperative sagittal malalignment (11.7 cm vs 5.4 cm, p < 0.001), and similar sagittal Cobb measurements (45.8° vs 57.7°, p = 0.113). Operating times were similar (393 vs 423 minutes, p = 0.130), although patients in the 3CO group sustained higher estimated blood loss (2120 vs 1700 ml, p = 0.066). Rates of new neurological deficits were similar (PSF: 6.7% vs 3CO: 9.9%, p = 0.389), and rates of any perioperative medical complication were similar (PSF: 46.7% vs 3CO: 50.8%, p = 0.571). Patients who underwent vertebral column resection (VCR) were more likely to sustain medical complications than those treated with pedicle subtraction osteotomy (73.7% vs 46.9%, p = 0.031), although new neurological deficits were similar (15.8% vs 8.8%, p = 0.348). Regression analysis did not reveal significant predictors of neurological injury or complication from collected data. CONCLUSIONS: Despite higher estimated blood loss, rates of all complications (49.3%) and new neurological deficits (8.7%) did not vary for patients who underwent complex reconstruction, whether or not a 3CO was performed. Patients who underwent VCR sustained more medical complications without an increase in new neurological deficits. Prospective studies of patient factors, provider factors, and refined surgical data are needed to define and optimize risk factors for complication and neurological deficits.

Relative benefit of TLIF versus PSF stratified by diagnostic indication.

STUDY DESIGN: Case-matched retrospective. OBJECTIVES: The purpose of this study is to compare 2-year health-related quality of life (HRQOL) outcomes of patients who underwent 1-level or 2-level posterolateral spine fusion (PSF) versus transforaminal interbody fusion (TLIF) for degenerative spondylolisthesis, disk pathology, and postdecompression instability. SUMMARY OF BACKGROUND DATA: The optimal surgical technique for patients with spondylolisthesis or other degenerative conditions has not been defined. Historically, PSF was the most common procedure, whereas in recent years TLIF has gained popularity. Although theoretical advantages for TLIF have been outlined, evidence for improved outcomes with the addition of interbody support is limited. METHODS: Patients with degenerative spondylolisthesis, with disk pathology and or postdecompression instability who underwent 1-level or 2-level TLIF and completed 2 years postoperative HRQOL measures were identified from a prospective database. These patients were then propensity-matched to a cohort of PSF patients based on age, number of surgical levels, body mass index, sex, smoking status, workers' compensation status, and preoperative outcome measures including the Oswestry Disability Index, SF-36 Physical Component Summary score, SF-36 Mental Composite Summary score, and back and leg pain scores. This produced 63 matched pairs with degenerative spondylolisthesis, 46 with disk pathology and 32 with postdecompression instability. RESULTS: All patients in both groups for each cohort reported statistically significant improvement in HRQOL scores at 2 years postoperatively compared with baseline. Improvements in the Oswestry Disability Index, SF-36 Physical Component Summary score, and back and leg pain scores within the spondylolisthesis and disk pathology subgroups were similar between patients who had a TLIF compared with those who had a PSF. The postdecompression instability subgroup was the only subgroup in which TLIF outperformed PSF for every outcome measure. CONCLUSIONS: Clinical outcome was not significantly altered with TLIF as compared with PSF in patients with spondylolisthesis or disk pathology. However, TLIF resulted in better outcomes at 2 years postoperatively in patients with postdecompression instability.