SPINE20 recommendations 2021: spine care for people's health and prosperity.

PURPOSE: The focus of SPINE20 is to develop evidence-based policy recommendations for the G20 countries to work with governments to reduce the burden of spine disease, and disability. METHODS: On September 17-18, 2021, SPINE20 held its annual meeting in Rome, Italy. Prior to the meeting, the SPINE20 created six proposed recommendations. These recommendations were uploaded to the SPINE20 website 10 days before the meeting and opened to the public for comments. The recommendations were discussed at the meeting allowing the participants to object and provide comments. RESULTS: In total, 27 societies endorsed the following recommendations. SPINE20 calls upon the G20 countries: (1) to expand telehealth for the access to spine care, especially in light of the current situation with COVID-19. (2) To adopt value-based interprofessional spine care as an approach to improve patient outcomes and reduce disability. (3) To facilitate access and invest in the development of a competent rehabilitation workforce to reduce the burden of disability related to spine disorders. (4) To adopt a strategy to promote daily physical activity and exercises among the elderly population to maintain an active and independent life with a healthy spine, particularly after COVID-19 pandemic. (5) To engage in capacity building with emerging countries and underserved communities for the benefit of spine patients. (6) To promote strategies to transfer evidence-based advances into patient benefit through effective implementation processes. CONCLUSIONS: SPINE20's initiatives will make governments and decision makers aware of efforts to reduce needless suffering from disabling spine pain through education that can be instituted across the globe.

SPINE20 A global advocacy group promoting evidence-based spine care of value.

PURPOSE: The Global Burden of Diseases (GBD) Studies have estimated that low back pain is one of the costliest ailments worldwide. Subsequent to GBD publications, leadership of the four largest global spine societies agreed to form SPINE20. This article introduces the concept of SPINE20, the recommendations, and the future of this global advocacy group linked to G20 annual summits. METHODS: The founders of SPINE20 advocacy group coordinated with G20 Saudi Arabia to conduct the SPINE20 summit in 2020. The summit was intended to promote evidence-based recommendations to use the most reliable information from high-level research. Eight areas of importance to mitigate spine disorders were identified through a voting process of the participating societies. Twelve recommendations were discussed and vetted. RESULTS: The areas of immediate concern were "Aging spine," "Future of spine care," "Spinal cord injuries," "Children and adolescent spine," "Spine-related disability," "Spine Educational Standards," "Patient safety," and "Burden on economy." Twelve recommendations were created and endorsed by 31/33 spine societies and 2 journals globally during a vetted process through the SPINE20.org website and during the virtual inaugural meeting November 10-11, 2020 held from the G20 platform. CONCLUSIONS: This is the first time that international spine societies have joined to support actions to mitigate the burden of spine disorders across the globe. SPINE20 seeks to change awareness and treatment of spine pain by supporting local projects that implement value-based practices with healthcare policies that are culturally sensitive based on scientific evidence.

Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized double-blind sham-controlled multi-center study.

BACKGROUND: Damaged or degenerated vertebral endplates are a significant cause of vertebrogenic chronic low back pain (CLBP). Modic changes are one objective MRI biomarker for these patients. Prior data from the treatment arm of a sham-controlled, RCT showed maintenance of clinical improvements at 2 years following ablation of the basivertebral nerve (BVN). This study reports 5-year clinical outcomes. METHODS: In total, 117 US patients were treated successfully with BVN ablation. Patient-reported outcomes of ODI, VAS, postablation treatments, and patient satisfaction were collected at a minimum of 5-years following BVN ablation. Primary outcome was mean change in ODI. Comparisons between the postablation and baseline values were made using an analysis of covariance with alpha 0.05. RESULTS: Of the 117 US treated patients 100 (85%) were available for review with a mean follow-up of 6.4 years (5.4-7.8 years). Mean ODI score improved from 42.81 to 16.86 at 5-year follow-up, a reduction of 25.95 points (p < 0.001). Mean reduction in VAS pain score was 4.38 points (baseline of 6.74, p < 0.001). In total, 66% of patients reported a > 50% reduction in pain, 47% reported a > 75% reduction in pain, and 34% of patients reported complete pain resolution. Composite responder rate using thresholds of ≥ 15-point ODI and ≥ 2-point VAS for function and pain at 5 years was 75%. CONCLUSION: CLBP patients treated with BVN ablation exhibit sustained clinical improvements in function and pain with high responder rates at a mean of 6.4 years following treatment. BVN ablation is a durable, minimally invasive treatment for vertebrogenic CLBP.

A prospective, open-label, single-arm, multi-center study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain.

PURPOSE: A prospective, single-arm, open-label study to evaluate the effectiveness of intraosseous radio frequency (RF) ablation of the basivertebral nerve (BVN) for the treatment of vertebrogenic-related chronic low back pain (CLBP) in typical spine practice settings using permissive criteria for study inclusion. METHODS: Consecutive patients with CLBP of at least 6 months duration and with Modic Type 1 or 2 vertebral endplate changes between L3 and S1 were treated with RF ablation of the BVN in up to four vertebral bodies. The primary endpoint was patient-reported change in Oswestry Disability Index (ODI) from baseline to 3 months post-procedure. Secondary outcome measures included change in visual analog scale (VAS), SF-36, EQ-5D-5L, and responder rates. RESULTS: Median age was 45 years; baseline ODI was 48.5; VAS was 6.36. Seventy-five percent (75%) of the study patients reported LBP symptoms for ≥ 5 years; 25% were actively using opioids; and 61% were previously treated with injections. Mean change in ODI at 3 months posttreatment was - 30.07 +14.52 points (p < 0.0001); mean change in VAS was - 3.50 + 2.33 (p < 0.0001). Ninety-three percent (93%) of patients achieved a ≥ 10-point improvement in ODI, and 75% reported ≥ 20-point improvement. CONCLUSIONS: Minimally invasive RF ablation of the BVN demonstrated a significant improvement in pain and function in this population of real-world patients with chronic vertebrogenic-related LBP. These slides can be retrieved under Electronic Supplementary Material.

A history of lumbar disc herniation from Hippocrates to the 1990s.

In ancient times, a supernatural understanding of the syndrome of lumbar radiculopathy often involved demonic forces vexing the individual with often crippling pain. The ancient Greeks and Egyptians began to take a more naturalistic view and, critically, suspected a relationship between lumbar spinal pathology and leg symptoms. Relatively little then changed for those with sciatica until the classic works by Cotugno and Kocher arrived in the late 18th century. Early lumbar canal explorations were performed in the late 1800s and early 1900s by MacEwen, Horsley, Krause, Taylor, Dandy, and Cushing, among others. In these cases, when compressive pathologies were found and removed, the lesions typically were (mis-)identified as enchondromas or osteochondritis dissecans. To better understand the history, learn more about the first treatments of lumbar disc herniation, and evaluate the impact of the early influences on modern spine practice, searches of PubMed and Embase were performed using the search terms discectomy, medical history, lumbar spine surgery, herniated disc, herniated nucleus pulposus, sciatica, and lumbar radiculopathy. Additional sources were identified from the reference lists of the reviewed papers. Many older and ancient sources including De Ischiade Nervosa are available in English translations and were used. When full texts were not available, English abstracts were used. The first true, intentional discectomy surgery was performed by Mixter and Barr in 1932. Early on, a transdural approach was favored. In 1938, Love described the intralaminar, extradural approach. His technique, although modified with improved lighting, magnification, and retractors, remains a staple approach to disc herniations today. Other modalities such as chymopapain have been investigated. Some remain a part of the therapeutic armamentarium, whereas others have disappeared. By the 1970s, CT scanning after myelography markedly improved the clinical evaluation of patients with lumbar disc herniation. In this era, use of discectomy surgery increased rapidly. Even patients with very early symptoms were offered surgery. Later work, especially by Weber and Hakelius, showed that many patients with lumbar disc herniation would improve without surgical intervention. In the ensuing decades, the debate over operative indications and timing continued, reaching another pivotal moment with the 2006 publication of the initial results of Spine Patient Outcomes Research Trial.

Feasibility of rigid upper cervical instrumentation in children: tomographic analysis of children aged 2-6.

STUDY DESIGN: Tomographic analysis of occipitocervical (OC) instability in children aged between 2 and 6 years. OBJECTIVE: To assess the feasibility of screw placement in various bone anchors in the OC region in young children. SUMMARY OF BACKGROUND DATA: The use of rigid stabilization in the pediatric patients is gradually increasing. No study has comprehensively assessed the suitability of bony anatomy of the OC region for screw placement, especially in younger children. METHODS: A total of 50 patients (2-6 y, 10 each) who underwent skull and cervical CT scanning were randomly queried using an x-ray database. Screw placement was considered feasible if there was at least 0.5 mm of bone around a 3.5 mm screw through its trajectory. When the bony channel measured 3.5-4.0 mm, placement was considered possible, but difficult. RESULTS: Statistically, most measures were similar from the right to left sides. External occipital protuberance thickness increased from a mean value of 8.60 mm to a mean value of 10.73 mm. The mean C1 lateral mass length and width varied from 15.26 to 16.67 mm (P=0.056) and 7.34 to 8.58 mm (P=0.0005), respectively, with age. The mean C2 pedicle width and length varied from 3.85 to 4.18 and 17.11 to 19.8 mm, respectively, with age. The mean C2 laminar screw length increased from 20.4 to 22.66 mm with age (P<0.001). C2 lamina widths did not vary much by age. The mean C1-C2 transarticular path length and height increased from 26.7 to 33.6 mm and 2.58 to 3.09 mm, respectively, with age. The width was less directly variable by age (2.68-3.09 mm). CONCLUSIONS: Standard 3.5 mm screws can be used for OC and upper cervical instabilities in children aged between 2 and 6 years. Some anchor points appeared safer compared with others. The occipital keel, C1 lateral mass, and C2 laminae offered adequate space for screw placement in almost all cases. C2 pedicles offered adequate space in 49 sides and barely adequate space in 25 pedicles. Transarticular screws could be safely placed in only 4 of 100 sides. Close radiographic assessment of the vertebral artery course and bony architecture are recommended before surgery in pediatric patients with OC and upper cervical instability.

How Minimal Clinically Important Difference and Patient Acceptable Symptom State Relate to Patient Expectations and Satisfaction in Spine Surgery: A Review.

This narrative review seeks to enhance our comprehension of how Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS) values in established Patient Reported Outcome Measures (PROMs) for spine surgery correspond with patient preoperative expectations and postoperative satisfaction. Through our literature search, we found that both MCID and PASS serve as dependable indicators of patient expectations. However, MCID may be more susceptible to a floor effect. This implies that PASS may offer a more accurate reflection of how patients anticipate surgery to address their symptoms. Nevertheless, it is crucial to recognize that achieving MCID or PASS may not be an absolute prerequisite for patients to be satisfied with their treatment.

Minimal Clinically Important Difference and Patient-Acceptable Symptom State in Orthopaedic Spine Surgery: A Review.

¼: Minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) are both metrics at interpreting patient-reported outcome measures (PROMs). ¼: MCID values tend to vary significantly depending on the baseline pain and function in both acute and chronic symptom states while PASS thresholds are more stable. ¼: MCID values are more easily attainable than PASS thresholds. ¼: Although PASS is more relevant to the patient, it should continue to be used in tandem with MCID when interpreting PROM data.

Clinical Characteristics of 96 Patients Presenting With Hematogenous Spinal Osteomyelitis- a Retrospective Study.

OBJECTIVE: To report clinical characteristics and course of care for patients diagnosed with hematogenous spinal osteomyelitis (HVO). METHODS: Medical records of patients presenting to two tertiary care centers with HVO were reviewed. RESULTS: 96 consecutive patients with HVO were identified. Mean follow-up was 8.9 months. Most infections occurred in the lumbar region (50.0%). Of the cultures taken, MRSA accounted for 9%; MSSA, 26%; Streptococcus species, 12%; other gram-positive bacteria, 23%; gram-negative, 17%; fungal, 2.6%; and 11.5% of cultures returned no growth. 57 patients underwent surgery. Of these, 79% of the patients had undergone a trial of empiric antibiotics (cefepime and vancomycin) of the day prior to surgery. 44% underwent secondary surgeries, typically due to a heavy wound burden of necrotic tissue and pus. Postoperative antibiotics were prescribed to all patients. 51.6% of the patients were prescribed antibiotic therapy >6 months. Overall mortality rate was 3.8%. Major cause of all deaths was septic shock. Post-infection sequelae occurred in 47.4% of patients. The most common sequelae were persistent or new sites of infection, sepsis, and abscess. CONCLUSIONS: Diabetes, hypertension, and renal failure appear to increase the risk of post-infection sequelae and death. While non-operative management was attempted in nearly 47%, ultimately 73% had surgery. This high rate may reflect our population of patients hospitalized in a tertiary care center. Available data suggests that patients presenting with hematogenous osteomyelitis be followed closely as failure of non-operative management, and resulting morbidity, was high.

Bridging the Cervicothoracic Junction During Multi-Level Posterior Cervical Decompression and Fusion: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and Meta-analysis. OBJECTIVE: This systematic review seeks to compare fusion, reoperation and complication rates, estimated blood loss (EBL), and surgical time between multi-level instrumented fusions with LIVs (lowest instrumented vertebra) in the cervical spine and those that extend into the thoracic spine. SUMMARY OF BACKGROUND DATA: Several studies address the question of whether to extend a long-segment, posterior cervical fusions, performed for degenerative disease, into the upper thoracic spine. Recommendations for appropriate LIV continue to vary. METHODS: A comprehensive computerized literature search through multiple electronic databases without date limits up until April 3rd, 2020 using combinations of key search terms and sets of inclusion/exclusion criteria was performed. RESULTS: Our comprehensive literature search yielded 3852 studies. Of these, 8 articles consisting of 1162 patients were included in the meta-analysis. In 61.2% of the patients, the fusion did not cross the cervicothoracic junction (CTJ) (cervical LIV, CLV). In the remaining 38.8%, the fusion extended into the upper thoracic spine (thoracic LIV, TLV). Overall, mean patient age was 62.5 years (range: 58.8-66.1 years). Our direct analysis showed that odds of fusion were not statistically different between the CLV and TLV groups (OR: .648, 95% CI: .336-1.252, P = .197). Similarly, odds of reoperation (OR: 0.726, 95% CI: 0.493-1.068, P = .104) and complication rates were similar between the 2 groups (OR: 1.214, 95% CI: 0.0.750-1.965, P = .430). Standardized mean difference (SMD) for the blood loss (SMD: .728, 95% CI: 0.554-.901, P = .000) and operative (SMD: 0.653, 95% CI: .479-.826, P = .000) differed significantly between the 2 groups. The indirect analysis showed similar fusion (Effect Size (ES)TLV: .892, 95% CI: .840-.928 vs ESCLV:0.894, 95% CI:0.849-.926); reoperation rate (ESTLV:0.112, 95% CI: 0.075-.164 vs ESCLV: .125, 95% CI: .071-.211) and complication rates (ESTLV: .108, 95% CI: .074-.154 vs ESCLV:0.081, 95% CI: .040-.156). CONCLUSIONS: Our meta-analysis showed that fusion, complication, and reoperation rates did not differ significantly between patients in whom multi-level posterior fusions ended in the cervical spine vs those of which was extended into the thoracic spine. The mean blood loss, operative time and length of stay were significantly lower in patients with CLV at C6 or C7, compared to their counterparts. These data suggest that, absent focal, C7-T1 pathology, extension of long, posterior cervical fusions into the thoracic spine may not be necessary.

Quality and Accuracy of Cervical Radiculopathy-specific Information on the Internet: A Cross-sectional Analysis.

STUDY DESIGN: Cross-sectional analysis. OBJECTIVE: This study aimed to evaluate the quality and accuracy of the content surrounding cervical radiculopathy available on the internet. SUMMARY OF BACKGROUND DATA: Those experiencing cervical radiculopathy and their families are increasingly browsing the worldwide web for medical information. As the information offered is likely to influence their health care choices, spine care providers must understand the quality and accuracy of that information. METHODS: Independent searches were conducted on the three most commonly accessed search engines (Google, Yahoo, and Bing) using the keyword "cervical radiculopathy." The searches were performed on June 28th, 2019. The top 50 sites from each search engines were reviewed. The websites were evaluated using quality, accuracy and usability markers. RESULTS: Seventy-seven unique websites were analyzed; 54.5% were physician or medical group professional sites, 20.8% as non-physician, 10.4% as unidentified, 7.8% as academics, and 6.5% were commercial. Accuracy ranged from <25% to >75% were recorded with a mean accuracy of 3.5 signifying 50% to 75% agreement. Overall, website categories had a significant effect on Journal of American Medical Association (JAMA) score, content quality, accuracy, total summary scores, distraction index, reading ease, and grade level (P  < 0.05). Academic sites had the highest mean quality content, accuracy and total summary scores. Four of the top five websites with the highest total summary scores were physician driven. On average, Health on the Net code (HONcode) certified websites had lower grade level readability with greater reading ease and higher DISCERN and JAMA scores than uncertified sites (P < 0.05). CONCLUSION: Despite the wide number of sources available, the quality, accuracy, pertinence, and intelligibility of the information remains highly variable. Clinicians treating patients with cervical radiculopathy should direct them to verifiable sites with regulated information and, where possible, contribute high- quality information to those sites.Level of Evidence: 4.

Social media as a new source of medical information and support: analysis of scoliosis-specific information.

BACKGROUND CONTEXT: It has never been easier for patients to obtain information about and to connect with others with a given health issue. Frequently, patients turn to social media. There, more information and emotional support from individuals with similar experiences should empower patients, contributing to a better functional and overall outcome. Unfortunately, social media often contains biased reports and misinformation. PURPOSE: This study aimed to assess the footprint of AIS (adolescent idiopathic scoliosis) on the top four social media platforms. STUDY DESIGN: Cross-sectional analysis. METHODS: Independent searches were conducted across four major social media platforms (Facebook, Instagram, YouTube, and LinkedIn) using the keywords "scoliosis" and "#scoliosis" for Instagram. The top 50 posts from each platform were evaluated based on the overall tone of the post (positive, negative, neutral); who made the post (business, patient, family/friend, hospital/physician); the intent of the postcy (advertisement, educate the viewer about scoliosis/disease process/treatments, raise awareness, provide support to patients and their family/friends, promote research); the credentials of the poster [MD, clinician (non-MD), non-clinician, unknown]; the type of media used in the post (text only, picture, video, multiple) and if the post had an external link and what content the link provided (academic, hospital/physician, health news outlet, alternative treatment, personal blog, business, other). RESULTS: 196 unique postings were analyzed for the various content criteria. Across all four platforms, the majority of posts were made by a non-clinician (42.8%) representing a business (49.3%), with the intent to educate (32.3%) using a neutral tone (52.5%). Pictures (61%) were the most common media, and 56.3% of all posts contained external links. Often, those links lead to sites promoting alternative treatments (28.8%). In comparison to the overall analysis, Instagram deviated from the patterns the most. Instagram was the only platform with a predominantly positive tone (62%). Here, 71% of the postings came from an actual patient with the intent to describe their experience or daily life with scoliosis (36%). Instagram had the lowest rate of external links (39%) and most of those lead to another person's Instagram account or a personal blog (47%). Hospital and physician groups had the highest presence on YouTube (35%), but the highest MD authorship was on Facebook (28%). CONCLUSION: Social media can be a powerful tool to disseminate information and create supportive communities for patients with chronic conditions. Healthcare providers and educators are underutilizing these outlets to reach our patients and help provide them the information and support networks they need.

Preoperative patient-reported outcome score thresholds predict the likelihood of reaching MCID with surgical correction of adult spinal deformity.

BACKGROUND CONTEXT: Preoperative (pre-op) identification of patients likely to achieve a clinically meaningful improvement following surgery for adult spinal deformity (ASD) is critical, especially given the substantial cost and comorbidity associated with surgery. Even though pain is a known indication for surgical ASD correction, we are not aware of established thresholds for baseline pain and function to guide which patients have a higher likelihood of improvement with corrective surgery. PURPOSE: We aimed to establish pre-op patient-reported outcome measure (PROM) thresholds to identify patients likely to improve by at least one minimum clinically important difference (MCID) with surgery for ASD. STUDY DESIGN: This is a retrospective cohort study using prospectively collected data. PATIENT SAMPLE: We reviewed 172 adult patients' charts who underwent corrective surgery for spinal deformity. OUTCOME MEASURES: Included measures were the Visual Analog Scale for pain (VAS), Oswestry Disability Index (ODI), and Scoliosis Research Society-22 (SRS-22). Our primary outcome of interest was improvement by at least one MCID on the ODI and SRS-22 at 2 years after surgery. METHODS: As part of usual care, the VAS, ODI, and SRS-22 were collected pre-op and re-administered at 1, 2, and 5 years after surgery. MCIDs were calculated using a distribution-based method. Determining significant predictors of MCID at two years was accomplished by Firth bias corrected logistic regression models. Significance of predictors was determined by Profile Likelihood Chi-square. We performed a Youden analysis to determine thresholds for the strongest pre-op predictors. RESULTS: At year two, 118 patients (83%) reached MCID for the SRS and 127 (75%) for the ODI. Lower pre-op SRS overall, lower pre-op SRS pain, and higher pre-op SRS function predicted a higher likelihood of reaching MCID on the overall SRS (p < 0.05). Higher pre-op ODI, lower SRS pain and self-image, and higher SRS overall predicted a higher likelihood of reaching MCID on the ODI (p < 0.05). An ODI threshold of 29 predicted reaching MCID with a sensitivity of 0.89 and a specificity of 0.64 (AUC = 0.7813). An SRS threshold of 3.89 predicted reaching MCID with a sensitivity of 0.93 and specificity of 0.68 (AUC = 0.8024). CONCLUSIONS: We identified useful thresholds for ODI and SRS-22 with acceptable predictive ability for improvement with surgery for ASD. Pre-op ODI, SRS, and multiple SRS subscores are predictive of meaningful improvement on the ODI and/or SRS at 2 years following corrective surgery for spinal deformity. These results highlight the usefulness of PROMs in pre-op shared decision-making.

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.

Management of degenerative spondylolisthesis: development of appropriate use criteria.

BACKGROUND CONTEXT: Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. PURPOSE: The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. STUDY DESIGN: A Modified Delphi process was used. METHODS: The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. RESULTS: There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. CONCLUSIONS: Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Preoperative embolization in the treatment of spinal metastasis.

Because of advances in the treatment of cancer, the average rate of patient survival is increasing. As patients with cancer live longer, the incidence of spinal metastasis also likely will increase. To help control pain and maintain function, some of these metastases will require surgical intervention. Because >60% of spinal metastases are hypervascular, preoperative embolization may be considered in order to decrease hemorrhage risk and improve outcomes. Embolization for spinal metastasis can be performed through the angiogram catheter. When such embolization is performed carefully, the complication rate is low.

Cross sectional analysis of scoliosis-specific information on the internet: potential for patient confusion and misinformation.

BACKGROUND CONTEXT: Patients and their families are increasingly turning to the internet for medical information. Most of these patients believe the information to be accurate and reliable. However, the quality and accuracy of that information on the internet is variable and unregulated. Accurate and applicable information may align patients' expectations and improve satisfaction and overall outcomes. PURPOSE: This study aimed to evaluate the quality and accuracy of scoliosis-related information available on the internet. STUDY DESIGN: Cross-sectional analysis. METHODS: Independent searches were conducted on the three most commonly accessed search engines (Google, Yahoo and Bing) using the keyword "scoliosis". The top 30 sites from each search engine were reviewed. Each website was categorized as per its authorship and sourcing. Each site was then evaluated for accuracy, readability and with quality-assurance markers such as Health on the Net code (HONcode), DISCERN, Journal of American Medical Association (JAMA) systems. The accuracy of the website was assessed by two fellowship-trained spine specialists. Website accuracy was rated on a scale of 1-4 based on the level of agreement with the information presented. Websites with greater than 75% agreement were rated 4. Finally, the sites were evaluated with a validated website distraction index and assessed for mobile friendliness. RESULTS: 42 unique websites were analyzed. 31% of the sites were categorized as academic (13 academic, 9 healthcare system, 12 health news outlets and 8 unspecified) and had the highest rate of physician authorship (54%). Accuracy ranged from less than 25% to more than 75% were recorded with a mean accuracy of 3 signifying 50-75% agreement. Academic sites had the highest scoliosis specific accuracy score (P < 0.05). Overall, average readability was at a 12th grade reading level. More than 90% of the sites were mobile friendly. Approximately 71% of the websites did not have HONcode certification, although health news outlets had the highest rate of certification (67%). There was a significant effect of HONcode certification on DISCERN, JAMA, grade level and reading ease. On average, HONcode certified websites had lower grade level readability with greater reading ease and higher DISCERN and JAMA scores than un-certified sites (p < 0.05). On average, health news outlets had the highest DISCERN, JAMA, and reading ease scores and were written at the lowest grade reading level but had the highest level of distraction (p < 0.05). CONCLUSION: For the iGeneration and their care-givers, the internet remains the most popular source of health-related and medical information. Despite the wide number of sources available, the quality, accuracy, pertinence and intelligibility of the information remains highly variable. As clinicians, we should direct patients to verifiable sites with regulated information and, where possible, contribute high quality information to those sites.

Relationship Between Preoperative Plasma Fibrinogen Concentration, Perioperative Bleeding, and Transfusions in Elective Adult Spinal Deformity Correction.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: This study sought to investigate the relationship between preoperative (preop) fibrinogen, bleeding, and transfusion requirements in adult spinal deformity corrections. SUMMARY OF BACKGROUND DATA: Blood loss after major spinal reconstruction increases the risks and costs of surgery. Preoperative fibrinogen levels may predict intra- and postoperative blood loss. METHODS: Data were collected from clinic charts and hospital medical records of all 142 of a single surgeon's consecutive adult spine patients undergoing 7 or more levels deformity correction surgeries from January 2011 to December 2014. t tests were used to compare perioperative variables between patients with total blood loss in the upper quartile (≥1,000 mL) and the remaining patients. Similarly, patients receiving >2 units of packed red cells (PRCs) were compared with others. Analysis of variance was used to compare the blood loss between the patients' groups (quartiles) based on their preoperative fibrinogen concentration. RESULTS: Mean total blood loss was 847.9 (±543.6) mL. Overall, mean preoperative fibrinogen concentration was 254.8 (±82.9) mg/dL. Patients with lower fibrinogen concentration (<193 mg/dL) experienced significantly higher blood loss than those with higher concentrations (p < .05). Patients with transfusion >2 units PRC had significantly greater number of spinal levels treated, higher mean operative time, total blood loss and lower mean preoperative fibrinogen than those transfused 2 or fewer units PRC (p < .05). Total blood loss correlated significantly with preoperative fibrinogen concentration (r = -0.51, p < .05). All the thromboelastography (TEG) variables (G, K, and Angle) correlated significantly with preoperative fibrinogen (p < .05). CONCLUSIONS: In our cohort undergoing correction of adult spinal deformity, patients with preoperative fibrinogen level lower than 193 mg/dL had significantly higher bleeding than their counterparts. Perioperative transfusion requirements correlated moderately both with the blood loss and preoperative fibrinogen concentration. Incorporation of preoperative fibrinogen allows better prediction of total perioperative blood loss and may therefore guide the treatment team in use of ameliorating therapies. LEVEL OF EVIDENCE: Level IV.