Race, Gender, and Primary Language Were Not Associated With Changes in Opioid Prescribing in Children: Results From a Single Institution, 2010 to 2020.

BACKGROUND: Patients should be prescribed medication based on their medical condition, without prejudice because of their race, gender, or primary language. However, previous research has shown that men are prescribed more medication than women, patients who are White are prescribed more medications than patients who are non-White, and English-speaking people are prescribed more medications than non-English-speaking patients. However, it is unclear whether these differences also occur in pediatric orthopaedic populations. QUESTIONS/PURPOSES: We asked: (1) Was the amount of opiates prescribed at discharge associated with patient age, gender, race, or primary language? (2) Did the amount of opiates prescribed to patients at discharge change from 2010 to 2020? METHODS: In a single center, between January 2010 and December 2019, we treated 331 patients younger than 18 years surgically for upper and lower long-bone extremity fractures. Patients were considered eligible if they had a nonpathologic fracture. Femur fractures were not included. Based on these criteria, all patients were eligible. The mean age was 12 ± 4 years. The mean weight was 57 ± 33 kg. Among these patients, 76% (253 of 331) were boys and 24% (78 of 331) were girls. From the hospital discharge records, we recorded the amount of opiates prescribed at the time of discharge as measured by morphine milligram equivalents (MMEs). We examined the association of age, gender, race, primary language, weight, and year of treatment using this measurement. We determined a patient's race retrospectively by information given by their parents at time of admission. We did not attempt to contact patients to obtain more nuanced information about their racial background. These data were obtained from the electronic health record. The Wilcoxon rank sum test, t-test, or chi-square test was used to assess associations depending on the distribution of variables, as appropriate. Because opioids as measured in MMEs is zero-inflated, a two-part model analysis was used to adjust for confounding variables. One component of the model was for the probability of having any opiate prescription and another was for the mean number of opioids received. Findings were considered statistically significant if p values were < 0.05. RESULTS: In total, 57% (189 of 331) of children were prescribed opiates at discharge after surgery for long-bone fractures. Opiate MMEs increased with patient age (r = 0.38; p < 0.01). Boys and girls showed no difference in the amounts of pain medication (adjusted odds ratio [OR] 1.38 [95% confidence interval (CI) 0.80 to 2.39]; p = 0.71; adjusted opioid difference: 0.35 MME [95% CI -51.7 to 52.4]; p = 0.99), nor were there differences between patients who were White and those who were non-White (adjusted OR 0.78 [95% CI 0.49 to 1.23]; p = 0.28; adjusted opioid difference: 21.5 MME [95% CI -19.3 to 62.4]; p = 0.30), or between patients for whom English was there primary language and those for whom English was not their primary language (adjusted OR 1.16 [95% CI 0.52 to 2.57]; p = 0.71; adjusted opioid difference: 22.7 MME [95% CI -55.7 to 101.3]; p = 0.57) when adjusted for age and weight. There was no change in opioid prescription amounts from 2010 to 2020 after adjusting for changes in patient age across years (Spearman r = -0.08; p = 0.16). CONCLUSION: Fairness in opioid prescribing based on race, gender, or primary language is possible. Additional research is needed to determine what factors in our institution led to this result. We suggest that prescribers should apply consistent protocols based on factors such as weight or injury type rather than making individual decisions for each patient. This will lead to fairer opioid prescribing to patients from different race and gender groups. LEVEL OF EVIDENCE: Level III, therapeutic study.

CT-to-fluoroscopy registration versus scan-and-plan registration for robot-assisted insertion of lumbar pedicle screws.

OBJECTIVE: Pedicle screw insertion for stabilization after lumbar fusion surgery is commonly performed by spine surgeons. With the advent of navigation technology, the accuracy of pedicle screw insertion has increased. Robotic guidance has revolutionized the placement of pedicle screws with 2 distinct radiographic registration methods, the scan-and-plan method and CT-to-fluoroscopy method. In this study, the authors aimed to compare the accuracy and safety of these methods. METHODS: A retrospective chart review was conducted at 2 centers to obtain operative data for consecutive patients who underwent robot-assisted lumbar pedicle screw placement. The newest robotic platform (Mazor X Robotic System) was used in all cases. One center used the scan-and-plan registration method, and the other used CT-to-fluoroscopy for registration. Screw accuracy was determined by applying the Gertzbein-Robbins scale. Fluoroscopic exposure times were collected from radiology reports. RESULTS: Overall, 268 patients underwent pedicle screw insertion, 126 patients with scan-and-plan registration and 142 with CT-to-fluoroscopy registration. In the scan-and-plan cohort, 450 screws were inserted across 266 spinal levels (mean 1.7 ± 1.1 screws/level), with 446 (99.1%) screws classified as Gertzbein-Robbins grade A (within the pedicle) and 4 (0.9%) as grade B (< 2-mm deviation). In the CT-to-fluoroscopy cohort, 574 screws were inserted across 280 lumbar spinal levels (mean 2.05 ± 1.7 screws/ level), with 563 (98.1%) grade A screws and 11 (1.9%) grade B (p = 0.17). The scan-and-plan cohort had nonsignificantly less fluoroscopic exposure per screw than the CT-to-fluoroscopy cohort (12 ± 13 seconds vs 11.1 ± 7 seconds, p = 0.3). CONCLUSIONS: Both scan-and-plan registration and CT-to-fluoroscopy registration methods were safe, accurate, and had similar fluoroscopy time exposure overall.

Phosphodiesterase type 5 inhibitor use among pregnant and reproductive-age women in the United States.

PURPOSE: To assess the prevalence and potential indications of PDE5 inhibitor use among pregnant and reproductive-age women in the United States. METHODS: We identified women 15 to 50 years with a livebirth from January 2001 through March 2018 in Sentinel Database. We assessed the prevalence of PDE5 inhibitor use prior to and during pregnancy by trimester, identified potential on- and off-label indications using predefined diagnosis codes recorded within 90 days before the estimated last menstrual period through delivery. Separately, we used data from IQVIA's National Prescription Audit and Total Patient Tracker to estimate the dispensed prescriptions for PDE5 inhibitors and the number of patients with PDE5 inhibitor prescriptions. RESULTS: We identified approximately 3.3 million pregnancies during 2001 to 2018, 96 of which had PDE5 inhibitor use during pregnancy. Prevalence of PDE5 inhibitor use was 2.61, 0.62, and 0.62 per 100, 000 live-born pregnancies during the first, second, or third trimesters, respectively. Among women exposed to a PDE5 inhibitor from 90 days before conception to the end of pregnancy, 25.0%, 31.1%, and 15.5% had a diagnosis code for fetal growth restriction, preeclampsia, and pulmonary arterial hypertension. In IQVIA data, an estimated 223, 000 prescriptions from July 2015 through June 2018 and 58, 000 women received prescriptions for PDE5 inhibitors in 2017, of whom approximately 15, 000 (26%) were aged 15 to 50 years. CONCLUSION: We found a low prevalence of PDE5 inhibitor use in pregnant and reproductive-age women. Given the very low prevalence of use and the inconsistency of neonatal mortality data across STRIDER centers, the risk to public health is low at present.

Spinal fusion in pediatric patients with marfan syndrome: a nationwide assessment on short-term outcomes and readmission risk.

PURPOSE: The purpose of this study was to utilize the National Readmission Database (NRD) to determine estimates for complication rates, 90-day readmission rates, and hospital costs associated with spinal fusion in pediatric patients with Marfan syndrome. METHODS: The 2012-2015 NRD databases were queried for all pediatric (< 19 years old) patients diagnosed with Marfan syndrome undergoing spinal fusion surgery. The primary outcome variables in this study were index admission complications and 90-day readmissions. RESULTS: A total of 249 patients with Marfan syndrome underwent spinal fusion surgery between 2012 and 2015 (mean age ± standard deviation at the time of surgery: 14 ± 2.0, 132 (53%) female). 25 (10.1%) were readmitted within 90 days of the index hospital discharge date. Overall, 59.7% of patients experienced at least one complication during the index admission. Unplanned 90-day readmission could be predicted by older age (odds ratio 2.3, 95% confidence interval 1.3-4.2, p = 0.006), Medicaid insurance status (56.0, 3.8-820.0, p = 0.003), and experiencing an inpatient medical complication (42.9, 4.6-398.7, p = 0.001). Patients were readmitted for wound dehiscence (8 patients, 3.2%), nervous system related complications (3 patients, 1.2%), and postoperative infectious related complications (4 patients, 1.6%). CONCLUSION: This study is the first to demonstrate on a national level the complications and potential risk factors for 90-day hospital readmission for patients with Marfan syndrome undergoing spinal fusion. Patients with Marfan syndrome undergoing spinal fusion often present with multiple medical comorbidities that must be managed carefully perioperatively to reduce inpatient complications and early hospital readmissions.

Tight metabolic control plus ACE inhibitor therapy improves GSD I nephropathy.

The onset of microalbuminuria (MA) heralds the onset of glomerulopathy in patients with glycogen storage disease (GSD) type I. Unlike tubulopathy, which responds to improved metabolic control, glomerulopathy in GSD I is considered refractory to medical intervention, and it is thought to inexorably progress to overt proteinuria and renal failure. Recent reports of reduced microalbuminuria following strict adherence to therapy counter this view. In contrast to type Ia, little is known regarding the prevalence of kidney disease in GSD Ib, 0, III, VI, and IX. Subjects were evaluated with 24-h urine collections between 2005 and 2014 as part of a longitudinal study of the natural history of GSD. ACE inhibitor therapy (AIT) was commenced after documentation of microalbuminuria. Elevated urine albumin excretion was detected in 23 of 195 GSD Ia patients (11.7%) and six of 45 GSD Ib (13.3%). The median age of onset of microalbuminuria in GSD Ia was 24 years (range 9-56); in GSD Ib it was 25 years (range 20-38). Of 14 with GSD Ia who complied with dietary and AIT during the study period, microalbuminuria decreased in 11, in whom metabolic control improved. All 135 patients with the ketotic forms of GSD (0, III, VI and IX) consistently had normal microalbumin excretion. Strict adherence to dietary therapy and maintenance of optimal metabolic control is necessary to halt the progression of GSD Ia glomerulopathy in patients treated with AIT. With optimal care, protein excretion can be reduced and even normalize.

Obesity, Metabolic Syndrome, and Cardiovascular Risk in Gluten-Free Followers Without Celiac Disease in the United States: Results from the National Health and Nutrition Examination Survey 2009-2014.

BACKGROUND: Despite unclear benefits of gluten-free diets (GFD) in the general population, gluten-free followers without medical indications are driving the market. Few studies have investigated health benefits of GFD in the general population. AIMS: To estimate metabolic and cardiovascular disease (CVD) risk profiles among gluten-free followers without celiac disease (CD). METHODS: Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2009-2014. There were 13,523 persons without CD who had GFD information. People with known CVD were excluded. We compared gluten-free followers without CD and the general population by selective metabolic and CVD risk profiles using survey-weighted generalized logistic regression. RESULTS: There were 155 gluten-free followers without CD and CVD, corresponding to a weighted prevalence of 1.3% (3.2 million Americans). Gluten-free followers tended to be women and have a smaller waist circumference and higher HDL cholesterol. They also had a lower BMI with a borderline p value (0.053) and significant self-reported weight loss (-1.33 kg) over one year. Moreover, gluten-free followers were more likely to consider their weight appropriate. There was no statistical difference by age, smoking, hypertension, total cholesterol, triglyceride cholesterol, HbA1c, or fasting glucose. Despite a lower probability of having metabolic syndrome (33.0 vs 38.5%) and lower 10-year CVD risk score (4.52 vs 5.70%) in gluten-free followers, there was no statistical difference. CONCLUSIONS: Although being on a GFD may be beneficial in weight management, there was no significant difference in terms of prevalence of metabolic syndrome and CVD risk score in gluten-free followers without CD.

Lipotoxicity in steatohepatitis occurs despite an increase in tricarboxylic acid cycle activity.

The hepatic tricarboxylic acid (TCA) cycle is central to integrating macronutrient metabolism and is closely coupled to cellular respiration, free radical generation, and inflammation. Oxidative flux through the TCA cycle is induced during hepatic insulin resistance, in mice and humans with simple steatosis, reflecting early compensatory remodeling of mitochondrial energetics. We hypothesized that progressive severity of hepatic insulin resistance and the onset of nonalcoholic steatohepatitis (NASH) would impair oxidative flux through the hepatic TCA cycle. Mice (C57/BL6) were fed a high-trans-fat high-fructose diet (TFD) for 8 wk to induce simple steatosis and NASH by 24 wk. In vivo fasting hepatic mitochondrial fluxes were determined by(13)C-nuclear magnetic resonance (NMR)-based isotopomer analysis. Hepatic metabolic intermediates were quantified using mass spectrometry-based targeted metabolomics. Hepatic triglyceride accumulation and insulin resistance preceded alterations in mitochondrial metabolism, since TCA cycle fluxes remained normal during simple steatosis. However, mice with NASH had a twofold induction (P< 0.05) of mitochondrial fluxes (µmol/min) through the TCA cycle (2.6 ± 0.5 vs. 5.4 ± 0.6), anaplerosis (9.1 ± 1.2 vs. 16.9 ± 2.2), and pyruvate cycling (4.9 ± 1.0 vs. 11.1 ± 1.9) compared with their age-matched controls. Induction of the TCA cycle activity during NASH was concurrent with blunted ketogenesis and accumulation of hepatic diacylglycerols (DAGs), ceramides (Cer), and long-chain acylcarnitines, suggesting inefficient oxidation and disposal of excess free fatty acids (FFA). Sustained induction of mitochondrial TCA cycle failed to prevent accretion of "lipotoxic" metabolites in the liver and could hasten inflammation and the metabolic transition to NASH.

Notes from the Field: Pediatric Emergency Department Visits for Buprenorphine/Naloxone Ingestion - United States, 2008-2015.

Expanding access to office-based medication-assisted treatment with buprenorphine/naloxone for opioid dependence is a key part of the national strategy to address the opioid abuse epidemic (1). However, as buprenorphine/naloxone prescribing increased, emergency department (ED) visits and hospitalizations for unsupervised ingestions by young children began to increase, with buprenorphine/naloxone ingestions becoming the most common cause of hospitalization for medication ingestions by young children during 2010-2011 (2). Buprenorphine ingestions might be asymptomatic or can cause drowsiness, vomiting, or respiratory depression, which if untreated can result in death (3). Buprenorphine/naloxone was available only as tablets in multidose child-resistant bottles (Suboxone) until late 2010, when film strips packaged in unit-dose, child-resistant pouches were introduced. In 2013, tablets became available in unit-dose packaging (Zubsolv). Because unit-dose, child-resistant packaging encloses each dose until opened, it might limit unintended ingestions by young children compared with traditional child-resistant bottles that must be resecured after every use (4). This study compared ED visits for pediatric buprenorphine/naloxone ingestions before and after these product packaging/formulation changes.

Applications of cone beam computed tomography for a prosthodontist.

Cone beam computed tomography (CBCT) is a medical imaging technique of X-ray computed tomography where the X-rays are divergent, forming a cone. CBCT systems have been designed for imaging hard tissues of the maxillofacial region. The increasing availability of this technology provides the dental clinician with an imaging modality capable of providing a three-dimensional representation of the maxillofacial skeleton with minimal distortion. This article is intended to elaborate and enunciate on the various applications and benefits of CBCT, in the realm of maxillofacial prosthodontics, over and beyond its obvious benefits in the rehabilitation of patients with implants. With the onus of meticulous reconstruction of near ideal occlusion resting on the prosthodontist, CBCT provides a unique imaging option, which can be a boon in various aspects of prosthodontic practice - from imaging of the temporomandibular joint for accurate movement simulation, to template assisted maxillofacial reconstruction or even over denture therapy. CBCT could play a crucial role in lessening the burden of a hectic prosthodontic routine for the clinician and critically contribute to accurate and effective treatment for the patient. Apart from the authors' clinical experiences shared here, a web-based search for relevant articles in this specific area of interest was also conducted. The selected articles were critically reviewed and the data acquired were systematically compiled.

Cross-talk between branched-chain amino acids and hepatic mitochondria is compromised in nonalcoholic fatty liver disease.

Elevated plasma branched-chain amino acids (BCAA) in the setting of insulin resistance have been relevant in predicting type 2 diabetes mellitus (T2DM) onset, but their role in the etiology of hepatic insulin resistance remains uncertain. We determined the link between BCAA and dysfunctional hepatic tricarboxylic acid (TCA) cycle, which is a central feature of hepatic insulin resistance and nonalcoholic fatty liver disease (NAFLD). Plasma metabolites under basal fasting and euglycemic hyperinsulinemic clamps (insulin stimulation) were measured in 94 human subjects with varying degrees of insulin sensitivity to identify their relationships with insulin resistance. Furthermore, the impact of elevated BCAA on hepatic TCA cycle was determined in a diet-induced mouse model of NAFLD, utilizing targeted metabolomics and nuclear magnetic resonance (NMR)-based metabolic flux analysis. Insulin stimulation revealed robust relationships between human plasma BCAA and indices of insulin resistance, indicating chronic metabolic overload from BCAA. Human plasma BCAA and long-chain acylcarnitines also showed a positive correlation, suggesting modulation of mitochondrial metabolism by BCAA. Concurrently, mice with NAFLD failed to optimally induce hepatic mTORC1, plasma ketones, and hepatic long-chain acylcarnitines, following acute elevation of plasma BCAA. Furthermore, elevated BCAA failed to induce multiple fluxes through hepatic TCA cycle in mice with NAFLD. Our data suggest that BCAA are essential to mediate efficient channeling of carbon substrates for oxidation through mitochondrial TCA cycle. Impairment of BCAA-mediated upregulation of the TCA cycle could be a significant contributor to mitochondrial dysfunction in NAFLD.

Fundamentals of cone beam computed tomography for a prosthodontist.

Cone beam computed tomography (CBCT, also referred to as C-arm computed tomography [CT], cone beam volume CT, or flat panel CT) is a medical imaging technique of X-ray CT where the X-rays are divergent, forming a cone.[1] CBCT systems have been designed for imaging hard tissues of the maxillofacial region. CBCT is capable of providing sub-millimeter resolution in images of high diagnostic quality, with short scanning times (10-70 s) and radiation dosages reportedly up to 15-100 times lower than those of conventional CT scans. Increasing availability of this technology provides the dental clinician with an imaging modality capable of providing a three-dimensional representation of the maxillofacial skeleton with minimal distortion. The aim of this article is to sensitize the Prosthodontist to CBCT technology, provide an overview of currently available maxillofacial CBCT systems and review the specific application of various CBCT display modes to clinical Prosthodontic practice. A MEDLINE search for relevant articles in this specific area of interest was conducted. The selected articles were critically reviewed and the data acquired were systematically compiled.

Biomechanics and Injury Prevention for Barefoot/Minimalist Running.

¼ Biomechanical studies indicate that barefoot/minimalist running coincides with a transition to an anterior foot strike, lower vertical loading rates, higher cadences, less energy absorption at the knee joint, and higher energy absorption at the ankle joint.¼ The clinical outcome studies indicate improvement of previous injuries and equivocal injury rates in the barefoot/minimal-style running groups.¼ Foot strike pattern is more important than footwear regarding injury prevention and vertical loading rate.¼ Minimalist footwear places higher degrees of stress on the ankle joints and an increased injury rate when abruptly transitioning to barefoot running. Runners must weigh the risks and benefits and take caution to properly strengthen their feet and safely transition to minimalist running.

Is There a Difference in Screw Accuracy, Robot Time Per Screw, Robot Abandonment, and Radiation Exposure Between the Mazor X and the Renaissance? A Propensity-Matched Analysis of 1179 Robot-Assisted Screws.

STUDY DESIGN: Prospective single-cohort analysis. OBJECTIVES: To compare the outcomes/complications of 2 robotic systems for spine surgery. METHODS: Adult patients (≥18-years-old) who underwent robot-assisted spine surgery from 2016-2019 were assessed. A propensity score matching (PSM) algorithm was used to match Mazor X to Renaissance cases. Preoperative CT scan for planning and an intraoperative O-arm for screw evaluation were preformed. Outcomes included screw accuracy, robot time/screw, robot abandonment, and radiation. Screw accuracy was measured using Vitrea Core software by 2 orthopedic surgeons. Screw breach was measured according to the Gertzbein/Robbins classification. RESULTS: After PSA, a total of 65 patients (Renaissance: 22 vs. X: 43) were included. Patient/operative factors were similar between robot systems (P > .05). The pedicle screw accuracy was similar between robots (Renaissance: 1.1%% vs. X: 1.3%, P = .786); however, the S2AI screw breach rate was significantly lower for the X (Renaissance: 9.5% vs. X: 1.2%, P = .025). Robot time per screw was not statistically different (Renaissance: 4.6 minutes vs. X: 3.9 minutes, P = .246). The X was more reliable with an abandonment rate of 2.3% vs. Renaissance:22.7%, P = .007. Radiation exposure were not different between robot systems. Non-robot related complications including dural tear, loss of motor/sensory function, and blood transfusion were similar between robot systems. CONCLUSION: This is the first comparative analyses of screw accuracy, robot time/screw, robot abandonment, and radiation exposure between the Mazor X and Renaissance systems. There are substantial improvements in the X robot, particularly in the perioperative planning processes, which likely contribute to the X's superiority in S2AI screw accuracy by nearly 8-fold and robot reliability by nearly 10-fold.

What Is the Impact of Surgical Approach in the Treatment of Degenerative Cervical Myelopathy in Patients With OPLL? A Propensity-Score Matched, Multi-Center Analysis on Inpatient and Post-Discharge 90-Day Outcomes.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Provide a comparison of surgical approach in the treatment of degenerative cervical myelopathy in patients with OPLL. METHODS: A national database was queried to identify adult (≥18 years) patients with OPLL, who underwent at least a 2-level cervical decompression and fusion for cervical myelopathy from 2012-2014. A propensity-score-matching algorithm was employed to compare outcomes by surgical approach. RESULTS: After propensity-score matching, 627 patients remained. An anterior approach was found to be an independent predictor for higher inpatient surgical complications(OR 5.9), which included dysphagia:14%[anterior]vs.1.1%[posterior] P-value < 0.001, wound hematoma:1.7%[anterior]vs.0%[posterior] P-value = 0.02, and dural tear:9.4%[anterior]vs.3.2%[posterior] P-value = 0.001. A posterior approach was an predictor for longer hospital length of stay by nearly 3 days(OR 3.4; 6.8 days[posterior]vs.4.0 days[anterior] P-value < 0.001). The reasons for readmission/reoperation did not vary by approach for 2-3-level fusions; however, for >3-level fusions, patients with an anterior approach more often had respiratory complications requiring mechanical ventilation(P-value = 0.038) and required revision fusion surgery(P-value = 0.015). CONCLUSIONS: The national estimates for inpatient complications(25%), readmissions(9.9%), and reoperations(3.5%) are substantial after the surgical treatment of multi-level OPLL. An anterior approach resulted in significantly higher inpatient surgical complications, but this did not result in a longer hospital length of stay and the overall 90-day complication rates requiring readmission or reoperation was similar to those seen after a posterior approach. For patients requiring >3-level fusion, an anterior approach is associated with significantly higher risk for respiratory complications requiring mechanical ventilation and revision fusion surgery. Precise neurological complications and functional outcomes were not included in this database, and should be further assessed in future studies.

Living with a C2-Sacrum Spinal Fusion: Surgical Outcomes and Quality of Life in Patients Fused from C2 to the Sacrum.

STUDY DESIGN: Single center, retrospective cohort study. OBJECTIVES: Little is known about the surgical outcomes and quality of life in patients with C2-sacrum posterior spinal fusion (PSF). Though it is thought to be a "final" construct, it remains unknown how patients fare postoperatively. We sought to evaluate the surgical outcomes and quality of life of patients after C2-sacrum PSF. METHODS: Consecutive patients undergoing C2-Sacrum PSF from 2015-2020 by 4 surgeons at a single institution were included. The study time period for each patient began after their index operation that led to the C2-sacrum fusion. Dates of surgery, complications, reoperations, patient reported outcomes (PROs) including EuroQol 5 Dimensions (EQ-5D), Oswestry Disability Index (ODI), Scoliosis Research Society (SRS) questionnaires, and activities of daily living (ADL) questions were collected and analyzed. Descriptive statistics, paired t-tests, student t-tests, and linear regression were used. RESULTS: Of the 23 patients who underwent C2-sacrum PSF, 6 patients (26%) required a total of 10 reoperations after a mean of 1.5 years (range 0-4 years) after C2-sacrum PSF. Five reoperations were for mechanical failure; 3 for wound complications/infection; and 2 for instrumentation and spinous process prominence. PROs were collected on 18 patients with mean follow-up of 2.4 years (range .5-4.5) after their C2-sacrum PSF. At 6-months, both SRS-22 and ODI scores improved significantly after C2-sacrum PSF (SRS: 57.5 to 76.3, P = .0014; ODI: 47.0 to 31.7, P = .013). Similarly, at a mean 2.4 years postoperatively, mean ODI improved significantly (47.0 to 30.4, P = .0032). Six patients (33%) had minimal symptoms (ODI <20). The median postoperative EQ-5D score was .74 (range .19 to 1.0), which compares favorably to patients with hip/knee osteoarthritis (EQ-5D .63) and diabetes mellitus (DM) (EQ-5D .69) and hypertension (HTN). In terms of activities of daily living (ADL), 10 patients (56%) exercised regularly-a mean 4.5 days/week. 11 (61%) could do light aerobic activity (e.g. stationary bike). 10 (55%) were able to play with children/grandchildren as desired. Eight patients (44%) hiked, and 2 (11%) drove independently. 11 (61%) could tolerate short air-travel comfortably. Of the 17 patients who could toilet and perform basic hygiene preoperatively, 16 (94%) were able to do so postoperatively. CONCLUSION: Though C2-sacrum PSF is thought to be a "final" construct, approximately 1 in 4 patients require subsequent operations. However, C2-sacrum PSF patients had a significant improvement in SRS and ODI scores by 6 months postop. Over 60% of patients were regularly performing light aerobic activity 2 years after their C2-sacrum PSF. EQ-5D suggests that this population fares better than those with degenerative hip/knee arthritis and similarly to those with common chronic conditions like DM and HTN.

Arthroscopy and Micronized Allogenic Cartilage Matrix Grafting for a Missed Talus Nonunion: A Case Report.

CASE: A 33-year-old man who had experienced polytraumatic injury from a motorcycle collision 5 months previously presented to the clinic with right ankle pain. On physical examination, anterior ankle tenderness was present, and imaging revealed a previously unrecognized nondisplaced talar body fracture with a chondral defect. The patient underwent arthroscopy of the right ankle, which influenced the senior author to perform a medial malleolar osteotomy and subsequent open reduction internal fixation with micronized allogenic cartilage matrix. CONCLUSION: Arthroscopy provides valuable information for the surgical planning of talar nonunions, and allogenic cartilage matrix graft may provide benefit with associated chondral defects.

Extremely Large Submandibular Sialolith Removal - A Case Report.

The Rationale: Sialoliths are calcified organic matter that form within the secretory system of the salivary glands. They rarely measure more than 1.5 cm. Giant sialoliths are rare and defined as a size of 3.5 cm or larger. Patient concerns: Patient complained of the pain and swelling in the right submandibular area for two years with increase in size during meals. Diagnosis: Based on the clinical and radiological investigations. Treatment: Sialolith measuring 39 mm and weighing 7.02 g, was removed in a minimally invasive manner through transoral sialolithotomy using diode 810 µm LASER unit under local anaesthesia. Outcomes: Patient was relieved of the preoperative symptoms and was on follow-up for one year. Take-Away Lessons: Various newer treatment modalities are effective alternatives to conventional surgical treatment of sialoliths. However, transoral sialolithotomy remains the mainstay of management.

Can Machine Learning Accurately Predict Postoperative Compensation for the Uninstrumented Thoracic Spine and Pelvis After Fusion From the Lower Thoracic Spine to the Sacrum?

STUDY DESIGN: Consecutively collected cases. OBJECTIVE: To determine if a machine-learning (ML) program can accurately predict the postoperative thoracic kyphosis through the uninstrumented thoracic spine and pelvic compensation in patients who undergo fusion from the lower thoracic spine (T10 or T11) to the sacrum. METHODS: From 2015 to 2019, a consecutive series of adult (≥18 years old) patients with adult spinal deformity underwent corrective spinal fusion from the lower thoracic spine (T10 or T11) to the sacrum. Deidentified data was processed by a ML system-based platform to predict the postoperative thoracic kyphosis (TK) and pelvic tilt (PT) for each patient. To validate the ML model, the postoperative TK (T4-T12, instrumented thoracic, and uninstrumented thoracic) and the pelvic tilt were compared against the predicted values. RESULTS: A total of 20 adult patients with a minimum 6-month follow-up (mean: 22.4 ± 11.3 months) were included in this study. No significant differences were observed for TK (predicted 37.6° vs postoperative 38.3°, P = .847), uninstrumented TK (predicted 33.9° vs postoperative 29.8°, P = .188), and PT (predicted 23.4° vs postoperative 22.7°, P = .754). The predicted PT and the TK of the uninstrumented thoracic spine correlated well with postoperative values (uninstrumented TK: R2 = 0.764, P < .001; PT: R2 = 0.868, P < .001). The mean error with which kyphosis through the uninstrumented thoracic spine can be measured was 4.8° ± 4.0°. The mean error for predicting PT was 2.5° ± 1.7°. CONCLUSION: ML algorithms can accurately predict the spinopelvic compensation after spinal fusion from the lower thoracic spine to the sacrum. These findings suggest that surgeons may be able to leverage this technology to reduce the risk of proximal junctional kyphosis in this population.

Artificial Learning and Machine Learning Applications in Spine Surgery: A Systematic Review.

OBJECTIVES: This current systematic review sought to identify and evaluate all current research-based spine surgery applications of AI/ML in optimizing preoperative patient selection, as well as predicting and managing postoperative outcomes and complications. METHODS: A comprehensive search of publications was conducted through the EMBASE, Medline, and PubMed databases using relevant keywords to maximize the sensitivity of the search. No limits were placed on level of evidence or timing of the study. Findings were reported according to the PRISMA guidelines. RESULTS: After application of inclusion and exclusion criteria, 41 studies were included in this review. Bayesian networks had the highest average AUC (.80), and neural networks had the best accuracy (83.0%), sensitivity (81.5%), and specificity (71.8%). Preoperative planning/cost prediction models (.89,82.2%) and discharge/length of stay models (.80,78.0%) each reported significantly higher average AUC and accuracy compared to readmissions/reoperation prediction models (.67,70.2%) (P < .001, P = .005, respectively). Model performance also significantly varied across postoperative management applications for average AUC and accuracy values (P < .001, P < .027, respectively). CONCLUSIONS: Generally, authors of the reviewed studies concluded that AI/ML offers a potentially beneficial tool for providers to optimize patient care and improve cost-efficiency. More specifically, AI/ML models performed best, on average, when optimizing preoperative patient selection and planning and predicting costs, hospital discharge, and length of stay. However, models were not as accurate in predicting postoperative complications, adverse events, and readmissions and reoperations. An understanding of AI/ML-based applications is becoming increasingly important, particularly in spine surgery, as the volume of reported literature, technology accessibility, and clinical applications continue to rapidly expand.