Functional nanoscale organization of signaling molecules downstream of the T cell antigen receptor.

Receptor-regulated cellular signaling often is mediated by formation of transient, heterogeneous protein complexes of undefined structure. We used single and two-color photoactivated localization microscopy to study complexes downstream of the T cell antigen receptor (TCR) in single-molecule detail at the plasma membrane of intact T cells. The kinase ZAP-70 distributed completely with the TCRζ chain and both partially mixed with the adaptor LAT in activated cells, thus showing localized activation of LAT by TCR-coupled ZAP-70. In resting and activated cells, LAT primarily resided in nanoscale clusters as small as dimers whose formation depended on protein-protein and protein-lipid interactions. Surprisingly, the adaptor SLP-76 localized to the periphery of LAT clusters. This nanoscale structure depended on polymerized actin and its disruption affected TCR-dependent cell function. These results extend our understanding of the mechanism of T cell activation and the formation and organization of TCR-mediated signaling complexes, findings also relevant to other receptor systems.

Identifying Risk Factors for 30-Day Readmissions After Triple Arthrodesis Surgery.

Rigid flatfoot deformity is a debilitating condition that can be managed by triple arthrodesis surgery. Triple arthrodesis has the potential to restore health-related quality of life, but it is also associated with several complications. Few studies have examined the 30-day readmission rates after triple arthrodesis. The objective of this study was to investigate risk factors for 30-day all-cause readmissions after triple arthrodesis. The nationwide readmission database was queried from 2013. By using International Classification of Disease, Ninth Revision, procedure codes, all triple arthrodesis procedures were identified. Demographic factors, comorbidities, insurance status, and hospital characteristics were statistically compared between patients who experienced a 30-day readmission and those who did not. Multivariable logistic regression was used to identify independent risk factors for 30-day readmission. Overall, 1916 triple arthrodesis cases were identified. The overall 30-day readmission rate after triple arthrodesis was 4.6%. Univariate analysis revealed a statistically higher proportion of patients with electrolyte abnormalities (13.8% vs 4.6%; p < .01) in the patients who were readmitted within 30 days compared with those who were not. Multivariable analysis demonstrated Medicaid insurance, relative to private insurance, as the only statistically significant predictor of 30-day readmission with an odds ratio of 4.43 (p < .05). These results suggest that patients of lower socioeconomic status may be at a greater risk for development of a short-term readmission after triple arthrodesis surgery. These findings are important for surgeon and patient communication, counseling, and postoperative care when choosing to pursue triple arthrodesis surgery.

Machine Learning Accurately Predicts Short-Term Outcomes Following Open Reduction and Internal Fixation of Ankle Fractures.

Ankle fractures are common orthopedic injuries with favorable outcomes when managed with open reduction and internal fixation (ORIF). Several patient-related risk factors may contribute to poor short-term outcomes, and machine learning may be a valuable tool for predicting outcomes. The objective of this study was to evaluate machine-learning algorithms for accurately predicting short-term outcomes after ORIF for ankle fractures. The Nationwide Inpatient Sample and Nationwide Readmissions Database were queried for adult patients ≥18 years old who underwent ORIF of an ankle fracture during 2013 or 2014. Morbidity and mortality, length of stay >3 days, and 30-day all-cause readmission were the outcomes of interest. Two machine-learning models were created to identify patient and hospital characteristics associated with the 3 outcomes. The machine learning models were evaluated using confusion matrices and receiver operating characteristic area under the curve values. A total of 16,501 cases were drawn from the Nationwide Inpatient Sample and used to assess morbidity and mortality and length of stay >3 days, and 33,504 cases were drawn from the Nationwide Readmissions Database to assess 30-day readmission. Older age, Medicaid, Medicare, deficiency anemia, congestive heart failure, chronic lung disease, diabetes, hypertension, and renal failure were the variables associated with a statistically significant increased risk of developing all 3 adverse events. Logistic regression and gradient boosting had similar area under the curve values for each outcome, but gradient boosting was more accurate and more specific for predicting each outcome. Our results suggest that several comorbidities may be associated with adverse short-term outcomes after ORIF of ankle fractures, and that machine learning can accurately predict these outcomes.

Comparing 30-day all-cause readmission rates between tibiotalar fusion and total ankle replacement.

BACKGROUND: End-stage ankle arthritis is a debilitating condition that negatively impacts patient quality of life. Tibiotalar fusion and total ankle replacement are treatment options for managing ankle arthritis. Few studies have examined short term readmission rates of these two procedures. The objective of this study was compare all-cause 30-day readmission rates between patients undergoing tibiotalar fusion vs. total ankle replacement. METHODS: This study queried the Nationwide Readmission Database (NRD) from 2013-2014 and used international classification of disease, 9th revision (ICD-9) procedure codes to identify all patients who underwent a tibiotalar fusion or a total ankle replacement. Comorbidities, insurance status, hospital characteristics, and readmission rates were statistically compared between the two cohorts. Risk factors were then identified for 30-day readmission. RESULTS: A total of 5660 patients were analyzed with 2667 in the tibiotalar fusion cohort and 2993 in the total ankle replacement cohort. Univariate analysis revealed that the readmission rate after tibiotalar fusion (4.4%) was statistically greater than after total ankle replacement (1.4%). Multivariable regression analysis indicated that deficiency anemia (OR 2.18), coagulopathy (OR 3.51), renal failure (OR 2.83), other insurance relative to private (OR 3.40), and tibiotalar fusion (OR 2.51) were all statistically significant independent risk factors for having a readmission within 30-days. CONCLUSIONS: These findings suggest that during the short-term period following discharge from the hospital, patients who received a tibiotalar fusion are more likely to experience a 30-day readmission. These findings are important for decision making when a surgeon encounters a patient with end stage ankle arthritis. LEVEL OF EVIDENCE: Level III, cohort study.

Potential protein biomarkers for burning mouth syndrome discovered by quantitative proteomics.

Burning mouth syndrome (BMS) is a chronic pain disorder characterized by severe burning sensation in normal looking oral mucosa. Diagnosis of BMS remains to be a challenge to oral healthcare professionals because the method for definite diagnosis is still uncertain. In this study, a quantitative saliva proteomic analysis was performed in order to identify target proteins in BMS patients' saliva that may be used as biomarkers for simple, non-invasive detection of the disease. By using isobaric tags for relative and absolute quantitation labeling and liquid chromatography-tandem mass spectrometry to quantify 1130 saliva proteins between BMS patients and healthy control subjects, we found that 50 proteins were significantly changed in the BMS patients when compared to the healthy control subjects ( p ≤ 0.05, 39 up-regulated and 11 down-regulated). Four candidates, alpha-enolase, interleukin-18 (IL-18), kallikrein-13 (KLK13), and cathepsin G, were selected for further validation. Based on enzyme-linked immunosorbent assay measurements, three potential biomarkers, alpha-enolase, IL-18, and KLK13, were successfully validated. The fold changes for alpha-enolase, IL-18, and KLK13 were determined as 3.6, 2.9, and 2.2 (burning mouth syndrome vs. control), and corresponding receiver operating characteristic values were determined as 0.78, 0.83, and 0.68, respectively. Our findings indicate that testing of the identified protein biomarkers in saliva might be a valuable clinical tool for BMS detection. Further validation studies of the identified biomarkers or additional candidate biomarkers are needed to achieve a multi-marker prediction model for improved detection of BMS with high sensitivity and specificity.

A phospholipase C-γ1-independent, RasGRP1-ERK-dependent pathway drives lymphoproliferative disease in linker for activation of T cells-Y136F mutant mice.

Mice expressing a germline mutation in the phospholipase C-γ1-binding site of linker for activation of T cells (LAT) show progressive lymphoproliferation and ultimately die at 4-6 mo age. The hyperactivated T cells in these mice show defective TCR-induced calcium flux but enhanced Ras/ERK activation, which is critical for disease progression. Despite the loss of LAT-dependent phospholipase C-γ1 binding and activation, genetic analysis revealed RasGRP1, and not Sos1 or Sos2, to be the major Ras guanine exchange factor responsible for ERK activation and the lymphoproliferative phenotype in these mice. Analysis of isolated CD4(+) T cells from LAT-Y136F mice showed altered proximal TCR-dependent kinase signaling, which activated a Zap70- and LAT-independent pathway. Moreover, LAT-Y136F T cells showed ERK activation that was dependent on Lck and/or Fyn, protein kinase C-θ, and RasGRP1. These data demonstrate a novel route to Ras activation in vivo in a pathological setting.

A case of conversion disorder presenting as chronic trismus.

Trismus can be the symptom of several diseases. For the most part, the inability to open the mouth is due to an articular disorder but occasionally, the cause may be extra-articular. In this case, being reported, non-articular hysterical trismus caused the jaw to lock in an 11-year-old boy for 3 months. During this period the jaw was completely locked and the locking was associated with moderate to severe pain. After three sessions of therapy the patient was able to open his mouth 33 mm and his eating was back to normal. Conversion disorders often present with dramatic physical presentation including trismus and jaw lock. This report highlights the importance of complete history taking and a thorough clinical examination to make a correct diagnosis in a patient with trismus.

Post-Operative Hyperextension Bracing Has the Potential to Reduce Proximal Junctional Kyphosis: A Propensity Matched Analysis of Braced versus Non-braced Cohorts.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Determine effects of bracing on proximal junctional kyphosis (PJK) after adult deformity correction. METHODS: Patients were identified from a single-surgeon dataset of posterior-only fusions for ASD (pelvis to UIV of T9-12) with a minimum of 1-year follow up. Starting in 2021, all lower thoracic fusions were braced using a hyperextension brace. Patients wore the brace at all times (unless in bed) for the first 6 weeks after surgery. A 1:1 propensity-match was performed based on age, number of levels, 3 column osteotomies, and magnitude of correction to identify a comparative non-braced cohort. RESULTS: 141 patients (113 non-brace, 28 brace) were evaluated. After matching, 56 patients were identified to form similar cohorts. Non-matched and matched groups had no statistically significant differences in demographics, comorbid conditions, surgical characteristics (except shorter operative time and lower EBL in the braced group), and preoperative radiographic parameters. For the overall cohort, the change in proximal junctional angle at 1-year was higher in the non-braced group (7.6° vs 8.1°, P = .047), and non-braced patients had a higher incidence of PJK at 1-year in both the overall cohort (36% vs 14%, P = .045) and matched cohort (43% vs 14%, P = .038). There was no difference in proximal junctional failure between groups. CONCLUSION: This pilot study shows that our protocol for extension bracing may reduce rates of PJK. These findings can form the basis for future multi-center trials examining the effect of extension bracing on junctional complications.

Opening Side of Unilateral Open-Door Laminoplasty Does Not Impact Improvement in Arm Pain or Space Available for the Spinal Cord.

Background/Objectives: There exists limited data guiding open-door laminoplasty. The objective of this study is to determine if open-door laminoplasty affects radiographic decompression or arm pain outcomes. Methods: Adult patients who underwent unilateral open-door laminoplasty cervical myelopathy were included. The side opened was dependent on surgeon discretion. We recorded preoperative side of symptoms, side of radiographic compression, arm pain scores, and canal diameter. Patients with open-side ipsilateral or contralateral to dominant symptoms or compression were compared to determine any effect on arm pain outcomes or spinal canal diameter. If the symptoms were equal bilaterally, patients were neutral. Results: A total of 167 patients were included, with an average age of 64 ± 11 years and average follow-up time of 64.5 ± 72 weeks. The average preoperative arm pain visual analog score (VAS) was 2.13 ± 2.86, and the average arm VAS after 6 months was 1.52 ± 2.68. For dominant symptoms, the ipsilateral, contralateral, and neutral groups had a significant improvement in arm VAS at >6 months postoperatively. For dominant compression, the ipsilateral and contralateral groups had a significant improvement in both arm VASs and canal diameter at >6 months postoperatively. No differences were seen between groups for either. We observed a significant correlation between size of plate and change in canal diameter; however, no differences were noted for arm pain. Conclusions: Laminoplasty may be effective in addressing radicular arm pain by increasing the spinal canal's diameter and space available for the cord. The laterality of open-door laminoplasty did not affect arm pain improvement or canal expansion.

Return to Sporting Activities Following Long Fusions to the Pelvis in Adult Spinal Deformity.

BACKGROUND CONTEXT: Returning to recreational sporting activities after adult spinal deformity (ASD) correction may significantly impact the patient's perceived quality of life. PURPOSE: This study sought to characterize participation in sporting activities before and after ASD surgery, and to identify factors associated with impaired return to sports. STUDY DESIGN: Cross-sectional survey and retrospective review of prospectively collected data. PATIENT SAMPLE: Patients who underwent posterior-only thoracolumbar ASD surgery between 2016-2021 with ≥1 year follow-up and ≥3 levels of fusion to the pelvis were included. OUTCOME MEASURES: Preoperative and postoperative participation in sports, timing of return to these activities, and reasons for limited sports participation postoperatively were assessed. METHODS: A survey was used to evaluate outcome measures. Differences in demographic, surgical, and perioperative variables between patients who reported improved, unchanged, or worsened activity tolerance were evaluated. RESULTS: Ninety-five patients were included (mean age: 64.3±10.1 years; BMI: 27.3±6.1 kg/m2; median levels fused: 7). The survey was completed at an average of 43.5 ± 15.9 months after surgery. Sixty-eight (72%) patients participated in sports preoperatively. The most common sports were swimming (n=33, 34.7%), yoga (n=23, 24.2%), weightlifting (n=20, 21.1%), elliptical (n=19, 20.0%), and golf (n=11, 11.6%). Fifty-seven (83.8%) returned to at least one sport postoperatively, most commonly 6-12 months after surgery (45%). Elliptical had the highest rate of equal or improved participation (53%). Patients generally returned below their preoperative level to all other sports. Reasons for reduced sporting activities included physical limitation (51.4%), fear (20.0%), pain (17.1%), and surgeon advice (8.6%). There were no differences in the demographic, surgical, or perioperative characteristics between those who returned to sports at the same or better level compared with those who returned at a lower level. CONCLUSIONS: 84% of patients successfully resumed sporting activities after undergoing fusion to the sacrum/pelvis for ASD. However, this return is typically at a lower level of participation than their preoperative participation, particularly in higher demand sports. Understanding trends in sporting activity may be valuable for counseling patients and setting expectations.

Ninety Percent of Patients Are Satisfied With Their Decision to Undergo Spine Surgery for Degenerative Conditions.

STUDY DESIGN: Cross-sectional survey and retrospective review of prospectively collected data. OBJECTIVE: To explore how patients perceive their decision to pursue spine surgery for degenerative conditions and evaluate factors correlated with decisional regret. SUMMARY OF BACKGROUND DATA: Prior research shows that one-in-five older adults regret their decision to undergo spinal deformity surgery. However, no studies have investigated decisional regret in patients with degenerative conditions. METHODS: Patients who underwent cervical or lumbar spine surgery for degenerative conditions (decompression, fusion, or disk replacement) between April 2017 and December 2020 were included. The Ottawa Decisional Regret Questionnaire was implemented to assess prevalence of decisional regret. Questionnaire scores were used to categorize patients into low (<40) or medium/high (≥40) decisional regret cohorts. Patient-reported outcome measures (PROMs) included the Oswestry Disability Index, Patient-reported Outcomes Measurement Information System, Visual Analog Scale (VAS) Back/Leg/Arm, and Neck Disability Index at preoperative, early postoperative (<6 mo), and late postoperative (≥6 mo) timepoints. Differences in demographics, operative variables, and PROMs between low and medium/high decisional regret groups were evaluated. RESULTS: A total of 295 patients were included (mean follow-up: 18.2 mo). Overall, 92% of patients agreed that having surgery was the right decision, and 90% would make the same decision again. In contrast, 6% of patients regretted the decision to undergo surgery, and 7% noted that surgery caused them harm. In-hospital complications (P=0.02) and revision fusion (P=0.026) were significantly associated with higher regret. The medium/high decisional regret group also exhibited significantly worse PROMs at long-term follow-up for all metrics except VAS-Arm, and worse achievement of minimum clinically important difference for Oswestry Disability Index (P=0.007), Patient-Reported Outcomes Measurement Information System (P<0.0001), and VAS-Leg (P<0.0001). CONCLUSIONS: Higher decisional regret was encountered in the setting of need for revision fusion, increased in-hospital complications, and worse PROMs. However, 90% of patients overall were satisfied with their decision to undergo spine surgery for degenerative conditions. Current tools for assessing patient improvement postoperatively may not adequately capture the psychosocial values and patient expectations implicated in decisional regret.

Concepts and Techniques to Prevent Cervical Spine Deformity After Spine Surgery: A Narrative Review.

Adult cervical spine deformity is associated with decreased health-related quality of life, disability, and myelopathy. A number of radiographic parameters help to characterize cervical deformity and aid in the diagnosis and treatment. There are several etiologies for cervical spine deformity, the most common being iatrogenic. Additionally, spine surgery can accelerate adjacent segment degeneration which may lead to deformity. It is therefore important for all spine surgeons to be aware of the potential to cause iatrogenic cervical deformity. The aim of this review is to highlight concepts and techniques to prevent cervical deformity after spine surgery.

The Association of Lumbar Plexus Lengthening with Neurologic Deficit After Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: This study aimed to evaluate the association between nerve lengthening after adult deformity correction and motor deficits dervied from the upper lumbar plexus or femoral nerve. SUMMARY OF BACKGROUND DATA: Adult spinal deformity (ASD) surgery is associated with high rates of neurological deficits. Certain postoperative deficits may be related to lengthening of the upper lumbar plexus (ULP) and/or femoral nerve (FN) after correction of lumbar deformity. METHODS: Patients with ASD who underwent posterior-only corrective surgery from the sacrum to L3 or above were included. The length of each lumbar nerve root (NR) was calculated geometrically using the distance from the foramen to the midpoint between the anterosuperior iliac crest and pubic symphysis on AP and lateral radiographs. The mean lengths of the L1-3 and L2-4 NRs were used to define the lengths of the ULP and FN, respectively. Pre- to postoperative changes in nerve length were calculated. Neurological examination was performed at discharge. Proximal weakness (PW) was defined as the presence of weakness compared to baseline in either hip flexors or knee extensors. Multiple linear regression analysis was used for estimating the postoperative lengthening according to the magnitude of preoperative curvature and postoperative correction angles. RESULTS: A total of 202 sides were analyzed in 101 patients, and PW was present on 15 (7.4%) sides in 10 patients. Excluding the 10 cases with three-column osteotomies, those with PW had a significantly higher rate of pure sagittal deformity (P<.001) and greater nerve lengthening than those without PW (ULP 24 vs 15 mm, P=0.02; FN 18 vs 11 mm, P=0.05). No patient had advanced imaging showing neural compression, and complete recovery of PW occurred in 8 patients at 1-year follow-up. CONCLUSIONS: After ASD surgery, lengthening of the ULP was associated with PW. In preoperative planning, surgeons must consider how the type of correction may influence the risk for nerve lengthening, which may contribute to postoperative neurologic deficit. LEVEL OF EVIDENCE: 3.

Provider Referral Patterns and Surgical Utilization Among New Patients Seen in Spine Clinic.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: The objective of this study was to elucidate the demographics of patient referrals from different sources and identify factors that affect a patient's likelihood of undergoing surgery. SUMMARY OF BACKGROUND DATA: Despite baseline factors for surgical consideration, such as attempting conservative management, surgeons encounter many patients who are not surgically indicated. Overreferrals, that is, a patient referred to a surgeon that does not need surgery, can result in long wait times, delayed care, worse outcomes, and resource waste. MATERIALS AND METHODS: All new patients at a single academic institution seen in the clinic by eight spine surgeons between January 1, 2018, and January 1, 2022, were analyzed. Referral types included self-referral, musculoskeletal (MSK), and non-MSK provider referral. Patient demographics included age, body mass index (BMI), zip code as a proxy for socioeconomic status, sex, insurance type, and surgical procedures undergone within 1.5 years postclinic visit. Analysis of variance and a Kruskal-Wallis test was used to compare means among normally and non-normally disturbed referral groups, respectively. Multivariable logistic regressions were run to assess demographic variables associated with undergoing surgery. RESULTS: From 9356 patients, 84% (7834) were self-referred, 3% (319) were non-MSK, and 13% (1203) were MSK. A statistically significant association with ultimately undergoing surgery was observed with MSK referral type compared with non-MSK referral [odds ratio (OR)=1.37, CI: 1.04-1.82, P =0.0246]. Additional independent variables observed to be associated with patients undergoing surgery included older age (OR=1.004, CI: 1.002-1.007, P =0.0018), higher BMI (OR=1.02, CI: 1.011-1.029, P <0.0001), high-income quartile (OR=1.343, CI: 1.177-1.533, P <0.0001), and male sex (OR=1.189, CI: 1.085-1.302, P =0.0002). CONCLUSIONS: A statistically significant association with undergoing surgery was observed with a referral by an MSK provider, older age, male sex, high BMI, and a high-income quartile home zip code. Understanding these factors and patterns is critical for optimizing practice efficiency and reducing the burdens of inappropriate referrals.

Postoperative Radiculitis After L5-S1 Anterior Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: This study aimed to examine postoperative radiculitis after isolated L5-S1 anterior lumbar interbody fusion (ALIF), determine which factors contribute to its development, and investigate the comparative outcomes of patients with versus without postoperative radiculitis. SUMMARY OF BACKGROUND DATA: Both standalone and traditionalALIF are common and safe lumbar spine fusion techniques. Although optimal safety and effectiveness are achieved through appropriate patient selection, postoperative radiculitis after L5-S1 ALIF is a potential complication that seems to be the least predictable in the absence of iatrogenic injury. PATIENTS AND METHODS: All adult patients (18-80 yr) with preoperative radiculopathies who underwent L5-S1 ALIF by 9 board-certified spine surgeons at a single academic institution from January 2016 to December 2021 with a minimum of 3 months follow-up were included. Patient records were assessed for data on clinical characteristics and patient-reported outcome scores (patient-reported outcome measures). All patient records were evaluated to determine whether postoperative radiculitis developed. Radiographic measurements using x-rays were completed using all available pre and postoperative imaging. Multivariable logistic regressions were performed utilizing radiculitis as the dependent variable and various independent predictor variables. RESULTS: One hundred forty patients were included, 48 (34%) patients developed postoperative radiculitis, with symptom onset and resolution occurring at 14.5 and 83 days, respectively. The two groups had no differences in preoperative or postoperative radiographic parameters. Multivariable regression showed 3 independent predictors of postoperative radiculitis: methylprednisolone use [OR: 6.032; (95% CI: 1.670-25.568)], increased implant height [OR: 1.509; (95% CI: 1.189-1.960)], and no posterior fixation [OR: 2.973; (95% CI: 1.353-0.806)]. CONCLUSIONS: Of the 34% of patients who developed postoperative radiculitis after L5-S1 ALIF, it resolved on average within 3 months of surgery. These findings may help reduce the risk of undue short-term morbidity after isolated L5-S1 ALIF by informing preoperative counseling and intraoperative decision-making.

Quality of Spine Surgery Information on Social Media: A DISCERN Analysis of TikTok Videos.

OBJECTIVE: The use of social media applications to disseminate information has substantially risen in recent decades. Spine and back pain-related hashtags have garnered several billion views on TikTok. As such, these videos, which share experiences, offer entertainment, and educate users about spinal surgery, have become increasingly influential. Herein, we assess the quality of spine surgery content TikTok from providers and patients. METHODS: Fifty hashtags encompassing spine surgery ("#spinalfusion," "#scoliosissurgery," and "#spinaldecompression") were searched using TikTok's algorithm and included. Two independent reviewers rated the quality of each video via the DISCERN questionnaire. Video metadata (likes, shares, comments, views, length) were all collected; type of content creator (musculoskeletal, layperson) and content category (educational, patient experience, entertainment) were determined. RESULTS: The overall DISCERN score was, on average, 24.4. #Spinalfusion videos demonstrated greater engagement, higher average likes (p = 0.02), and more comments (p < 0.001) compared to #spinaldecompression and #scoliosissurgery. #Spinaldecompression had the highest DISCERN score (p < 0.001), likely explained by the higher percentage of videos that were educational (p < 0.001) and created by musculoskeletal (MSK) professionals (p < 0.001). Compared to laypersons, MSK professionals had significantly higher quality videos (p < 0.001). Similarly, the educational category demonstrated higher quality videos (p < 0.001). Video interaction trended lower with MSK videos and educational videos had the lowest interaction of the content categories (likes: p = 0.023, comments: p = 0.005). CONCLUSION: The quality of spine surgery videos on TikTok is low. As the influence of the new social media landscape governs how the average person consumes information, MSK providers should participate in disseminating high-quality content.

Why Didn't You Walk Yesterday? Factors Associated With Slow Early Recovery After Adult Spinal Deformity Surgery.

STUDY DESIGN: This is a retrospective case-control study. OBJECTIVES: The objectives of this study are to identify (1) risk factors for delayed ambulation following adult spinal deformity (ASD) surgery and (2) complications associated with delayed ambulation. METHODS: One-hundred and ninety-one patients with ASD who underwent posterior-only fusion (≥5 levels, LIV pelvis) were reviewed. Patients who ambulated with physical therapy (PT) on POD2 or later (LateAmb, n = 49) were propensity matched 1:1 to patients who ambulated on POD0-1 (NmlAmb, n = 49) based on the extent of fusion and surgical invasiveness score (ASD-S). Risk factors, as well as inpatient medical complications were compared. Logistic regressions were used to identify risk factors for late ambulation. RESULTS: Of the patients who did not ambulate on POD0-1, 32% declined participation secondary to pain or dizziness/fatigue, while 68% were restricted from participation by PT/nursing due to fatigue, inability to follow commands, nausea/dizziness, pain, or hypotension. Logistic regression showed that intraoperative estimated blood loss (EBL) >2L (OR = 5.57 [1.51-20.55], P = .010) was independently associated with an increased risk of delayed ambulation, with a 1.25 times higher risk for every 250 mL increase in EBL (P = .014). Modified 5-Item Frailty Index (mFI-5) was also independently associated with delayed ambulation (OR = 2.53 [1.14-5.63], P = .023). LateAmb demonstrated a higher hospital LOS (8.4 ± 4.0 vs 6.2 ± 2.6, P < .001). The LateAmb group trended toward an increase in medical complications on POD3+ (14.3% vs 26.5%, P = .210). CONCLUSIONS: EBL demonstrates a dose-response relationship with risk for delayed ambulation. Delayed ambulation increases LOS and may impact medical complications.

Predictors of Subsidence and its Clinical Impact After Expandable Cage Insertion in Minimally Invasive Transforaminal Interbody Fusion.

STUDY DESIGN: Retrospective review of prospectively collected multisurgeon data. OBJECTIVE: Examine the rate, clinical impact, and predictors of subsidence after expandable minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) cage. SUMMARY OF BACKGROUND DATA: Expandable cage technology has been adopted in MI-TLIF to reduce the risks and optimize outcomes. Although subsidence is of particular concern when using expandable technology as the force required to expand the cage can weaken the endplates, its rates, predictors, and outcomes lack evidence. MATERIALS AND METHODS: Patients who underwent 1 or 2-level MI-TLIF using expandable cages for degenerative lumbar conditions and had a follow-up of >1 year were included. Preoperative and immediate, early, and late postoperative radiographs were reviewed. Subsidence was determined if the average anterior/posterior disc height decreased by >25% compared with the immediate postoperative value. Patient-reported outcomes were collected and analyzed for differences at the early (<6 mo) and late (>6 mo) time points. Fusion was assessed by 1-year postoperative computed tomography. RESULTS: One hundred forty-eight patients were included (mean age, 61 yr, 86% 1-level, 14% 2-level). Twenty-two (14.9%) demonstrated subsidence. Although statistically not significant, patients with subsidence were older, had lower bone mineral density, and had higher body mass index and comorbidity burden. Operative time was significantly higher ( P = 0.02) and implant width was lower ( P < 0.01) for subsided patients. Visual analog scale-leg was significantly lower for subsided patients compared with nonsubsided patients at a >6 months time point. Long-term (>6 mo) patient-acceptable symptom state achievement rate was lower for subsided patients (53% vs . 77%), although statistically not significant ( P = 0.065). No differences existed in complication, reoperation, or fusion rates. CONCLUSIONS: Of the patients, 14.9% experienced subsidence predicted by narrower implants. Although subsidence did not have a significant impact on most patient-reported outcome measures and complication, reoperation, or fusion rates, patients had lower visual analog scale-leg and patient-acceptable symptom state achievement rates at the >6-month time point. LEVEL OF EVIDENCE: Level 4.

Case report: an orofacial pain patient with spots on the brain-multiple sclerosis versus central systemic lupus erythematosus.

Orofacial pain bridges an important gap between medicine and dentistry. This article presents the case of a man who reported preauricular pain, tinnitus, and vertigo that began after extraction of an impacted third molar and who was sent for evaluation of a possible temporomandibular joint disorder. However, he was subsequently found to have markers and imaging results consistent with recurrent and more centralized lupus and/or multiple sclerosis.

Cone beam computed tomography imaging in the evaluation of the temporomandibular joint.

A radiological examination is an essential part of the diagnosis and management of temporomandibular joint disease. Accurate evaluation of the TMJ has been difficult due to the superimposition of other structure in convention radio graphs. Cone beam computed tomography provides precise imaging of TMJ anatomy without superimposition and distortion. The CBCT's preciseness enables practitioners to better identify problems, as well for other strategies. Common conditions of the TMJ in which CBCT plays a role are discussed.