Development of a Highly Sensitive Hybrid LC/MS Assay for the Quantitative Measurement of CTLA-4 in Human T Cells.

Cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) is a check point protein expressed on the surface of T cells and plays a central role in regulating the immune response. In recent years, CTLA-4 has become a popular target for cancer immunotherapy in which blocking CTLA-4 can restore T-cell function and enhance the immune response against cancer. Currently, there are many CTLA-4 inhibitors in a variety of modalities, including cell therapies, which are being developed in both preclinical and clinical stages to further harness the potential of the target for the treatment of certain types of cancer. In drug discovery research, measuring the level of CTLA-4 in T cells is important for drug discovery and development because it provides key information for quantitative assessment of the pharmacodynamics, efficacy, and safety of the CTLA-4-based therapies. However, to our best knowledge, there is still no report of a sensitive, specific, accurate, and reliable assay for CTLA-4 measurement. In this work, an LC/MS-based method was developed to measure CTLA-4 in human T cells. The assay demonstrated high specificity with an LLOQ of 5 copies of CTLA-4 per cell when using 2.5 million T cells for analysis. As shown in the work, the assay was successfully used to measure CTLA-4 levels in subtype T-cell samples from individual healthy subjects. The assay could be applied in supporting the studies of CTLA-4-based cancer therapies.

Use of Blood Flow Restriction Training for Postoperative Rehabilitation.

Blood flow restriction (BFR) training is commonly used to induce muscle hypertrophy and strength and is gaining popularity as a modality for treatment of musculoskeletal conditions and postoperative rehabilitation. This article reviews the current literature on BFR as a rehabilitative tool, identifies gaps in the literature, and reports the authors experience using BFR in the postoperative environment.

What Is the Impact of Smoking on Revision Total Knee Arthroplasty?

BACKGROUND: There is a paucity of literature evaluating the impact of smoking on revision arthroplasty procedures. The purpose of this study was to identify the effect of smoking on complications after revision total knee arthroplasty (rTKA). METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to identify patients who underwent rTKA between 2006 and 2014. Patients were divided into current smokers and nonsmokers according to the NSQIP definitions. Each cohort was compared in terms of demographic data, preoperative comorbidities, and operative time. Infection end points were created from composite surgical site infection variables defined by the NSQIP database. Multivariate logistic regression analysis was utilized to adjust for confounding variables and calculate adjusted odds ratios (ORs) and associated 95% confidence intervals (95% CIs). RESULTS: In total, 8776 patients underwent rTKA. Of these patients, 11.6% were current smokers. Univariate analyses demonstrated that smokers had a higher rate of any wound complication (3.8% vs 1.8%, P < .0001), deep infection (2.5% vs 1.0%, P < .0001), pneumonia (1.3% vs 0.4%, P < .0001), and reoperation (5.0% vs 3.1%, P = .001) compared to nonsmokers undergoing revision total knee arthroplasty. Multivariate analysis identified current smokers as being at a significantly increased risk of any wound complication (OR 2.1; 95% CI 1.4-3.1) and deep infection (OR 2.1, 95% CI 1.2-3.6) after rTKA. CONCLUSION: This study demonstrates that smoking significantly increases the risk of infection, wound complications, and reoperation after rTKA. The results are even more magnified for revision procedures compared to published effects of smoking on primary total knee arthroplasty complications. Further research is needed regarding the impact of smoking cessation on mitigation of these observed risks.

Outcomes of Modified Harrington Reconstructions for Nonprimary Periacetabular Tumors: An Effective and Inexpensive Technique.

BACKGROUND: Metastatic disease to the acetabulum presents a difficult technical and philosophical challenge: complicated surgeries in patients with often short life expectancies force us to examine both the outcome and cost of these operations. Therefore, we studied the durability of a cement-screw rebar reconstruction technique and risk factors for failure, and we compare the results to other reconstruction options. METHODS: This is a retrospective review of 52 acetabular reconstructions in 50 patients for nonprimary disease using a retrograde screw-rebar-cement all-polyethylene technique. Mean age was 57 years (range 25-81 years). Twenty-four lesions were classified as Harrington class II; 28 were Harrington class III. Mean follow-up was 17.7 months (range 1-92 months). Outcomes included patient survival, prosthesis survival, and complications. RESULTS: Forty-eight of 50 (96 %) patients ambulated after surgery. Five of 52 (9.6 %) of prostheses failed, three from loosening due to tumor progression, one from aseptic loosening, and one from soft tissue instability (dislocation). The three cases of tumor progression failure occurred in patients with massive preoperative ischial tumor burden. Mean surgical time was 198 min, and hospital stay was 5.2 days. DISCUSSION: The screw-cement-rebar all-polyethylene cup reconstruction technique is a comparatively successful and inexpensive reconstruction option for treating nonprimary oncologic disease in the acetabulum. All cases of loosening occurred beyond the median patient survival. Surgeons should be wary of massive ischial tumor burden in patients with projected longevity, as it may be associated with implant failure. Surgical time and hospital stay are consistent with historical data for alternative implants, and implant cost is lower.

Surgical technique: Posterior retropleural thoracotomy for resection of a T10 dumbbell schwannoma.

Background: Myelopathy and nerve root dysfunction resulting from the imperceptible growth of intraspinal schwannomas have been well documented.[1] Thoracic spine schwannomas, in particular, have exceptional growth potential due to the presence of the posterior mediastinum and retropleural spaces accommodating insidious and often subclinical tumor expansion.[5] Extraspinal extension of these lesions, however, poses a distinct challenge for surgeons.[3,4]. Case Description: Here, we provide a two-dimensional intraoperative video demonstrating the technical nuances concerning maximally safe resection of a partially cystic thoracic dumbbell schwannoma having extraspinal extension with associated bony remodeling of the T10 vertebral body and neural foramen in a middle-aged male. A posterolateral approach with T8-T12 fusion, retropleural thoracotomy, facetectomies, and pediculectomies allowed for gross total resection. No intraoperative or postoperative complications were observed, and the parietal pleura was kept intact throughout the surgery. In addition, the patient continued to have improved symptoms and was ambulatory at 6-month follow-up. Conclusion: Gross total resection of a partially cystic thoracic dumbbell schwannoma was achieved without complications. Our use of a preoperative three-dimensional reconstruction for surgical planning,[2] intraoperative ultrasound,[6] and a durable instrumentation construct were essential for a successful outcome. Moreover, great care was taken to avoid violating the tumor-parietal pleura plane, which would have resulted in postoperative respiratory complications.

Metastatic choroid plexus papilloma presenting as a sellar mass: A case report and literature review.

Background: Choroid plexus papillomas (CPPs) are rare neoplasms arising from choroid plexus epithelium representing <1% of all intracranial tumors. Symptoms vary based on location and regional mass effect; however, hydrocephalus is common due to cerebrospinal fluid flow obstruction and/or overproduction. Distant site metastasis or de novo formation in extraventricular sites is rare. Case Description: A 57-year-old female with a history of a 4th ventricular CPP status post resection in 2004 and 2018 with subsequent gamma knife therapy in 2019 presented with increased thirst and urination. Since her initial surgery, she has experienced significant gait imbalance, diplopia, dysphagia, and right-sided hemiparesis and hemisensory loss. Magnetic resonance imaging revealed a new 1.5 × 1.8 cm suprasellar lesion. She underwent a left supraorbital craniotomy for tumor resection, with pathology revealing metastatic World Health Organization grade II CPP. Conclusion: Extraventricular manifestation of CPP is rare. De novo or metastatic involvement of the sella has seldom been reported. Treatment should target gross total surgical resection. Adjuvant chemotherapy and radiation may be useful in higher-grade lesions.

C5 palsy following esophageal diverticulum resection.

Background: C5 palsy (C5P) is a recognized potential postoperative complication of cervical spine surgery but has rarely been reported following an open esophageal diverticulectomy. Methods: A 61-year-old underwent an open esophageal diverticulectomy for symptomatic Zencker's diverticulum. Results: Postoperatively, she presented with right upper extremity weakness and sensory deficits consistent with a C5P that was later confirmed by electromyography. Conclusion: The potential for C5P after esophageal diverticulectomy for symptomatic Zencker's diverticulum is rare. Postoperative recognition and appropriate management are critical to recovery.

Intracranial malignant peripheral nerve sheath tumor: A case report and comprehensive literature review.

Background: Malignant peripheral nerve sheath tumors (MPNSTs) are rare malignant soft-tissue sarcomas arising from peripheral nerves. Little data exist regarding MPNST originating intracranially. Here, we present a 7th/8th nerve complex MPNST, discuss the treatment strategy and patient outcome, and provide a comprehensive review of existing literature. Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed and crossed references were queried, yielding 37 publications from 1952 to the present. Fifty-three cases of primary intracranial and extra-axial MPNST were identified. Results: We additionally report a 40-year-old female presented with acute onset dizziness and subsequent hearing loss with associated right-sided facial numbness. Magnetic resonance imaging revealed a 0.5 cm × 1.7 cm enhancing lesion within the right internal auditory canal extending into the cerebellopontine angle. The patient was initially treated with retro sigmoid craniotomy for tumor resection followed by a trans labyrinth approach for residual tumor resection. She completed adjuvant fractionated radiation therapy and underwent facial nerve transfer to restore complete hemifacial paralysis. The most common cranial nerves involved were V and VIII (43.4% each), with 66% of patients male and 34% female. The average age was 43.4 ± 17.4 years. The mean survival time for reported non-survivors after tissue diagnosis was 15 ± 4 months. Two-year survival for patients receiving gross total resection was 33.3% versus 22.8% with subtotal resection. Conclusion: MPNSTs comprise a group of highly aggressive neoplasms that rarely arise intracranially. Gross total surgical resection should be pursued when feasible.

Pseudogout mimicking cervical spine osteomyelitis and ventral epidural abscess: A case report and literature review.

Background: Calcium pyrophosphate deposition disease (CPPD), also known as "pseudogout," is a crystal deposition arthropathy involving the synovial and periarticular tissues. Pseudogout rarely presents in the axial spine. Here, we present the case of an 80-year-old female patient admitted after a mechanical fall, initially misdiagnosed on computed tomography (CT)/magnetic resonance studies with cervical osteodiscitis/ventral epidural abscess that proved to be pseudogout. Case Description: An 80-year-old female was admitted after a mechanical fall. The initial cervical CT scan showed multilevel degenerative changes with an acute C6 anterior wedge compression fracture, focal kyphosis, C5-6 disc space collapse, and endplate destruction. The magnetic resonance imaging showed marked contrast enhancement of the C5-6 vertebral bodies and disc space. An interventional radiology-guided biopsy of the C5-6 vertebral bodies and disc space was consistent with calcium pyrophosphate deposits, was diagnostic for pseudogout, and was negative for infection. She was managed conservatively with a rigid collar and seven days of oral prednisone. Conclusion: CPPD involvement in the axial spine is rare. Prompt pathologic diagnosis should be pursued to rule out an infectious process.

The Biomechanical Effects of Intramedullary Fixation to the Level of the Physeal Scar on Distal Tibia Fracture Stability.

INTRODUCTION: The purpose of this study was to evaluate whether intramedullary nail contact with physeal scar improves construct mechanics when treating distal tibial shaft fractures. METHODS: Axially unstable extra-articular distal tibia fractures were created in 30 fresh frozen cadaveric specimens (15 pairs, mean age 79 years). Specimens underwent intramedullary nailing to the level of the physeal scar locked with one or two interlocks or short of the physeal scar locked with two interlocks (reference group). Specimens were subjected to 800N of axial load for 25,000 cycles. Primary outcomes were stiffness before and after cyclic loading. Secondary outcomes were load to failure, load at 3 mm displacement, plastic deformation, and total deformation. RESULTS: The physeal scar with one interlock cohort demonstrated 3.8% greater stiffness before cycling ( P = 0.75) and 1.7% greater stiffness after cycling ( P = 0.86) compared with the reference group. The physeal scar with two interlocks group exhibited 0.3% greater stiffness before cycling ( P = 0.98) and 8.4% greater stiffness after cycling ( P = 0.41) in relation to the reference group. No differences were identified regarding load to failure or load at 3 mm displacement. In specimens with two interlocks, those in contact with the physeal scar demonstrated significantly less plastic ( P = 0.02) and total ( P = 0.04) deformation. CONCLUSIONS: Constructs ending at the physeal scar demonstrated stiffness and load to failure similar to those without physeal scar contact. Less plastic and total deformation was noted in two-interlock constructs with physeal scar contact, suggesting a possible protective effect provided by the physeal scar. These data argue that physeal scar contact may offer a small mechanical benefit in nailing distal tibia fractures, but clinical relevance remains unknown.

Thymoma metastatic to the epidural thoracic spine.

Background: Thymomas rarely metastasize to the spine. Here, we present a 69-year-old female diagnosed with stage IV thymoma, which subsequently developed a symptomatic epidural thoracic spinal lesion causing thoracic myelopathy. Case Description: The patient initially presented with paraspinal rib pain, lower extremity weakness, and gait imbalance. The magnetic resonance revealed a T10 vertebral body lesion with epidural extension causing severe spinal cord compression. A T9-T10 hemilaminotomy for tumor resection was performed; this was followed by adjuvant chemotherapy and radiation. Gross total resection was achieved, and the final pathology was metastatic thymoma. Postoperatively, the patient significantly improved. Conclusion: Metastatic thymomas to the thoracic spine are rare. For those presenting with epidural lesions causing myelopathy, surgical resection is beneficial and may be accompanied by adjunctive radiation and chemotherapy.

Technical improvements in preparing 3D printed anatomical models for comminuted fracture preoperative planning.

Preoperative planning of comminuted fracture repair using 3D printed anatomical models is enabling surgeons to visualize and simulate the fracture reduction processes before surgery. However, the preparation of such models can be challenging due to the complexity of certain fractures, particularly in preserving fine detail in bone fragments, maintaining the positioning of displaced fragments, and accurate positioning of multiple bones. This study described several key technical considerations for preparing 3D printed anatomical models for comminuted fracture preoperative planning. An optimized segmentation protocol was developed that preserves fine detail in bone fragments, resulting in a more accurate representation of the fracture. Additionally, struts were manually added to the digital model to maintain the positioning of displaced fragments after fabrication, reducing the likelihood of errors during printing or misrepresentation of fragment positioning. Magnets were also used to enable separation and visualization of accurate positioning of multiple bones, making it easier to visualize fracture components otherwise obscured by the anatomy. Finally, the infill for non-target structures was adjusted to minimize print time and material wastage. These technical optimizations improved the accuracy and efficiency of preparing 3D printed anatomical models for comminuted fracture preoperative planning, improving opportunities for surgeons to better plan surgical treatment in advance, reducing the likelihood of errors, with the goal of improving surgical outcomes.

Technical nuances for the resection of cervical dumbbell schwannomas.

The majority of spinal nerve sheath tumors are within the intradural/extramedullary compartment. A subset of these tumors develop extraforaminal components that gradually expand into potential spaces. Herein, the authors provide a 2D video demonstrating the technical nuances concerning resection of cervical dumbbell schwannomas with extraspinal extension. Although nerve sheath tumors with large extraforaminal extension are often associated with complications and pose unique challenges to surgeons, circumferential exposure with intradural exploration allows for gross-total resection and nerve root preservation, without need for adjuvant treatments. The use of intraoperative ultrasound, neurophysiological monitoring, Doppler imaging, and meticulous surgical techniques aided to circumvent complications.

A deep surgical site infection risk score for patients with open tibial shaft fractures treated with intramedullary nail.

OBJECTIVES: To identify deep infection risk factors in patients with open tibial shaft fractures and to develop a scoring algorithm to predict the baseline deep infection risk in this patient population. METHODS: A retrospective cohort study conducted at a single academic trauma center identified patients with open tibial shaft fractures treated with intramedullary nail fixation from December 2006 to October 2020. The primary outcome was a deep surgical site infection requiring surgical debridement. The outcome was identified by Current Procedural Terminology codes and confirmed with a medical chart review documenting evidence of a tibial draining wound or sinus tract. RESULTS: Deep surgical site infection occurred in 13% of patients (97/769). Factors that predicted deep surgical site infection were identified. Gustilo-Anderson type IIIB or IIIC was the strongest predictor with a 12-fold increase in the odds of deep infection (OR 11.8, p < 0.001). Additional factors included age >40 years (OR 1.7, p = 0.03), American Society of Anesthesiologists score ≥3 (OR 1.9, p < 0.01), Gustilo-Anderson type IIIA vs. type I or II (OR 2.8, p = 0.004), and gunshot wounds (OR 2.9, p = 0.02). The risk scoring model predicted patients who would develop an infection with an acceptable level of accuracy (AUC 0.79). The risk score categorized patients from a low probability of deep infection 2%-6% with <10 points to high risk (58%-69%) with >40 points. CONCLUSIONS: This risk score model predicts deep postoperative infection in patients with open tibial shaft fractures treated with intramedullary nails. The ability to accurately estimate deep infection risk at the time of presentation might aid patient expectation management and allow clinicians to focus infection prevention strategies on the high-risk subset of this population.

Operative Technique for Resection of a Ventral Transdural Retro-Odontoid Pannus: A 2-Dimensional Operative Video.

BACKGROUND: Retro-odontoid pseudotumors are rare inflammatory complications of atlantoaxial instability often associated with cervical degenerative disease and rheumatoid arthritis. While propagation of these lesions has been shown to cause spinal cord compression and cervical myelopathy, intradural extension has rarely been reported. METHODS: In this manuscript and 2-dimensional illustrative intraoperative video, we demonstrate cervical decompression, removal of the intradural component, and stabilization with C1-2 instrumentation using a posterior approach. A 71-year-old patient presented with progressive cervical myelopathy. Preoperative imaging demonstrated a large retro-odontoid pannus causing severe spinal cord compression and an associated contrast-enhancing intradural lesion, in the absence of obvious C1-2 instability or fractures on computed tomography scan. C1-2 posterior decompression and fusion were performed with maximally safe intradural pannus resection and ventral dural reconstruction. RESULTS: Postoperatively, the patient experienced significant improvement in myelopathic symptoms. Imaging demonstrated good spinal cord decompression with complete intradural pannus resection and debulking of the extradural component. CONCLUSIONS: Our outcome in this rare complication suggests a posterior approach may be effective in treating similar patients.

The Operative Treatment of Scapula Fractures: An Analysis of 10,097 Patients.

Background: The indications for operative treatment of scapula fractures have been debated over the past decade. Our purpose was to determine 1) the incidence and trends in the operative treatment of scapula fractures, 2) the incidence of conversion from operative fixation to total or hemi-shoulder arthroplasty (THSA) and 3) rates of associated injuries in scapula fractures. We hypothesized that the operative treatment of scapula fractures is increasing over time and that scapula fractures treated with open reduction and internal fixation (ORIF) would have increased risk for conversion to THSA. Methods: The Humana Inc. administrative claims database was queried from 2008 to 2015. Patients with any scapular fracture, ORIF of scapula fracture, total or hemi-shoulder arthroplasty, and associated injuries were identified by ICD-9 and CPT codes. Analysis was performed for 1) all patients with a scapula fracture undergoing operative fixation (i.e. ORIF and THSA), 2) all scapular fractures treated with ORIF with subsequent conversion to ipsilateral THSA, and 3) all associated injuries. Results: There were 10,097 scapula fractures (28.4% glenoid, 48% female). 60% occurred in patients 65 years and older. There were 198 (1.96%) fractures (70% glenoid) treated with ORIF. There were 287 (2.84%) fractures (45% glenoid) treated with THSA (76% total shoulder). The rate of ORIF of scapular fractures did not significantly increase (RR=0.87, p=0.58). There was a significant increase in THSA as primary treatment of scapula fractures in 2015 compared to 2007 (RR=0.43, p=0.0016). Conversion from ORIF to THSA was 12.6% (25/198). Scapula fractures treated with ORIF were at significant risk for conversion to THSA (RR=4.77, p<0.0001). Associated injuries occurred in nearly 50% of scapula fractures-other fractures, lung contusion and pneumothorax/hemothorax ranking the highest, accounting for 37%, 14.5% and 8.3% of all associated injuries, respectively. Conclusion: The incidence of operative treatment of scapula fractures was 1.96% and 2.84% for ORIF and THSA, respectively. Scapular fractures previously treated with ORIF were at significant risk for conversion to THSA. Although ORIF in scapular fractures did not significantly increase over time, both THSA and overall (ORIF+THSA) operative treatment of scapula fractures increased significantly. Level of Evidence: IV.

Educational impact of early COVID-19 operating room restrictions on neurosurgery resident training in the United States: A multicenter study.

BACKGROUND: The coronavirus (COVID-19) pandemic has caused unprecedented suspensions of neurosurgical elective surgeries, a large proportion of which involve spine procedures. The goal of this study is to report granular data on the impact of early COVID-19 pandemic operating room restrictions upon neurosurgical case volume in academic institutions, with attention to its secondary impact upon neurosurgery resident training. This is the first multicenter quantitative study examining these early effects upon neurosurgery residents caseloads. METHODS: A retrospective review of neurosurgical caseloads among seven residency programs between March 2019 and April 2020 was conducted. Cases were grouped by ACGME Neurosurgery Case Categories, subspecialty, and urgency (elective vs. emergent). Residents caseloads were stratified into junior (PGY1-3) and senior (PGY4-7) levels. Descriptive statistics are reported for individual programs and pooled across institutions. RESULTS: When pooling across programs, the 2019 monthly mean (SD) case volume was 214 (123) cases compared to 217 (129) in January 2020, 210 (115) in February 2020, 157 (81), in March 2020 and 82 (39) cases April 2020. There was a 60% reduction in caseload between April 2019 (207 [101]) and April 2020 (82 [39]). Adult spine cases were impacted the most in the pooled analysis, with a 66% decrease in the mean number of cases between March 2020 and April 2020. Both junior and senior residents experienced a similar steady decrease in caseloads, with the largest decreases occurring between March and April 2020 (48% downtrend). CONCLUSIONS: Results from our multicenter study reveal considerable decreases in caseloads in the neurosurgical specialty with elective adult spine cases experiencing the most severe decline. Both junior and senior neurosurgical residents experienced dramatic decreases in case volumes during this period. With the steep decline in elective spine cases, it is possible that fellowship directors may see a disproportionate increase in spine fellowships in the coming years. In the face of the emerging Delta and Omicron variants, programs should pay attention toward identifying institution-specific deficiencies and developing plans to mitigate the negative educational effects secondary to such caseloads reduction.

Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients.

BACKGROUND: Tibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds. METHODS: A retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure. RESULTS: Of the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39). CONCLUSION: Data from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.

Intraoperative Spinal Cord Monitoring Does Not Decrease New Postoperative Neurological Deficits in Patients With Cervical Radiculopathy or Spondylotic Myelopathy Undergoing One or Two Level Anterior Cervical Discectomy And Fusion.

BACKGROUND: Intraoperative neurological monitoring (IONM) is commonly used in spine surgery. However, the utility of IONM in anterior cervical decompression and fusion (ACDF) remains a topic of debate. The purpose of the study was to investigate the utility and cost of IONM (both Somatosensory evoked potentials (SSEPs) and Motor Evoked Potentials (Tc-MEPs)) in reducing postoperative neurological deficits in myelopathic and non-myelopathic patients undergoing ACDF. METHODS: Retrospective chart review was performed to include only patients with cervical radiculopathy or myelopathy undergoing one or two level ACDF over a 7-year period at a busy academic center. SSEP and Tc-MEP tracings were reviewed for all monitored patients and significant changes and inconsistencies were noted. IONM billing codes (SSEP/Tc-MEP) were reviewed and summed to evaluate the average procedural cost. Medical records were reviewed for preoperative physical exam and for new postoperative neurological deficits on postoperative day one and again at six weeks and matched to the monitored tracings. RESULTS: There were 249 total patients (48 Non-monitored, 201 monitored). There was no difference in gender, age, or BMI between monitored and non-monitored groups. There was no difference in new neurological deficits in monitored compared with non-monitored patients with radiculopathy (p=0.1935) or myelopathy (p=0.1977). However, when radiculopathy and myelopathy patients were combined, there was an increased incidence of new neurologic deficits in monitored patients (8.0%) versus non-monitored patients (0%) (p=0.0830). All new neurological deficits occurred in patients with normal IONM tracings. There were no new neurologic deficits in the non-monitored radiculopathy or myelopathy groups. The average IONM procedure charge was $6500. CONCLUSION: Our results indicate that intraoperative spinal cord monitoring did not reduce new neurological deficits in our cohort of patients. The higher incidence in new neurological deficits despite no IONM changes in our monitored group suggests a lack of utility of IONM in ACDF. Furthermore, at an average of $6500 per IONM procedure, the present study underlines the importance of prudence when choosing to use IONM in the era of cost containment.Level of Evidence: III.

Sensitivity and specificity of modified RUST score using clinical and radiographic findings as a gold standard.

AIMS: The modified Radiological Union Scale for Tibia (mRUST) fractures score was developed in order to assess progress to union and define a numerical assessment of fracture healing of metadiaphyseal fractures. This score has been shown to be valuable in predicting radiological union; however, there is no information on the sensitivity, specificity, and accuracy of this index for various cut-off scores. The aim of this study is to evaluate sensitivity, specificity, accuracy, and cut-off points of the mRUST score for the diagnosis of metadiaphyseal fractures healing. METHODS: A cohort of 146 distal femur fractures were retrospectively identified at our institution. After excluding AO/OTA type B fractures, nonunions, follow-up less than 12 weeks, and patients aged less than 16 years, 104 sets of radiographs were included for analysis. Anteroposterior and lateral femur radiographs at six weeks, 12 weeks, 24 weeks, and final follow-up were separately scored by three surgeons using the mRUST score. The sensitivity and specificity of mean mRUST score were calculated using clinical and further radiological findings as a gold standard for ultimate fracture healing. A receiver operating characteristic curve was also performed to determine the cut-off points at each time point. RESULTS: The mean mRUST score of ten at 24 weeks revealed a 91.9% sensitivity, 100% specificity, and 92.6% accuracy of predicting ultimate fracture healing. A cut-off point of 13 points revealed 41.9% sensitivity, 100% specificity, and 46.9% accuracy at the same time point. CONCLUSION: The mRUST score of ten points at 24 weeks can be used as a viable screening method with the highest sensitivity, specificity, and accuracy for healing of metadiaphyseal femur fractures. However, the cut-off point of 13 increases the specificity to 100%, but decreases sensitivity. Furthermore, the mRUST score should not be used at six weeks, as results show an inability to accurately predict eventual fracture healing at this time point. Cite this article: Bone Jt Open 2021;2(10):796-805.