Radiological severity of hip osteoarthritis in patients with adult spinal deformity: the effect on spinopelvic and lower extremity compensatory mechanisms.

PURPOSE: Sagittal spinal deformity (SSD) patients utilize pelvic tilt (PT) and their lower extremities in order to compensate for malalignment. This study examines the effect of hip osteoarthritis (OA) on compensatory mechanisms in SSD patients. METHODS: Patients ≥ 18 years with SSD were included for analysis. Spinopelvic, lower extremity, and cervical alignment were assessed on standing full-body stereoradiographs. Hip OA severity was graded by Kellgren-Lawrence scale (0-4). Patients were categorized as limited osteoarthritis (LOA: grade 0-2) and severe osteoarthritis (SOA: grade 3-4). Patients were matched for age and T1-pelvic angle (TPA). Spinopelvic [sagittal vertical axis (SVA), T1-pelvic angle, thoracic kyphosis (TK), pelvic tilt (PT), lumbar lordosis (LL), pelvic incidence minus lumbar lordosis (PI-LL), T1-spinopelvic inclination (T1SPi)] and lower extremity parameters [sacrofemoral angle, knee angle, ankle angle, posterior pelvic shift (P. Shift), global sagittal axis (GSA)] were compared between groups using independent sample t test. RESULTS: 136 patients (LOA = 68, SOA = 68) were included in the study. SOA had less pelvic tilt (p = 0.011), thoracic kyphosis (p = 0.007), and higher SVA and T1Spi (p < 0.001) than LOA. SOA had lower sacrofemoral angle (p < 0.001) and ankle angle (p = 0.043), increased P. Shift (p < 0.001) and increased GSA (p < 0.001) compared to LOA. There were no differences in PI-LL, LL, knee angle, or cervical alignment (p > 0.05). CONCLUSIONS: Patients with coexisting spinal malalignment and SOA compensate by pelvic shift and thoracic hypokyphosis rather than PT, likely as a result of limited hip extension secondary to SOA. As a result, SOA had worse global sagittal alignment than their LOA counterparts. These slides can be retrieved under Electronic Supplementary Material.

Cluster analysis describes constellations of cardiac anomalies presenting in spinal anomaly patients.

BACKGROUND: Cardiac anomalies are prevalent in patients with bony spinal anomalies. Prior studies evaluating incidences of bony congenital anomalies of the spine are limited. The Kids' Inpatient Database (KID) yields national discharge estimates of rare pediatric conditions like congenital disorders. This study utilized cluster analysis to study patterns of concurrent vertebral anomalies, anal atresia, cardiac malformations, trachea-esophageal fistula, renal dysplasia, and limb anomalies (VACTERL anomalies) co-occurring in patients with spinal congenital anomalies. METHODS: Retrospective review of KID 2003-2012. KID-supplied hospital- and year-adjusted weights allowed for incidence assessment of bony spinal anomalies and cardiac, gastrointestinal, urinary anomalies of VACTERL. K-means clustering assessed relationships between most frequent anomalies within bony spinal anomaly discharges; k set to n - 1(n = first incidence of significant drop/little gain in sum of square errors within clusters). RESULTS: There were 12,039,432 KID patients 0-20 years. Incidence per 100,000 discharges: 2.5 congenital fusion of spine, 10.4 hemivertebra, 7.0 missing vertebra. The most common anomalies co-occurring with bony vertebral malformations were atrial septal defect (ASD 12.3%), large intestinal atresia (LIA 11.8%), and patent ductus arteriosus (PDA 10.4%). Top congenital cardiac anomalies in vertebral anomaly patients were ASD, PDA, and ventricular septal defect (VSD); all three anomalies co-occur at 6.6% rate in this vertebral anomaly population. Cluster analysis revealed that of bony anomaly discharges, 55.9% of those with PDA had ASD, 34.2% with VSD had PDA, 22.9% with LIA had ASD, 37.2% with ureter obstruction had LIA, and 35.5% with renal dysplasia had LIA. CONCLUSIONS: In vertebral anomaly patients, the most common co-occurring congenital anomalies were cardiac, renal, and gastrointestinal. Top congenital cardiac anomalies in vertebral anomaly patients were ASD, PDA, and VSD. VACTERL patients with vertebral anomalies commonly presented alongside cardiac and renal anomalies.

Inhibition of peptidylarginine deiminase attenuates inflammation and improves survival in a rat model of hemorrhagic shock.

BACKGROUND: We have recently shown that inhibition of peptidylarginine deiminase (PAD) improves survival in a rodent model of lethal cecal ligation and puncture. The roles of PAD inhibitors in hemorrhagic shock (HS), however, are largely unknown. The goal of this study was to investigate the effects of YW3-56, a novel PAD inhibitor, on survival after severe HS. METHODS: Mouse macrophages were exposed to hypoxic conditions followed by reoxygenation in the presence or absence of YW3-56. Enzyme-linked immunosorbent assay (ELISA) was performed to measure levels of secreted tumor necrosis factor α and interleukin-6 in the culture medium. Cell viability was determined by methyl thiazolyl tetrazolium assay. In the survival experiment, anesthetized male Wistar-Kyoto rats (n = 10/group) were subjected to 55% blood loss, and treated with or without YW3-56 (10 mg/kg, intraperitoneally). Survival was monitored for 12 h. In the nonsurvival experiment, morphologic changes of the lungs were examined. Levels of circulating cytokine-induced neutrophil chemoattractant 1 (CINC-1) and myeloperoxidase (MPO) in the lungs were measured by ELISA. Expression of lung intercellular adhesion molecules-1 (ICAM-1) was also determined by Western blotting. RESULTS: Hypoxia/reoxygenation (H/R) insult induced tumor necrosis factor α and interleukin-6 secretion from macrophages, which was significantly attenuated by YW3-56 treatment. YW3-56 treatment also increased cell viability when macrophages were exposed to H/R up to 6/15 h and improved survival rate from 20% to 60% in lethal HS rat model. Compared to the sham groups, pulmonary MPO activity and ICAM-1 expression in the HS group were significantly increased, and acute lung injury was associated with a higher degree of CINC-1 levels in serum. Intraperitoneal delivery of YW3-56 significantly reduced pulmonary MPO and ICAM-1 expression and attenuated acute lung injury. CONCLUSIONS: Our results demonstrate for the first time that administration of YW3-56, a novel PAD inhibitor, can improve survival in a rat model of HS and in a cell culture model of H/R. The survival advantage is associated with an attenuation of local and systemic pro-inflammatory cytokines and the protection against acute lung injury after hemorrhage. Thus, PAD inhibition may represent a novel and promising therapeutic strategy for severe HS.

Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Knee Arthroplasty?

BACKGROUND: Many preventive methodologies seek to reduce the risk of surgical site infections after total knee arthroplasty (TKA), including the use of preoperative chlorhexidine baths and cloths. Although we have demonstrated in previous studies that this may be an efficacious method for infection prevention, our study was underpowered and we therefore set out to evaluate this with a larger sample size. QUESTIONS/PURPOSES: (1) Does a preadmission chlorhexidine cloth skin preparation protocol decrease the risk of surgical site infection in patients undergoing TKA? (2) When stratified using the National Healthcare Safety Network (NHSN) risk categories, which categories are associated with risk reduction from the preadmission chlorhexidine preparation protocol? METHODS: In our study, all patients (3717 total) who had undergone primary or revision TKA at a single institution between January 1, 2007, and December 31, 2013, were identified, of whom 991 patients used the chlorhexidine cloths before surgery and 2726 patients did not. All patients were provided cloths with instructions before surgery; however, as a result of a lack of compliance, we were able to substratify patients into treatment and control cohorts. Additionally, we substratified patients by NHSN risk category to determine differences in infection between the two cohorts (cloth versus no cloth). Patient medical records and an infection-tracking database were reviewed to determine the development of periprosthetic infection (patients who had superficial infections were excluded from our study) in both groups after 1 year surveillance. We then calculated relative risk reductions with use of chlorhexidine gluconate and stratified results based on NHSN risk category. RESULTS: Use of a preoperative chlorhexidine cloth skin preparation protocol is associated with reduced relative risk of periprosthetic infection after TKA (infections with protocol: three of 991 [0.3%]; infections in control: 52 of 2726 [1.9%]; relative risk [RR]: 6.3 [95% confidence interval [CI], 1.9-20.1]; p = 0.002). When stratified by NHSN risk category, periprosthetic infection risk reduction was seen in the medium-risk category (protocol: one of 402 [0.3%]; control: 25 of 1218 [2.0%]; RR, 8.3 [CI, 1.1-60.7]; p = 0.038), but no significant difference was detected in the low- and medium-risk groups (RR, 2.1 [CI, 0.5-9.6; p = 0.33] and RR, 11.3 [CI, 0.7-186.7; p = 0.09]). CONCLUSIONS: A prehospital chlorhexidine gluconate wipe protocol appears to reduce the risk of periprosthetic infections after TKA, primarily in those patients with medium and high risk. Although future multicenter randomized trials will need to confirm these preliminary findings, the intervention is inexpensive and is unlikely to be risky and therefore might be considered on the basis of this retrospective, comparative study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Protective effect of suberoylanilide hydroxamic acid against lipopolysaccharide-induced liver damage in rodents.

BACKGROUND: Lipopolysaccharide (LPS) has a deleterious effect on several organs, including the liver, and eventually leads to endotoxic shock and death. LPS-induced hepatotoxicity is characterized by disturbed intracellular redox balance and excessive reactive oxygen species (ROS) accumulation, leading to liver injury. We have shown that treatment with suberoylanilide hydroxamic acid (SAHA), a histone deacetylase inhibitor, improves survival in a murine model of LPS-induced shock, but the protective effect of SAHA against liver damage remains unknown. The goal of this study was to investigate the mechanism underlying SAHA action in murine livers. METHOD: Male C57BL/6J mice (6-8 wk), weighing 20-25 g, were randomly divided into three groups: (A) a sham group was given isotonic sodium chloride solution (10 µL/g body weight, intraperitoneal, i.p.) with dimethyl sulfoxide (DMSO; 1 µL/g body weight, i.p.); (B) an LPS group was challenged with LPS (20 mg/kg, i.p.) dissolved in isotonic sodium chloride solution with DMSO; (C) and an LPS plus SAHA group was treated with SAHA (50 mg/kg, i.p.) dissolved in DMSO immediately after injection of LPS (20 mg/kg, i.p.). Mice were anesthetized, and their livers were harvested 6 or 24 h after injection to analyze whether SAHA affected production of ROS and activation of apoptotic proteins in the liver cells of challenged mice. RESULTS: SAHA counteracted LPS-induced production of ROS (thiobarbituric acid reactive substances and nitrite) and reversed an LPS-induced decrease in antioxidant enzyme, glutathione. SAHA also attenuated LPS-induced hepatic apoptosis. Moreover, SAHA inhibited activation of the redox-sensitive kinase, apoptosis signal-regulating kinase-1, and the mitogen-activated protein kinases, p38 and Jun N-terminal kinase. CONCLUSIONS: Our data indicate, for the first time, that SAHA is capable of alleviating LPS-induced hepatotoxicity and suggest that a blockade of the upstream events required for apoptosis signal-regulating kinase-1 action may serve as a new therapeutic option in the treatment of LPS-induced inflammatory conditions.

Recent Smoking History Is Not Associated with Adverse 30-Day Standardized Postoperative Outcomes following Microsurgical Reconstructive Procedures of the Upper Extremity.

Background: Upper extremity (UE) microsurgical reconstruction relies upon proper wound healing for optimal outcomes. Cigarette smoking is associated with wound healing complications, yet conclusions vary regarding impact on microsurgical outcomes (replantation, revascularization, and free tissue transfer). We investigated how smoking impacted 30-day standardized postoperative outcomes following UE microsurgical reconstruction. Methods: Utilizing the National Surgical Quality Improvement Program, all patients who underwent (1) UE free flap transfer (n = 70) and (2) replantation/revascularization (n = 270) were identified. For each procedure, patients were stratified by recent smoking history (current smoker ≤1-year preoperatively). Baseline demographics and standardized 30-day complications, reoperations, and readmissions were compared between smokers and nonsmokers. Results: Replantation/revascularization patients had no differences in sex, race, or body mass index between smokers (n = 77) and nonsmokers. Smokers had a higher prevalence of congestive heart failure (5.2% vs 1.0%, P = .036) and nonsmokers were more often on hemodialysis (15.6% vs 10.4%, P = .030). Free flap transfer patients had no differences in age, sex, or race between smokers (n = 14) and nonsmokers. Smokers had a longer length of stay (6.6 vs 4.2 days, P = .001) and a greater prevalence of chronic obstructive pulmonary disorder (COPD; 7.1% vs 0%, P = .044). Recent smoking was not associated with increased odds of any 30-day minor and major standardized surgical complications, readmissions, or reoperations following UE microsurgical reconstruction via free flap transfer or replantation/revascularization. Baseline diagnosis of COPD was also not a predictor of adverse 30-day outcomes following free flap transfer. Conclusion: Recent smoking history was not associated with any 30-day adverse outcomes following UE microsurgical reconstruction via replantation/revascularization or free flap transfer. In light of these findings, further investigation is warranted, with particular focus on adverse events specific to free flaps and replantation/revascularization.

Contexte: La reconstruction microchirurgicale du membre supérieur repose sur la bonne guérison de la plaie pour des résultats optimaux. Le tabagisme est associé à des complications pour la guérison des plaies; toutefois, les conclusions concernant ses répercussions sur les résultats microchirurgicaux (réimplantation, revascularisation et transfert de tissu libre) sont variables. Nous avons cherché à savoir quelles étaient les répercussions du tabagisme sur les résultats postopératoires standardisés à 30 jours après reconstruction microchirurgicale du membre supérieur. Méthodes: Utilisant le Programme national d'amélioration de la qualité de la chirurgie, tous les patients ayant subi (1) un transfert de lambeau libre du membre supérieur (n = 70) et (2) une réimplantation/revascularisation (n = 270) ont été identifiés. Pour chaque procédure, les patients ont été classés en fonction de leurs antécédents de tabagisme récent (fumeur actuel ≤ 1 an préopératoire). Les données démographiques initiales et les complications standardisées à 30 jours, les réinterventions et les réhospitalisations ont été comparées entre fumeurs et non-fumeurs. Résultats: Concernant les réimplantations/revascularisations, il n'y a pas eu de différences en termes de sexe, race ou IMC entre les fumeurs (n = 77) et les non-fumeurs. Les fumeurs avaient une plus grande prévalence d'insuffisance cardiaque congestive (5,2 % contre 1,0 %, P = 0,036) et les non-fumeurs étaient plus souvent sous hémodialyse (15,6 % contre 10,4 %, P = 0,030). Concernant les patients ayant eu un transfert de lambeau libre, il n'y a pas eu de différences en termes d'âge, de sexe ou de race entre les fumeurs (n = 14) et les non-fumeurs. La durée d'hospitalisation des fumeurs a été plus longue (6,6 jours contre 4,2 jours, P =0,001) avec une prévalence plus élevée de MPOC (7,1 % contre 0 %, P = 0,044). Le tabagisme récent n'a pas été associé à une augmentation de la probabilité de complications chirurgicales standardisées, majeures ou mineures, à 30 jours, de réhospitalisation ou reprises chirurgicales après reconstruction microchirurgicale du membre supérieur par transfert de lambeau libre ou réimplantation/revascularisation. Le diagnostic de MPOC à l'inclusion dans l'étude n'était pas non plus un facteur prédictif d'événements indésirables à 30 Jours après transfert de lambeau libre. Conclusion: Un antécédent de tabagisme récent n'a pas été associé à des résultats indésirables à 30 jours après reconstruction microchirurgicale du membre supérieur via réimplantation/revascularisation ou transfert de lambeau libre. À la lumière de ces constatations, des études supplémentaires portant particulièrement sur les événements indésirables propres aux procédures de lambeaux libres et de réimplantation/revascularisation sont justifiées.

The 5-factor modified frailty index (mFI-5) is predictive of 30-day postoperative complications and readmission in patients with adult spinal deformity (ASD).

BACKGROUND: There is limited research regarding the association between the mFI-5 and postoperative complications among adult spinal deformity (ASD) patients. METHODS: Using the National Surgical Quality Improvement Project (NSQIP) database, patients with Current Procedural Terminology (CPT) codes for > 7-level fusion or < 7-level fusion with International Classification of Diseases, Ninth Revision (ICD-9) codes for ASD were identified between 2008 and 2016. Univariate analyses with post-hoc Bonferroni correction for demographics and preoperative factors were performed. Logistic regression assessed associations between mFI-5 scores and 30-day post-operative outcomes. RESULTS: 2,120 patients met criteria. Patients with an mFI-5 score of 4 or 5 were excluded, given there were<20 patients with those scores. Patients with mFI-5 scores of 1 and 2 had increased 30-day rates of pneumonia (3.5 % and 4.3 % vs 1.6 %), unplanned postoperative ventilation for > 48 h (3.1 % and 4.3 % vs 0.9 %), and UTIs (4.4 % and 7.4 % vs 2.0 %) than patients with a score of 0 (all, p < 0.05). Logistic regression revealed that compared to an mFI-5 of 0, a score of 1 was an independent predictor of 30-day reoperations (OR = 1.4; 95 % CI 1.1-18). A score of 2 was an independent predictor of overall (OR = 2.4; 95 % CI 1.4-4.1) and related (OR = 2.2; 95 % CI 1.2-4.1) 30-day readmissions. A score of 3 was not predictive of any adverse outcome. CONCLUSION: The mFI-5 score predicted complications and postoperative events in the ASD population. The mFI-5 may effectively predict 30-day readmissions. Further research is needed to identify the benefits and predictive value of mFI-5 as a risk assessment tool.

Photogrammetric analysis: An objective measure to assess the craniocervical range of motion after cervical laminoplasty surgeries.

Surgical decompression using laminoplasty is commonly performed for multilevel stenosis with cervical spondylotic myelopathy. However, the long-term effects on the craniocervical range of motion (ROM) after surgery are not well understood. This study represents the first entry into the literature of photogrammetric analysis for clinical measurement of craniocervical ROM. All patients underwent a French-door laminoplasty from 1995 to 2016 and were evaluated radiologically and with postoperative photographs (photogrammetric analysis) to measure craniocervical ROM and axial rotation. Radiographic parameters were occiput to C2 angle, C1-2 angle, C2-7 angle/cervical lordosis (CL), T1-slope (T1S), and TS-CL were measured. Chin-brow vertical angle (CBVA) was utilized for flexion and extension, while nose-turn angle (NTA) was used to assess axial rotation. Forty-four patients (mean age: 65.7 years, 50% female) had a mean follow-up of 37.9 months. Mean values in neutral, flexion, and extension were occiput to C2 = 30°, 15°, and 43°; C1-C2 = -32°, -25°, -32°; and C2-C7 = -4°, 11°, -20°, respectively. Mean CL was within 1 SD of the established -17° (±13.86°). Mean T1S and TS-CL were 33° and 30° in the neutral position, respectively. Mean radiographic full range of motion from flexion to extension was 53°. NTA towards patients' left was 48° and the right side was 45°. Mean CBVA, was -4°, mean flexion 37°, and extension -45°; full range was 81°. Global craniocervical ROM has proven to be well preserved for many years following cervical laminoplasty. Photogrammetric analysis is a cost-effective and radiation-free method, accurate for quantitative assessment of craniocervical and cervical ROM.

McGregor's slope and slope of line of sight: two surrogate markers for Chin-Brow vertical angle in the setting of cervical spine pathology.

BACKGROUND CONTEXT: Chin-Brow Vertical Angle (CBVA) is not routinely measured on radiographs even though it is a strong assessor of horizontal gaze. STUDY DESIGN: Retrospective cohort study of patients with full-body stereoradiographs and a primary cervical diagnosis at the time of presentation. PURPOSE: Assess the utility of McGregor's Slope (McGS) and Slope of Line of Sight (SLS) as surrogate markers for the CBVA in cervical spine pathology. METHODS: A retrospective review of patients with full-body stereoradiographs was performed. Patients were ≥18 years of age with a primary cervical diagnosis. Analysis of CBVA, McGS, and SLS was conducted as markers of horizontal gaze. Sagittal alignment was characterized by: pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI-LL), T1-pelvic angle (TPA), sagittal vertical axis (SVA), T2-T12 thoracic kyphosis, C2-C7 SVA (cSVA), C2-C7 Cervical lordosis, T1-Slope minus Cervical Lordosis (TS-CL), and C2-Slope (C2S). A subgroup analysis was performed in patients with cervical deformity. Independent sample t tests and paired t tests compared radiographic alignment. Pearson correlations characterized linear relationships. Linear regression analysis identified relationships between the parameters. RESULTS: In all, 329 patients were identified with primary cervical spine diagnoses. Chin-Brow Vertical Angle was visible in 171 patients (52.0%), McGS in 281 (85.4%), and SLS in 259 (78.7%). Of the 171 patients with visible CBVA, the mean CBVA was 2.30±7.7, mean McGS was 5.02±8.1, and mean SLS was -1.588±2.03. Chin-Brow Vertical Angle strongly correlated with McGS (r=0.83) and SLS (r=0.89) with p<.001. McGregor's Slope positively correlated with SLS (r=0.89, p=.001). CONCLUSIONS: This study demonstrates that McGS and SLS serve as strong, positive correlates for CBVA. The reported mean differences between these measurements provide a useful conversion, broadening CBVA's use as a radiographic assessment of horizontal gaze.

Use of Gabapentin in Posterior Spinal Fusion is Associated With Decreased Postoperative Pain and Opioid Use in Children and Adolescents.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study was to examine associations of gabapentin use with inpatient postoperative daily pain scores and opioid use in children undergoing PSF for AIS. SUMMARY OF BACKGROUND DATA: Gabapentin use in posterior spinal fusion (PSF) postoperative pain management for adolescent idiopathic scoliosis (AIS) is increasingly common in order to decrease opioid use and improve pain control, though there is conflicting data on dosing and effectiveness to support this practice in real world settings. METHODS: Retrospective cohort study of children aged 10 to 21 years undergoing PSF for AIS between January 2013 and June 2016 at an urban academic tertiary care center. Adjuvant gabapentin exposure was defined as at least 15 mg/kg/d by postoperative day (POD) 1 with an initial loading dose of 10 mg/kg on day of surgery. Primary outcomes were daily postoperative mean pain score and opioid use [morphine milligram equivalents/kg/day(mme/kg/d)]. Secondary outcomes were short and long-term complications. RESULTS: Among 129 subjects (mean age, 14.6 y, 74% female, mean coronal cobb, 55.2 degrees), 24 (19%) received gabapentin. Unadjusted GABA exposure was associated with significantly lower opioid use on POD1 and 2 (49% and 31%mme/kg/d, respectively) and lower pain scores (14%) on POD2. Adjusting for preexisting back pain, preoperative coronal Cobb angle, and site, GABA use was associated with significantly lower mean pain scores on POD1 through POD3 (-0.68, P=0.01; -0.86, P=0.002; -0.63, P=0.04). Gabapentin use was also associated with decreased opioid use on POD1 and POD2 (-0.39mme/kg/d, P<0.001; -0.27, P=0.02). There was no difference in complications by gabapentin exposure. CONCLUSIONS: Addition of gabapentin as adjuvant therapy for adolescent PSF, beginning on day of surgery, is associated with improved pain scores and decreased opioid use in the first 48 to 72 hours postoperatively. LEVEL OF EVIDENCE: This is a retrospective cohort study, classified as Level III under "Therapeutic Studies Investigating the Results of a Treatment."

Spinopelvic Compensatory Mechanisms for Reduced Hip Motion (ROM) in the Setting of Hip Osteoarthritis.

STUDY DESIGN: Retrospective review from a single institution. OBJECTIVE: To investigate the effect of hip osteoarthritis (OA) on spinopelvic compensatory mechanisms as a result of reduced hip range of motion (ROM) between sitting and standing. SUMMARY OF BACKGROUND DATA: Hip OA results in reduced hip ROM and contracture, causing pain during postural changes. Hip flexion contracture is known to reduce the ability to compensate for spinal deformity while standing; however, the effects of postural spinal alignment change between sitting and standing is not well understood. METHODS: Sit-stand radiographs of patients without prior spinal fusion or hip prosthesis were evaluated. Hip OA was graded by Kellgren-Lawrence grades and divided into low-grade (LOA; grade 0-2) and severe (SOA; grade 3 or 4) groups. Radiographic parameters evaluated were pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), PI-LL, thoracic kyphosis (TK), SVA, T1-pelvic angle (TPA), T10-L2, proximal femoral shaft angle (PFSA), and hip flexion (PT change-PFSA change). Changes in sit-stand parameters were compared between LOA and SOA groups. RESULTS: 548 patients were included (LOA = 311; SOA = 237). After propensity score matching for age, body mass index, and PI, 183 LOA and 183 SOA patients were analyzed. Standing analysis demonstrated that SOA had higher SVA (31.1 vs. 21.7), lower TK (-36.2 vs. -41.1), and larger PFSA (9.1 vs. 7.4) (all p < .05). Sitting analysis demonstrated that SOA had higher PT (29.7 vs. 23.3), higher PI-LL (21.6 vs. 12.4), less LL (31.7 vs. 41.6), less TK (-33.2 vs. -38.6), and greater TPA (27.9 vs. 22.5) (all p < .05). SOA had less hip ROM from standing to sitting versus LOA (71.5 vs. 81.6) (p < .05). Therefore, SOA had more change in PT (15.2 vs. 7.3), PI-LL (20.6 vs. 13.7), LL (-21.4 vs. -13.1), and T10-L2 (-4.9 vs. -1.1) (all p < .001), allowing the femurs to change position despite reduced hip ROM. SOA had greater TPA reduction (15.1 vs. 9.6) and less PFSA change (86.7 vs. 88.8) compared with LOA (both p < .001). CONCLUSIONS: Spinopelvic compensatory mechanisms are adapted for reduced hip joint motion associated with hip OA in standing and sitting. LEVEL OF EVIDENCE: Level III.

Klippel-Feil: A constellation of diagnoses, a contemporary presentation, and recent national trends.

BACKGROUND: Klippel-Feil syndrome (KFS) includes craniocervical anomalies, low posterior hairline, and brevicollis, with limited cervical range of motion; however, there remains no consensus on inheritance pattern. This study defines incidence, characterizes concurrent diagnoses, and examines trends in the presentation and management of KFS. METHODS: This was a retrospective review of the Kid's Inpatient Database (KID) for KFSpatients aged 0-20 years from 2003 to 2012. Incidence was established using KID-supplied year and hospital-trend weights. Demographics and secondary diagnoses associated with KFS were evaluated. Comorbidities, anomalies, and procedure type trends from 2003 to 2012 were assessed for likelihood to increase among the years studied using ANOVA tests. RESULTS: Eight hundred and fifty-eight KFS diagnoses (age: 9.49 years; 51.1% females) and 475 patients with congenital fusion (CF) (age: 8.33 years; 50.3% females) were analyzed. We identified an incidence rate of 1/21,587 discharges. Only 6.36% of KFS patients were diagnosed with Sprengel's deformity; 1.44% with congenital fusion. About 19.1% of KFS patients presented with another spinal abnormality and 34.0% presented with another neuromuscular anomaly. About 36.51% of KFS patients were diagnosed with a nonspinal or nonmusculoskeletal anomaly, with the most prevalent anomalies being of cardiac origin (12.95%). About 7.34% of KFS patients underwent anterior fusions, whereas 6.64% of KFS patients underwent posterior fusions. The average number of levels operated on was 4.99 with 8.28% receiving decompressions. Interbody devices were used in 2.45% of cases. The rate of fusions with <3 levels (7.46%) was comparable to that of 3 levels or greater (7.81%). CONCLUSIONS: KFS patients were more likely to have other spinal abnormalities (19.1%) and nonnervous system abnormalities (13.63%). Compared to congenital fusions, KFS patients were more likely to have congenital abnormalities such as Sprengel's deformity. KFS patients are increasingly being treated with spinal fusion. LEVEL OF EVIDENCE: III.

Suboptimal Age-Adjusted Lumbo-Pelvic Mismatch Predicts Negative Cervical-Thoracic Compensation in Obese Patients.

BACKGROUND: Given the paucity of literature regarding compensatory mechanisms used by obese patients with sagittal malalignment, it is necessary to gain a better understanding of the effects of obesity on compensation after comparing the degree of malalignment to age-adjusted ideals. This study aims to compare baseline alignment of obese and nonobese patients using age-adjusted spino-pelvic alignment parameters, describing associated spinal changes. METHODS: Patients ≥ 18 years with full-body stereoradiographs were propensity-score matched for sex, baseline pelvic incidence (PI), and categorized as nonobese (body mass index < 30kg/m2) or obese (body mass index ≥ 30). Age-adjusted ideals were calculated for sagittal vertical axis, spino-pelvic mismatch (PI-LL), pelvic tilt, and T1 pelvic angle using established formulas. Patients were stratified as meeting alignment ideals, being above ideal, or being below. Spinal alignment parameters included C0-C2, C2-C7, C2-T3, cervical thoracic pelvic angle, cervical sagittal vertical axis SVA, thoracic kyphosis, T1 pelvic angle, T1 slope, sagittal vertical axis, lumbar lordosis (LL), PI, PI-LL, pelvic tilt. Lower-extremity parameters included sacrofemoral angle, knee flexion (KA), ankle flexion (AA), pelvic shift (PS), and global sagittal angle (GSA). Independent t tests compared parameters between cohorts. RESULTS: Included: 800 obese, 800 nonobese patients. Both groups recruited lower-extremity compensation: sacrofemoral angle (P = .004), KA, AA, PS, GSA (all P < .001). Obese patients meeting age-adjusted PI-LL had greater lower-extremity compensation than nonobese patients: lower sacrofemoral angle (P = .002), higher KA (P = .008), PS (P = .002), and GSA (P = .02). Obese patients with PI-LL mismatch higher than age-adjusted ideal recruited greater lower-extremity compensation than nonobese patients: higher KA, AA, PS, GSA (all P < .001). Obese patients showed compensation through the cervical spine: increased C0-C2, C2-C7, C2-T3, and cervical sagittal vertical axis (all P < .001), high T1 pelvic angle (P < .001), cervical thoracic pelvic angle (P = .03), and T1 slope (P < .001), with increased thoracic kyphosis (P = .015) and decreased LL (P < .001) compared to nonobese patients with PI-LL larger than age-adjusted ideal. CONCLUSIONS: Regardless of malalignment severity, obese patients recruited lower-limb compensation more than nonobese patients. Obese patients with PI-LL mismatch larger than age-adjusted ideal also develop upper-cervical and cervicothoracic compensation for malalignment. LEVEL OF EVIDENCE: III. CLINICAL RELEVANCE: Clinical evaluation should extend to the cervical spine in obese patients not meeting age-adjusted sagittal alignment ideals.

Traumatic Fracture of the Pediatric Cervical Spine: Etiology, Epidemiology, Concurrent Injuries, and an Analysis of Perioperative Outcomes Using the Kids' Inpatient Database.

BACKGROUND: The study aimed to characterize trends in incidence, etiology, fracture types, surgical procedures, complications, and concurrent injuries associated with traumatic pediatric cervical fracture using a nationwide database. METHODS: The Kids' Inpatient Database (KID) was queried. Trauma cases from 2003 to 2012 were identified, and cervical fracture patients were isolated. Demographics, etiologies, fracture levels, procedures, complications, and concurrent injuries were assessed. The t-tests elucidated significance for continuous variables, and χ2 for categoric values. Logistic regressions identified predictors of spinal cord injury (SCI), surgery, any complication, and mortality. Level of significance was P < .05. RESULTS: A total of 11 196 fracture patients were isolated (age, 16.63 years; male, 65.7%; white, 65.4%; adolescent, 55.4%). Incidence significantly increased since 2003 (2003 vs 2012, 2.39% vs 3.12%, respectively), as did Charlson Comorbidity Index (CCI; 2003 vs 2012, 0.2012 vs 0.4408, respectively). Most common etiology was motor vehicle accidents (50.5%). Infants and children frequently fractured at C2 (closed: 43.1%, 32.9%); adolescents and young adults frequently fractured at C7 (closed: 23.9%, 26.5%). Upper cervical SCI was less common (5.8%) than lower cervical SCI (10.9%). Lower cervical unspecified-SCI, anterior cord syndrome, and other specified SCIs significantly decreased since 2003. Complications were common (acute respiratory distress syndrome, 7.8%; anemia, 6.7%; shock, 3.0%; and mortality, 4.2%), with bowel complications, cauda equina, anemia, and shock rates significantly increasing since 2003. Concurrent injuries were common (15.2% ribs; 14.4% skull; 7.1% pelvis) and have significantly increased since 2003. Predictors of SCI included sports injury and CCI. Predictors of surgery included falls, sports injuries, CCI, length of stay, and SCI. CCI, SCIs, and concurrent injuries were predictors of any complication and mortality, all (P < .001). CONCLUSIONS: Since 2003, incidence, complications, concurrent injuries, and fusions have increased. CCI, SCI, falls, and sports injuries were significant predictors of surgical intervention. Decreased mortality and SCI rates may indicate improving emergency medical services and management guidelines. LEVEL OF EVIDENCE: III. CLINICAL RELEVANCE: Clinicians should be aware of increased case complexity in the onset of added perioperative complications and concurrent injuries. Cervical fractures resultant of sports injuries should be scrutinized for concurrent SCIs.

Trends in Treatment of Scheuermann Kyphosis: A Study of 1,070 Cases From 2003 to 2012.

STUDY DESIGN: Retrospective review of KID Inpatient Database (KID) from 2003, 2006, 2009, and 2012. OBJECTIVES: The aim of this study was to evaluate the impact of advances in spinal surgery on patient outcomes in the treatment of Scheuermann kyphosis (SK). SUMMARY OF BACKGROUND DATA: SK is one of the most common causes of back pain in adolescents. Trends in diagnoses and surgical treatment and approach to SK have not been well described. METHODS: SK patients aged 0-20 years in KID were identified by ICD-9 code 732.0. KID-supplied year- and hospital-trend weights were used to establish prevalence. Patient demographics, surgical details, and outcomes were analyzed with analysis of variance. RESULTS: A total of 1,070 SK patients were identified (33.2% female), with increasing incidence of SK diagnosed from 2003 to 2012 (3.6-7.5 per 100,000, p < .001). The average age of operative patients was 16.1±2.0 years and did not change (16.27-16.06 years, p = .905). The surgical rate has not changed over time (72.8%-72.8%, p = .909). Overall, 96.3% of operative patients underwent fusion, with 82.2% of cases spanning ≥4 levels; in addition, 8.6% underwent an anterior-only surgery, 74.6% posterior-only, and 13.6% combined approach. From 2003 to 2012, rates of posterior-only surgeries increased (62.4%-84.4%, p < .001) whereas the rate of combined-approach surgeries decreased (37.6%-8.8%, p < .001). Overall complication rates for SK surgeries have decreased (2003: 20.9%; 2012: 11.9%, p = .029). Concurrently, the rate of ≥4-level fusions has increased (43.5%-89.6%, p < .001), as well as the use of Smith-Peterson (7.8%-23.6%, p < .001) and three-column osteotomies (0.0%-2.7%, p = .011). In subanalysis comparing posterior to combined approaches, complication rates were significantly different (posterior: 9.88%, combined: 19.46%, p = .005). Patients undergoing a combined approach have a longer length of stay (LOS) than patients undergoing a posterior-only approach (7.8 vs. 5.6 days, p < .001). CONCLUSIONS: Despite unchanged demographics and operative rates in SK, there has been a shift from combined to isolated posterior approaches, with a concurrent increase in levels treated. A combined approach was associated with increased complication rates, LOS, and total charges compared to isolated approaches. Awareness of these inherent differences is important for surgical decision making and patient education. LEVELS OF EVIDENCE: Level III.

The Impact of Adult Thoracolumbar Spinal Deformities on Standing to Sitting Regional and Segmental Reciprocal Alignment.

BACKGROUND: Regional and segmental changes of the lumbar spine have previously been described as patients transition from standing to sitting; however, alignment changes in the cervical and thoracic spine have yet to be investigated. So, the aim of this study was to assess cervical and thoracic regional and segmental changes in patients with thoracolumbar deformity versus a nondeformed thoracolumbar spine population. METHODS: This study was a retrospective cohort study of a single center's database of full-body stereoradiographic imaging and clinical data. Patients were ≥ 18 years old with nondeformed spines (nondegenerative, nondeformity spinal pathologies) or thoracolumbar deformity (ASD: PI-LL > 10°). Patients were propensity-score matched for age and maximum hip osteoarthritis grade and were stratified by Scoliosis Research Society (SRS)-Schwab classification by PI-LL, SVA, and PT. Patients with lumbar transitional anatomy or fusions were excluded. Outcome measures included changes between standing and sitting in global alignment parameters: sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), pelivc tilt (PT), thoracic kyphosis, cervical alignment, cervical SVA, C2-C7 lordosis (CL), T1 slop minus CL (TS-CL), and segmental alignment from C2 to T12. Another analysis was performed using patients with cervical and thoracic segmental measurements. RESULTS: A total of 338 patients were included (202 nondeformity, 136 ASD). After propensity-score matching, 162 patients were included (81 nondeformity, 81 ASD). When categorized by SRS-Schwab classification, all nondeformity patients were nonpathologically grouped for PI-LL, SVA, and PT, whereas ASD patients had mix of moderately and markedly deformed modifiers. There were significant differences in pelvic and global spinal alignment changes from standing to sitting between nondeformity and ASD patients, particularly for SVA (nondeformed: 49.5 mm versus ASD: 27.4 mm; P < .001) and PI-LL (20.12° versus 13.01°, P < .001). With application of the Schwab classification system upon the cohort, PI-LL (P = .040) and SVA (P = .007) for severely classified deformity patients had significantly less positional alignment change. In an additional analysis of patients with segmental measurements from C2 to T12, nondeformity patients showed significant mobility of T2-T3 (-0.99° to -0.54°, P = .023), T6-T7 (-3.39° to -2.89°, P = .032), T7-T8 (-2.68° to -2.23°, P = .048), and T10-T11 (0.31° to 0.097°, P = .006) segments from standing to sitting. ASD patients showed mobility of the C6-C7 (1.76° to 3.45°, P < .001) and T11-T12 (0.98° to 0.54°, P = 0.014) from standing to sitting. The degree of mobility between nondeformity and ASD patients was significantly different in C6-C7 (-0.18° versus 1.69°, P = .003), T2-T3 (0.45° versus -0.27°, P = .034), and T10-T11 (0.45° versus -0.30°, P = .001) segments. With application of the Schwab modifier system upon the cohort, mobility was significant in the C6-C7 (nondeformed: 0.18° versus moderately deformed: 2.12° versus markedly deformed: 0.92°, P = .039), T2-T3 (0.45° versus -0.08° versus -0.63°, P = .020), T6-T7 (0.48° versus 0.36° versus -1.85°, P = .007), and T10-T11 (0.45° versus -0.21° versus -0.23°, P = .009) segments. CONCLUSIONS: Nondeformity patients and ASD patients have significant differences in mobility of global spinopelvic parameters as well as segmental regions in the cervical and thoracic spine between sitting and standing. This study aids in our understanding of flexibility and compensatory mechanisms in deformity patients, as well as the possible impact on unfused segments when considering deformity corrective surgery.

Alcoholism as a predictor for pseudarthrosis in primary spine fusion: An analysis of risk factors and 30-day outcomes for 52,402 patients from 2005 to 2013.

INTRODUCTION: This study assessed the incidence and risk factors for pseudarthrosis among primary spine fusion patients. METHODS: Retrospective review of ACS-NSQIP (2005-2013). Differences in comorbidities between spine fusion patients with and without pseudarthrosis (Pseud, N-Pseud) were assessed using chi-squared tests and Independent Samples t-tests. Binary logistic regression assessed patient-related and procedure-related predictors for pseudarthrosis. RESULTS: 52,402 patients (57yrs, 53%F, 0.4% w/pseudarthrosis). Alcohol consumption (OR:2.6[1.2-5.7]) and prior history of surgical revision (OR:1.6[1.4-1.8]) were risk factors for pseudarthrosis operation. Pseud patients at higher risk for deep incisional SSI (at 30-days:OR:6.6[2.0-21.8]). Pseud patients had more perioperative complications (avg:0.24 ±â€¯0.43v0.18 ±â€¯0.39,p=0.026). CONCLUSIONS: Alcoholism and surgical revision are major risk factors for pseudarthrosis in patients undergoing spine fusion.

Rates of Mortality in Cervical Spine Surgical Procedures and Factors Associated With Its Occurrence Over a 10-Year Period: A Study of 342 477 Patients on the Nationwide Inpatient Sample.

BACKGROUND: Risk of death is important in counseling patients and improving quality of care. Incidence of death in cervical surgery is not firmly established due to its rarity and limited sample sizes, particularly in the context of different surgeries, demographics, and risk factors. Particularly, different patient risk profiles may have varying degrees of risk in terms of surgeries, comorbidities, and demographics. This study aims to use a large patient cohort available on a national database to study the prevalence of death associated with cervical spine surgery. METHODS: This study was a retrospective review of the Nationwide Inpatient Sample (NIS) years 2003-2012. A total of 342 477 patients were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes undergoing spinal fusion or decompression for disc degeneration, stenosis, spondylosis, myelopathy, postlaminectomy syndrome, scoliosis, or neck pain associated with the cervical region. Patients with malignancy were excluded from analysis. Incidence of mortality was assessed by χ2 tests across different patient demographics and comorbidities, procedures performed, and concurrent in-hospital complications. Binary logistic regression identified significant increases or decreases in risk of death while controlling for comorbidities, race, sex, and Mirza invasiveness. Significance was defined as P < .05 differences relative to overall cohort. RESULTS: The study analyzed 342 477 patients with an overall mortality rate of 0.32%. A total of 231 977 simple fusions (single approach and <3 levels) experienced a mortality rate of 0.256%; 49 594 complex fusions (combined approach or ≥3 levels) had a mortality rate of 0.534%; and 61 285 decompression-only procedures reported a 0.424% mortality rate, all P < .001 from overall rate. In reporting rates across different demographics, male patients experienced a significantly higher risk for mortality (odds ratio [OR], 2.16; 95% CI, 1.87-4.49), as did black patients (OR, 1.58; CI, 1.32-1.90) and patients over age 75 (OR, 7.55; 95% CI, 6.58-8.65), all P < .001. Patients with liver disease reported 6.40% mortality. Similarly, patients with congestive heart failure (3.91%), cerebrovascular disease (3.41%), and paraplegia (3.79%) experienced high mortality rates, all in cohorts of over 2000 patients, all P < .001. Concurrent in-hospital complications with the highest risk of mortality were shock (OR, 51.41; 95% CI, 24.08-109.76), pulmonary embolism (OR, 25.01; 95% CI, 14.70-42.56), and adult respiratory distress disorder (OR, 14.94; 95% CI, 12.75-17.52), all P < .001. CONCLUSION: In 342 477 cervical spine surgery patients an overall mortality rate of 0.32% was reported. The rate was 3.91% in a cohort of 5933 patients with congestive heart failure and 3.79% in a cohort of 6947 patients with paraplegia. These findings are consistent with previous estimates and may help counsel patients and improve in-hospital safety. LEVEL OF EVIDENCE: 3.

Lack of Consensus in Physician Recommendations Regarding Return to Driving After Cervical Spine Surgery.

STUDY DESIGN: A cross-sectional study. OBJECTIVE: The goal of this study is to investigate how surgeons differ in collar and narcotic use, as well as return to driving recommendations following cervical spine surgeries and the associated medico-legal ramifications of these conditions. SUMMARY OF BACKGROUND DATA: Restoration of quality of life is one of the main goals of cervical spine surgery. Patients frequently inquire when they may safely resume driving after cervical spine surgery. There is no consensus regarding postoperative driving restrictions. This study addresses how surgeons differ in their recommendations concerning cervical immobilization, narcotic analgesia, and suggested timeline of return to driving following cervical spine surgery. METHODS: Surgeons at the Cervical Spine Research Society annual meeting completed anonymous surveys assessing postoperative patient management following fusion and nonfusion cervical spine surgeries. RESULTS: Seventy percent of surgeons returned completed surveys (n = 71). About 80.3% were orthopedic surgeons and 94.2% completed a spine fellowship. Experienced surgeons (>15 years in practice) were more likely to let patients return to driving within 2 weeks than less experienced surgeons (47.1% vs. 24.3%, P = 0.013) for multilevel anterior discectomy and fusion (ACDF) and laminectomy with fusion procedures. There were no differences between surgeons practicing inside and outside the USA for prescribing collars or return to driving time. Cervical collars were used more for fusions than nonfusions (57.7% vs. 31.0%, P = 0.001). Surgeons reported 75.3% of patients ask when they may resume driving. For cervical fusions, 31.4% of surgeons allowed their patients to resume driving while restricting them with collars for longer durations. Furthermore, 27.5% of surgeons allowed their patients to resume driving while taking narcotics postoperatively. CONCLUSION: This survey-based study highlights the lack of consensus regarding patient "fitness to drive" following cervical spine surgery. The importance of establishing evidence-based guidelines is critical, as recommendations for driving in the postoperative period may have significant medical, legal, and financial implications. LEVEL OF EVIDENCE: 5.

Interpretation of Spinal Radiographic Parameters in Patients With Transitional Lumbosacral Vertebrae.

STUDY DESIGN: Retrospective radiographic review. OBJECTIVES: To understand the effect of variability in sacral endplate selection in transitional lumbosacral vertebrae (TLSV) and its impact on pelvic, regional, and global spinal alignment parameters. BACKGROUND: TLSV can have the characteristics of both lumbar and sacral vertebrae. Difficulties in identification of the S1 endplate may come from nomenclature, number of lumbar vertebrae, sacra, and morphology and may influence the interpretation and consistency of spinal alignment parameters. METHODS: Patients with TLSV were identified and radiographic measurements including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), sagittal vertical axis (SVA), T1-pelvic angle (TPA), pelvic incidence-lumbar lordosis (PI-LL) mismatch, thoracic kyphosis (TK), and spinal inclination (T1SPi) were obtained. Radiographic measurements were performed twice with the sacral endplate at the cephalad and caudal options. Paired t tests assessed the difference between different selection groups. RESULTS: Of 1,869 patients, 70 (3.7%) were found to have TLSV on radiographic imaging. Fifty-eight (82.9%) had lumbarized sacral segments whereas 12 (17.1%) had sacralized lumbar segments. T1-SPi (mean: -1.77°) and TK (mean: 34.86°) did not vary from altering sacral endplate selection. Selection of the caudal TLSV as the sacral endplate resulted in an increase in all pelvic parameters (PI: 66.8° vs. 44.3°, PT: 25.1° vs. 12.7°, and SS: 41.6° vs. 31.6°), regional lumbar parameters (LL: -54.1° vs. 44.0°, PI-LL: 12.7° vs. 0.3°), and global parameters (SVA: 46.1 mm vs. 28.3 mm, TPA: 23.3° vs. 10.8°) as compared to selecting the cephalad TLSV. All mean differences between radiographic parameters were found to be statistically significant (p < .001). CONCLUSIONS: Variation in sacral endplate selection in TLSV significantly affects spinal alignment parameter measurements. A standardized method for measuring TLSV is needed to reduce measurement error and ultimately allow more accurate understanding of alignment targets in patients with TLSV. LEVEL OF EVIDENCE: Level III.