Insulin Dependence Negatively Impacts Outcomes in Anterior Cervical Discectomy with Fusions: A Ten-Year Retrospective Analysis.

BACKGROUND CONTEXT: Although anterior cervical discectomy and fusion (ACDF) procedures for cervical spine disease have been increasing amid a growing diabetic patient population, there is a paucity of literature focusing on insulin-dependence as a risk-factor for post-operative ACDF complications. PURPOSE: To evaluate the differential impact of insulin dependence on perioperative outcomes including total length of stay, surgical, and medical complications within thirty days following ACDF. STUDY DESIGN/SETTING: A retrospective cohort, large multicenter database study. PATIENT SAMPLE: The American College of Surgeons National Surgical Quality Improvement Program database was queried to retrospectively identify patients who had undergone ACDF between 2011 and 2021 using the Current Procedural Terminology code 22551. OUTCOME MEASURES: Perioperative surgical and medical complications. METHODS: The study population was divided into three groups 1) insulin-dependent diabetes mellitus (IDDM), 2) insulin-independent diabetes mellitus (NIDDM), and 3) no diabetes mellitus (non-DM). One-way analysis of variance for continuous variables and chi-square tests for categorical variables were used to identify differences in perioperative variables between the three groups. Multivariable logistic regression analysis assessed the effect of diabetes mellitus status on post-operative medical and surgical outcomes. RESULTS: A total of 85,758 ACDF procedures were identified between 2011 and 2021, of which 5,178 were IDDM, 9,652 were NIDDM, and 70,982 were non-DM. The rates of surgical and medical complication varied between the three groups. IDDM patients had the highest rates of at least one medical complication (6.1%). Only IDDM increased the risk for medical complications (OR: 1.320, 95% CI [1.144-1.518]) and extended hospital length of stay (LOS) (OR: 1.244, 95% CI [1.071-1.441]) following a multivariate logistic regression analysis. CONCLUSION: Patients with IDDM were at an increased risk for postoperative medical complications and extended hospital LOS. Personalized postoperative management, guided by risk assessment is indicated for this population. These findings can be used to improve risk stratification and informed consent for DM patients who are insulin dependent.

Feasibility of Machine Learning in the Prediction of Short-Term Outcomes Following Anterior Cervical Discectomy and Fusion.

BACKGROUND: Increased emphasis is being placed on efficiency and resource utilization when performing anterior cervical discectomy and fusion (ACDF), and accurate prediction of complications is increasingly important to optimize care. This study aimed to compare predictive models for postoperative complications following ACDF using machine learning (ML) models based on traditional comorbidity indices. METHODS: In this retrospective case series, the American College of Surgeons National Surgical Quality Improvement Program database was queried between 2011 and 2017 for all elective, primary ACDF cases. Levels of surgery, use of interbody implants, and graft selection were calculated by procedural codes. Six ML algorithms were constructed using available preoperative and intraoperative features. The overall dataset was randomly split into training (80%) and validation (20%) subsets wherein the training subset optimized the model, and the validation subset was evaluated for accuracy. ML models were compared with models constructed from American Society of Anesthesiologists classification and frailty index alone. RESULTS: There were 42,194 ACDF cases eligible for inclusion. Mean age was 47.7 ± 11.6 years, body mass index was 30.4 ± 6.7, and levels of operation were 1.6 ± 0.7. ML algorithms uniformly outperformed comorbidity indices in predicting complications. Logistic regression ML algorithm was the best performing for predicting any adverse event (area under the curve [AUC] 0.73), transfusion (AUC 0.90), surgical site infection (AUC 0.63), and pneumonia (AUC 0.80). Gradient boosting trees ML algorithm was the best performing for predicting extended length of stay (AUC 0.73). CONCLUSIONS: ML algorithms modeled the development of postoperative adverse events with superior accuracy to that of comorbidity indices and may guide preoperative clinical decision making before ACDF.

A Novel Local Cancellous Autograft Source for Anterior Cervical Discectomy With Fusion.

STUDY DESIGN: Case series. OBJECTIVES: Successful clinical outcome scores following anterior cervical discectomy and fusion (ACDF) have been correlated with high fusion rate. Published fusion rates using iliac crest bone graft (ICBG) have been shown to be as high as 100% for single-level fusions in some studies; however, there is potential associated morbidity with ICBG harvest. This technical description and preliminary case series assessed the clinical efficacy and results of a novel grafting technique for ACDF. METHODS: Twelve patients underwent novel grafting technique for ACDF in which autograft was procured from the cervical vertebra adjacent to the operative disk. Patients were followed for 2 years using visual analogue pain scale (VAS) and radiological assessment of fusion. RESULTS: Patients experienced clinically meaningful reduction of radicular symptoms in the affected arm(s) with an average preoperative VAS score of 5.0 ± 0.8 and an average 2-year postoperative score of 1.108 ± 0.475 (P = .0013). Patients also experienced significant resolution of neck pain with an average preoperative VAS score of 7.1 ± 0.5 and average 2-year postoperative score of 2.708 ± 0.861 (P = .0018). All patients achieved solid fusion by 1 year. There were no major or minor complications noted during follow-up. CONCLUSIONS: This procedure allows for both autograft harvest and cervical decompression to be performed through a single incision. In this series, this technique eliminated the morbidity associated with autograft harvest from the iliac crest while achieving high fusion rates and without additional technique-related complications.

Bilateral Pedicle Fractures at Contiguous Segments in a Low Trauma Setting: A Case Report.

CASE: A 74-year-old patient with a history of osteoporosis presented with a 2-month history of lower back pain after low-energy trauma. Imaging revealed bilateral subacute L4 and L5 pedicle fractures-the first reported case of this low-energy mechanism of bilateral contiguous-segment pedicle fractures. CONCLUSION: Bilateral pedicle fractures have infrequently been reported in the literature. There have been a few reports of bilateral pedicle fractures because of isolated osteoporosis, and these have all been single level. The current report presents an unusual fragility fracture pattern that can be conservatively managed.

Correlation of Voice Hoarseness and Vocal Cord Palsy: A Prospective Assessment of Recurrent Laryngeal Nerve Injury Following Anterior Cervical Discectomy and Fusion.

BACKGROUND: Injury to the recurrent laryngeal nerve (RLN) has been implicated as a common complication following anterior cervical discectomy and fusion (ACDF) surgery. The purpose of this study is to determine the true incidence of voice hoarseness and RLN palsy following ACDF surgery, to determine the reliability of symptoms in the diagnosis of RLN injury, and to evaluate factors related to the development of these symptoms. METHODS: All patients undergoing elective (primary or secondary) ACDF surgery at a single institution consented to and enrolled in the present study. All approaches were through the left side. Enrolled patients received both preoperative and postoperative (within 1 month following surgery) laryngoscopy by a fellowship-trained ENT physician for evaluation of RLN function. Patients also responded as to whether they were experiencing postoperative symptoms of dysphagia, aspiration, and voice changes. RESULTS: In total, 108 patients were included in this study. Mean age of the population was 59.2 ± 10.7 years and mean body mass index was 31.2 ± 7.1 kg/m2. Three patients had previously undergone a thyroidectomy, whereas 20 patients had undergone a previous ACDF. Average intubation time for ACDF surgery was 121.6 ± 38.5 minutes. After surgery and excluding patients who were experiencing preoperative symptoms, 19 patients (20.4%) complained of dysphagia, 2 patients (1.9%) complained of aspiration symptoms, and 5 patients (4.6%) complained of voice hoarseness. There was no incidence of vocal cord palsy from postoperative laryngoscopy. From multivariate analysis, endotracheal cuff pressure after retractor placement was correlated to postoperative voice hoarseness, dysphagia, and aspiration symptoms. CONCLUSIONS: From the results of this prospective study, the RLN remained functional even a month after surgery despite several cases of postoperative dysphagia, aspiration, and voice changes. Endotracheal cuff pressure, number of vertebral levels, body mass index, and intubation time were important variables related to postoperative symptoms. CLINICAL RELEVANCE: Voice hoarseness does not necessarily indicate recurrent laryngeal nerve injury after ACDF but may be caused by compressive forces on laryngeal tissue during retraction or intubation. Laryngoscopy should be performed in cases with high clinical suspicion. LEVEL OF EVIDENCE: 2.

The Clinical Impact of Fracture Liaison Services: A Systematic Review.

INTRODUCTION: A fracture liaison service (FLS) is a coordinated system of care that streamlines osteoporosis management in the orthopaedic setting and can serve as an effective form of secondary preventative care in these patients. The present work reviews the available evidence regarding the impact of fracture liaison services on clinical outcomes. METHODS: The literature was reviewed for studies reporting changes in the rates of bone mineral density scanning (DXA), antiresorptive therapy, new minimum trauma fractures, and mortality between cohorts with access to an FLS or not. Studies including intention to treat level data were retained. A Medline search for "fracture liaison" OR "secondary fracture prevention" produced 146 results, 98 were excluded based on the abstract, 38 were excluded based on full-text review. Ten level III studies encompassing 48,045 patients were included, of which 5 studies encompassing 7,086 were analyzed. Odds-ratios for DXA and anti-osteoporosis pharmacotherapy rates were calculated from data. Fixed and random effects analyses were performed using the Mantel-Haenszel method. RESULTS: Four studies reported, on average, a 6-fold improvement in DXA scanning rates (Figure 1). Six studies reported, on average, a 3-fold improvement in antiresorptive therapy rates (Figure 2). Four large studies reported significant reductions in the rate of new fractures using time-dependent Cox proportional hazards models at 12 months (HR = 0.84, 0.95), 24 months (HR = 0.44, 0.65), and 36 months (HR = 0.67). Five large studies reported mortality improvements using time-dependent Cox proportional hazards models at 12 months (HR = 0.88, 0.84, 0.81) and 24 months (HR = 0.65, 0.67). CONCLUSIONS: The findings suggest that fracture liaison services improve rates of DXA scanning and antiresorptive therapy as well as reductions in the rates of new fractures and mortality among patients seen following minimum trauma fractures across many time points.

Pelvic Fragility Fractures: An Opportunity to Improve the Undertreatment of Osteoporosis.

BACKGROUND: Osteoporosis is often undiagnosed until patients experience fragility fractures. Pelvic fractures are common but underappreciated sentinel fractures. Screening patients with a pelvic fracture for osteoporosis may provide an opportunity to initiate appropriate treatments such as anti-osteoporosis therapy to prevent additional fractures. METHODS: This retrospective cohort review examined the management of osteoporosis after pelvic fractures at a large tertiary care center without an established secondary fracture prevention program. Data were extracted from electronic medical records of all new patients with a pelvic fracture who were ≥50 years of age from this center and its affiliated community hospitals from 2008 to 2014. Outcome measures included the initiation of anti-osteoporosis therapy before the fracture, within the year following the fracture, >1 year following the fracture, or never and new osteoporotic fractures within 2 years after a pelvic fracture. RESULTS: From 2008 to 2014, 947 patients presented with pelvic fractures. Of these patients, 27.1% (257 patients) were taking anti-osteoporosis medications before the fracture. Four percent of treatment-naïve patients began anti-osteoporosis therapy within 1 year of fracture, with 1.2% (11 patients) starting after 1 year. Of the treatment-naïve patients, 92.3% (637 patients) were never prescribed anti-osteoporosis therapy. Treatment rates were consistent over time. Within 2 years, 41.0% (388 patients) developed fragility fractures at secondary sites: 12.0% (114 patients) experienced a hip fracture, and 16.4% (155 patients) experienced a vertebral fracture. CONCLUSIONS: Osteoporosis screening and initiation of secondary fracture prevention after a pelvic fracture were inadequate in the study population. Of the patients in this study, 909 (96.0%) never underwent a dual x-ray absorptiometry (DXA) scan during the study period. Of the 690 treatment-naïve patients, 637 (92.3%) were never administered anti-osteoporosis medications. Within 2 years, 41.0% of all patients developed additional osteoporotic fractures. This study demonstrates an opportunity to improve bone health by screening for and treating osteoporosis in patients with a pelvic fragility fracture. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Passive stiffness characteristics and neutral zone quality of the scoliotic lumbar torso in the principle anatomical planes of motion.

BACKGROUND: The 1-10% prevalence rate of adult scoliosis frequently requires expensive therapy and surgical treatments and demands further research into the disease, especially with an aging population. Most studies examining the mechanics of scoliosis have focused on in vitro testing or computer simulations. This study quantitatively defined the passive stiffness properties of the in vivo scoliotic spine in three principle anatomical motions and identified differences relative to healthy controls. METHODS: Adult scoliosis (n = 14) and control (n = 17) participants with no history of spondylolisthesis, spinal fracture, or spinal surgery participated in three different tests (torso lateral side bending, torso axial rotation, and torso flexion/extension) that isolated mobility to the in vivo lumbar spine. The spinal stiffnesses and spinal neutral zone width were calculated. These parameters were statistically compared between factor of population and within factor of direction. FINDINGS: Torque-rotational displacement data were fit using a double sigmoid function, resulting an in excellent overall fit (Avg. R2 = 0.95). There was a significant interaction effect between populations when comparing axial twist neutral zone width vs. lateral bend neutral zone width and axial twist stiffness vs. lateral bend stiffness. The axial twist neutral zone width magnitude was significantly larger in scoliosis patients. INTERPRETATION: The present study is the first investigation to quantify the whole trunk neutral zone of the scoliotic lumbar spine. Future research is needed to determine if lumbar spine mechanical characteristics can help explain progression of scoliosis and complement scoliosis classification systems.

Proximal Humerus Fractures in the Geriatric Population Present an Opportunity to Improve Recognition and Treatment of Osteoporosis.

INTRODUCTION: Osteoporosis remains an undertreated disease entity causing substantial morbidity and mortality. Proximal humerus fractures are a common sentinel fracture, providing an opportunity to intervene with antiresorptive therapy before more subsequent fractures occur. Despite the success of programs aimed to improve postfracture osteoporosis recognition and management, less than 30% of patients presenting with a fragility fracture are diagnosed or treated for osteoporosis nationally. Further elucidation of diagnosis and management of osteoporosis following humerus fracture is warranted. METHODS: This study is a retrospective cohort review intended to demonstrate the current state and clinical import of osteoporosis diagnosis and management following a humerus fracture at a large academic tertiary care center without an established secondary fracture prevention program. All patients 50 years of age or older who presented with a new humerus fracture between 2008 and 2014 were included. Outcome measures included: The initiation of antiresorptive therapy or screening before fracture, within the year following fracture, or not at all. RESULTS: One thousand seven hundred unique geriatric patients were seen for humerus fractures. Nineteen percent of these patients (n = 324) were already on an antiresorptive medication. Three percent of previously untreated patients were started on antiresorptive therapy during the year after their fracture, with 31 or 2% of untreated patients starting at any subsequent point. Seventy-six percent of patients (n = 1301) were never prescribed antiresorptive therapy. DISCUSSION AND CONCLUSION: In the absence of a dedicated program to improve secondary fracture prevention following minimal trauma spinal fractures, recognition and treatment of osteoporosis in patients remained inadequate over time despite numerous calls to action on the topic in the orthopedic literature and public health initiatives. Undertreatment of osteoporosis puts patients at increased risk for additional fractures. This study underscores an opportunity to improve bone health by aggressively screening for and treating osteoporosis in geriatric humerus fracture patients.

Postoperative Anemia Predicts Length of Stay for Geriatric Patients Undergoing Minimally Invasive Lumbar Spine Fusion Surgery.

INTRODUCTION: We hypothesize that postoperative anemia will predict length of stay (LOS) for geriatric patients undergoing minimally invasive (MIS) lumbar spine fusions. MATERIALS AND METHODS: Patients who underwent MIS lateral and transforaminal lumbar interbody fusion between January 2017 and March 2018 at an academic tertiary care referral center were selected. Eighty-one patients were included. The primary outcome variable was LOS, measured in days. The predictors studied were preoperative hemoglobin (Hgb), postoperative day 1 Hgb, postoperative nadir Hgb, intraoperative Hgb decrement (preoperative Hgb-postoperative day 1 Hgb), perioperative Hgb decrement (preoperative Hgb-postoperative nadir Hgb), age, American Society of Anesthesiologists-Physical Status (ASA-PS) score, volume of perioperative intravenous (IV) fluids (IVFs), and number of levels fused. Simple linear regression and analysis of variance were used for statistical analysis. RESULTS: In the present study, preoperative anemia was not associated with longer LOS (P = .15). Postoperative anemia was associated with longer LOS as both postoperative day 1 Hgb (P = .05*) and postoperative nadir Hgb (P < .0001*) predicted longer LOS. Greater intraoperative Hgb decrement did not predict longer LOS (P = .36); however, greater perioperative Hgb decrement predicted longer LOS (P < .0001*). Older age (P = .01*) and greater number of levels fused (P = .03*) predicted longer LOS; however, a greater ASA-PS classification did not predict longer LOS. Greater IVF administration was associated with longer LOS (P < .0001*). DISCUSSION: Postoperative nadir Hgb (P < .0001*) was more predictive of longer LOS than postoperative day 1 Hgb (P = .05*). There is a perioperative Hgb decrement associated with longer LOS (P < .0001*). Geriatric patients may be more susceptible to the potential contributors to Hgb decrement, including occult bleeding post-op and hemodilution from IVF administration. CONCLUSION: Postoperative anemia, perioperative decrement in Hgb, older age, greater number of levels fused, and greater total IVFs administered predict longer LOS. Understanding the impact of these factors on LOS is critical as these procedures increasingly move to the outpatient setting.

Timing of Bisphosphonate Initiation After Fracture: What Does the Data Really Say?

INTRODUCTION: Osteoporosis is often not clinically recognized until after a fracture occurs. Individuals who have 1 fracture are at increased risk of future fractures. Prompt initiation of osteoporosis treatment following fracture is critical to reducing the rate of future fractures. Antiresorptives are the most widely used class of medications for the prevention and treatment of osteoporosis. Many providers are hesitant to initiate antiresorptives in the acute post-fracture period. Concerns include interference with bone remodeling necessary for successful fracture healing, which would cause increased rates of non-union, malunion, and refracture. While such concerns should not extend to anabolic medications, physicians may also hesitate to initiate anabolic osteoporosis therapies due to high cost and/or lack of familiarity. This article aims to briefly review the available data and present a digestible narrative summary to familiarize practicing orthopaedic surgeons with the essential details of the published research on this topic. RESULTS: The results of 20 clinical studies and key pre-clinical studies related to the effect of anti-resorptive medications for osteoporosis on fracture healing are summarized in the body of this narrative review. DISCUSSION & CONCLUSIONS: While few level I studies have examined the impact of timing of initiation of osteoporosis medications in the acute post-fracture period, the few that have been published do not support these concerns. Specifically, data from level I clinical trials indicate that initiating bisphosphonates as early as 2 weeks post-fracture does not increase rates of non-union or malunion. By reviewing the available data, we hope to give clinicians the confidence to initiate osteoporosis treatment promptly post-fracture.

Orthopedic surgeons' views on the osteoporosis care gap and potential solutions: survey results.

INTRODUCTION: Osteoporosis is often not recognized until one or more fractures occur, yet post-fracture screening remains uncommon. Orthopedic surgeons are well situated to address this care gap. Both a protocol-based approach and fracture liaison services (FLS) have been proposed. The present surveys assess orthopedists' attitudes to these alternative models for addressing this care gap. METHODS: Two digital surveys were sent to all orthopedic surgeons and orthopedic midlevel providers at a large level 1 trauma center 1.5 years apart. RESULTS: Thirty-six of 47 survey recipients (77%) responded to the first survey; all 55 recipients (100%) responded to the second. Respondents recognized the importance of osteoporosis care, the inadequacy of current measures, and the potential of orthopedic surgeons to help address this gap. Respondents reported regular encounters with fragility fracture patients but limited familiarity with core aspects of osteoporosis screening and treatment, especially pharmacotherapy. While some respondents (40%) reported willingness to attempt a protocol-based approach to addressing this care gap, many others expressed reservations (60%) and support for a FLS-based approach was much higher (95%). CONCLUSIONS: A fracture liaison service model best fits the observed attitudes of orthopedic surgeons at this level 1 trauma center relative to a protocol-based approach. Protocol-based approaches may be preferable in alternate settings.

Rates of osteoporosis screening and treatment following vertebral fracture.

BACKGROUND CONTEXT: Osteoporosis remains an underrecognized and undertreated disease entity in the orthopaedic setting, accounting for substantial long-term morbidity and mortality. Osteoporosis is often not diagnosed or treated until multiple fractures have occurred. Vertebral compression fractures are the most common sentinel fracture, providing an opportunity to intervene with antiresorptive therapy before more debilitating fractures occur. Little data has been published on osteoporosis screening and treatment following vertebral fractures. Further elucidation of the osteoporosis care gap in these patients is warranted. PURPOSE: To demonstrate the current state of post vertebral fracture osteoporosis management at a large tertiary care center with no established secondary fracture prevention program. STUDY DESIGN: Retrospective cohort study. SETTING: A large tertiary care hospital or one of its affiliated community hospitals. PATIENT SAMPLE: All 2,933 patients, 50 years of age or older, who presented to an emergency department with a new vertebral fracture between 2008 and 2014. OUTCOME MEASURES: The physiological measures are rates of new fractures within 2 years following first vertebral fracture. PATIENT CARE METRICS: Post vertebral fracture rates of dual energy X-ray absorptiometry (DXA) testing, calcium and vitamin D supplementation, and pharmacotherapy for osteoporosis within 1 year postfracture, and more than 1 year postfracture. Linear trend of the rate of new antiosteoporosis pharmacotherapy among previously antiosteoporosis medication naive patients within 1 year of fracture over time from 2008 to 2014. METHODS: All patients aged 50 years or older presenting to an emergency department with a vertebral fracture between 2008 and 2014 were included. Only an individual's first documented vertebral fracture was considered. Individuals were assessed for DXA screening, calcium and vitamin D supplementation, treatment with an antiosteoporosis medication, and additional fractures following incident vertebral fracture. Statistical analyses included descriptive statistics and a simple logistic regression. No specific funding was provided for this study. The authors of this study report no relevant financial conflicts of interests or associated biases. RESULTS: Between 2008 and 2014, 2,933 unique patients were seen at an included emergency department for one or more vertebral fracture encounters. Ninety-eight percent did not receive a DXA scan within the preceding 2 years or 1 year following fracture. Seven percent of patients were started on antiresorptive therapy after their fracture, with 341 (5%) starting within 1 year of fracture and 211 (2%) starting thereafter. Twenty-one percent (n=616) had taken an antiresorptive medication before their fracture. Seventy three percent (n=2,128) were never prescribed antiresorptive therapy. Treatment rates slightly decreased over time. Thirty eight percent of patients presenting with a vertebral fracture (n=1,115) went on to develop a second fragility fracture within 2 years. CONCLUSIONS: In the absence of a specific local program to improve secondary fracture prevention following minimal trauma spinal fractures, recognition and treatment of osteoporosis in patients at this institution remained dismal over time despite numerous calls to action on the topic in the orthopaedic literature and elsewhere. Undertreatment of osteoporosis puts patients at increased risk of incurring additional fractures. Within 2 years, 38% of the patients in this sample developed an additional fragility fracture. This study demonstrates a profound post vertebral fracture osteoporosis care gap.

Unilateral S2 alar-iliac screws for spinopelvic fixation.

BACKGROUND: This study compared the clinical complications, radiographic measurements of deformity, and quality of life outcomes for patients with de novo scoliosis undergoing thoracolumbar fusions for spinopelvic fixation (SPF) utilizing unilateral S2 alar-iliac (S2AI) screw or unilateral iliac bolt fixation. METHODS: This retrospective review was performed in 29 patients who underwent SPF at one institution; 10 patients received unilateral S2AI screws, and 19 patients received unilateral iliac bolts. The following variables were studied: reoperation rates, pseudarthrosis, sacral insufficiency fracture, hardware prominence, infection, proximal junctional kyphosis (PJK), deformity correction (radiographs), windshield wipering, hardware fracture, and hardware removal. Outcomes were analyzed utilizing both the visual analog scale (VAS) and Oswestry Disability Index (ODI). The mean follow-up period was 27 months. RESULTS: The reoperation rate for unilateral S2AI screws was 30% vs. 53% for unilateral iliac bolts (P = 0.43); reoperations were performed with a 1:5 ratio for infection, a 1:4 ratio for pseudarthrosis, and 1:1 a ratio for PJK comparing S2AI screws to iliac bolts, respectively. CONCLUSION: There were no significant differences in postoperative complications and reoperation rates between unilateral S2AI screws and unilateral iliac bolts utilized for SPF. For the S2AI screw group, there were no instances of hardware prominence or need for removal. The use of unilateral S2AI screws resulted in adequate fixation and comparably low complication rates.

Prevention and Management of Postoperative Delirium in Elderly Patients Following Elective Spinal Surgery.

STUDY DESIGN: This study is a systematic review. OBJECTIVE: Propose an evidence-based algorithm for prevention, diagnosis, and management of postoperative delirium in geriatric patients undergoing elective spine surgery. SUMMARY OF BACKGROUND DATA: Delirium is associated with longer stays after elective surgery, increased risk of readmission, and $6.9 billion annually in medical costs. Early diagnosis and treatment of delirium can reduce length of stay (LOS), in-hospital morbidity, and health care costs. After spinal surgery, postoperative delirium increases average LOS to >7 days and is diagnosed in 12.5%-24.3% of geriatric patients. Currently, studies for management of postoperative delirium after elective spinal procedures are not available. METHODS: A literature review was performed for observational studies, randomized controlled trials, and systematic reviews between 1990 and 2015. RESULTS: Risk factors for delirium after elective spinal surgery include age, functional impairment, preexisting dementia, general anesthesia, surgical duration >3 hours, intraoperative hypercapnia and hypotension, greater blood loss, low hematocrit and albumin, preoperative affective dysfunction, and postoperative sleep disorders. Postoperatively, decreasing the use of methylprednisolone and promoting movement with an appropriate orthosis can reduce delirium incidence (P=0.0091). Polypharmacy is an independent risk factor for delirium (P=0.01) and decreasing use of delirium-inducing medications may reduce incidence. The delirium observation screening scale diagnoses and monitors delirium and is rated by nurses as easier to use than the NEECHAM Confusion Scale (P<0.003). Haloperidol is used widely to treat postoperative delirium. Randomized controlled trials show that adding quetiapine results in delirium resolution an average of 3.5 days faster than haloperidol alone (P=0.001) and decreases agitation and LOS (P=0.02; P=0.05). CONCLUSIONS: An evidence-based algorithm is proposed to prevent, diagnose, and manage postoperative delirium that can be used clinically for geriatric patients undergoing elective spine surgery. Prevention and diagnosis involve efforts from the anesthesiologist and postoperative clinical care team. Treatment may include a therapeutic regimen of low-dose neuroleptic medications as needed. LEVEL OF EVIDENCE: Level II.

Symptomatic sacrococcygeal joint dislocation treated using closed manual reduction: A case report with 36-month follow-up and review of literature.

Dislocation of the sacrococcygeal joint is a rare injury from trauma to the buttocks, most often from falling backwards. Standard of care for this injury has not been determined because it is rare. Left untreated this can cause coccydynia in the long-term. Here we present a case report to describe the treatment of an anterior sacrococcygeal dislocation with closed manual reduction. A 13-year-old female presented to the emergency department with buttock pain after slipping backwards down the stairs. On X-ray the coccyx was in bayonette apposition to the anterior distal sacrum and shortened by 6 mm. To manage the injury, closed manual reduction of the sacrococcygeal joint was performed. To our knowledge, this is the first successful case of sacrococcygeal dislocation treated with closed manual reduction, resulting in complete relief of symptoms at 36 months follow-up. Sacrococcygeal dislocations can be treated with closed manual reduction, resulting in lower morbidity and faster recovery compared to surgical treatment.

C1-2 Fixation Approach for Patients With Vascular Irregularities: A Case Report.

In posterior spinal fusion (PSF), the vertebral artery is most vulnerable to injury at C1-2. C2 pedicle screws are often placed into the dorsomedial isthmus of C2. Alternative techniques include C2 laminar screws and wiring techniques. A 67-year-old male underwent PSF for persistent severe intractable neck pain and degeneration at C1-2. The patient had an enlarged left vertebral artery with midline migration into the C2 body. This pattern was within one standard deviation of normal; however, it rendered typical placement of a C2 pedicle screw unsafe. As a salvage, a C2 laminar screw was placed on the left to avoid risk of vertebral artery injury. The operation and recovery were without complication. C2 laminar screws can be viable alternatives to C2 pedicle screws in cases of midline vertebral artery migration or other vascular anomalies preventing normal safe placement of C2 pedicle screws.

Effects of pilot hole preparation technique on pedicle screw fixation in different regions of the osteoporotic thoracic and lumbar spine.

OBJECT: The authors evaluated the effects of pilot hole preparation technique on insertional torque and axial pullout resistance in osteoporotic thoracic and lumbar vertebrae. METHODS: Using a probe technique and fluoroscopy, 102 pedicle screws were placed in 51 dual-energy x-ray absorptiometry-proven osteoporotic thoracic and lumbar levels. Screws were inserted using the same-size tapping, one-size-under tapping, or no-tapping technique. Insertional torque and axial pullout resistance were measured. Analysis of variance, Fisher exact test, and regression analysis were performed. Same-size tapping decreased pullout resistance in the lumbar spine. There was no effect on pullout resistance in the thoracic spine. Pullout resistance values were lower for all insertion techniques in the upper thoracic spine. Insertional torque and bone mineral density correlated with pullout resistance in the thoracic and lumbar spine. CONCLUSIONS: Tapping decreased pedicle screw pullout resistance in the osteoporotic human lumbar spine, although it did not affect pullout strength in the thoracic spine. Tapping decreased insertional torque in upper thoracic levels. Surgeons should optimize overall construct rigidity when placing thoracic pedicle screws in patients with spinal segment osteoporosis.

Lead exposure inhibits fracture healing and is associated with increased chondrogenesis, delay in cartilage mineralization, and a decrease in osteoprogenitor frequency.

Lead exposure continues to be a significant public health problem. In addition to acute toxicity, Pb has an extremely long half-life in bone. Individuals with past exposure develop increased blood Pb levels during periods of high bone turnover or resorption. Pb is known to affect osteoblasts, osteoclasts, and chondrocytes and has been associated with osteoporosis. However, its effects on skeletal repair have not been studied. We exposed C57/B6 mice to various concentrations of Pb acetate in their drinking water to achieve environmentally relevant blood Pb levels, measured by atomic absorption. After exposure for 6 weeks, each mouse underwent closed tibia fracture. Radiographs were followed and histologic analysis was performed at 7, 14, and 21 days. In mice exposed to low Pb concentrations, fracture healing was characterized by a delay in bridging cartilage formation, decreased collagen type II and type X expression at 7 days, a 5-fold increase in cartilage formation at day 14 associated with delayed maturation and calcification, and a persistence of cartilage at day 21. Fibrous nonunions at 21 days were prevalent in mice receiving very high Pb exposures. Pb significantly inhibited ex vivo bone nodule formation but had no effect on osteoclasts isolated from Pb-exposed animals. No significant effects on osteoclast number or activity were observed. We conclude that Pb delays fracture healing at environmentally relevant doses and induces fibrous nonunions at higher doses by inhibiting the progression of endochondral ossification.

Epidural abscess and discitis complicating instrumented posterior lumbar interbody fusion: a case report.

STUDY DESIGN: A case of epidural abscess and discitis following instrumented PLIF using a single carbon fiber interbody cage is presented. OBJECTIVE: To describe a previously unreported complication of epidural abscess and discitis following posterior lumbar interbody fusion using a single carbon fiber cage. SUMMARY OF BACKGROUND DATA: Various complications have been reported with PLIF. These include graft migration, pseudarthrosis, implant subsidence, epidural hemorrhage, incidental durotomy, arachnoiditis, transient or permanent neurologic deficits, persistence of pain, and wound infections. There are no reported cases of epidural abscess or refractory discitis associated with PLIF. METHODS: A 35-year-old infantryman on active duty with chronic low back pain and single-level lumbar disc degeneration underwent instrumented PLIF after reporting no improvement with 3 years of extension-based physical therapy and nonsteroidal pain medications. His back pain was reported improved at 6 weeks after surgery. At 12 weeks after surgery, he presented to the emergency department with intense back pain and fevers. Laboratory data were remarkable for elevated erythrocyte sedimentation rate (118) and C-reactive protein (38). Initial imaging studies, including a lumbar MRI, did not demonstrate any abnormalities. The patient continued to spike fevers, and a repeat lumbar MRI 1 week later clearly demonstrated the presence of an epidural abscess at the level of the PLIF surgery. The patient was treated with surgical debridement and epidural abscess drainage. The interbody cage was left in place. Surgical cultures identified Staphylococcus aureus as the pathogen, and the patient was placed on intravenous vancomycin. During the ensuing 3 weeks, his clinical symptoms worsened and his radiographs demonstrated lucency in the region of his interbody cage. Repeat debridement was performed, and his interbody cage and pedicle screw instrumentation were removed 4 months after initial surgery. RESULTS: The disc space infection resolved following removal of the implants. Radiographs at 6 months after instrumentation removal demonstrated solid bilateral posterolateral arthrodesis. The patient returned to active duty 1 year after his initial surgery, reporting that his back pain was reduced compared with his preoperative level. CONCLUSIONS: There is a paucity of literature on epidural abscess and discitis as complications associated with PLIF. In this case, the infection persisted despite surgical debridement and intravenous antibiotics. The patient ultimately required removal of the interbody implant and posterior instrumentation. The patient developed solid posterolateral arthrodesis despite the presence of deep infection, which led to early implant removal 4 months after the initial surgery. This case underscores the potential importance of concomitant posterolateral fusion, particularly following wide laminectomy and facetectomy required for PLIF.