Malpractice Litigation Involving Chiropractic Spinal Manipulation.

OBJECTIVE: To evaluate the relationship between chiropractic spinal manipulation and medical malpractice using a legal database. METHODS: The legal database VerdictSearch was queried using the terms "chiropractor" OR "spinal manipulation" under the classification of "Medical Malpractice" between 1988 and 2018. Cases with chiropractors as defendants were identified. Relevant medicolegal characteristics were obtained, including legal outcome (plaintiff/defense verdict, settlement), payment amount, nature of plaintiff claim, and type and location of alleged injury. RESULTS: Forty-eight cases involving chiropractic management in the United States were reported. Of these, 93.8% (n = 45) featured allegations involving spinal manipulation. The defense (practitioner) was victorious in 70.8% (n = 34) of cases, with a plaintiff (patient) victory in 20.8% (n = 10) (mean payment $658,487 ± $697,045) and settlement in 8.3% (n = 4) (mean payment $596,667 ± $402,534). Overaggressive manipulation was the most frequent allegation (33.3%; 16 cases). A majority of cases alleged neurological injury of the spine as the reason for litigation (66.7%, 32 cases) with 87.5% (28/32) requiring surgery. C5-C6 disc herniation was the most frequently alleged injury (32.4%, 11/34, 83.3% requiring surgery) followed by C6-C7 herniation (26.5%, 9/34, 88.9% requiring surgery). Claims also alleged 7 cases of stroke (14.6%) and 2 rib fractures (4.2%) from manipulation therapy. CONCLUSIONS: Litigation claims following chiropractic care predominately alleged neurological injury with consequent surgical management. Plaintiffs primarily alleged overaggressive treatment, though a majority of trials ended in defensive verdicts. Ongoing analysis of malpractice provides a unique lens through which to view this complicated topic.

Risk of Postoperative Complications and Revision Surgery Following Robot-assisted Posterior Lumbar Spinal Fusion.

STUDY DESIGN: Retrospective Study. OBJECTIVE: This investigation examined matched cohorts of lumbar spinal fusion (LSF) patients undergoing robot-assisted and conventional LSF to compare risk of revision, 30-day readmission, 30-day complications, and postoperative opioid utilization. SUMMARY OF BACKGROUND DATA: Patient outcomes and complication rates associated with robot-assisted LSF compared to conventional fusion techniques are incompletely understood. METHODS: The PearlDiver Research Program (www.pearldiverinc.com) was used to identify patients undergoing primary LSF between 2011 and 2017. Patients receiving robot-assisted or conventional LSF were matched using key demographic and comorbidity variables. Indication for revision was also studied. Risk of revision, 30-day readmission, 30-day complications, and postoperative opioid utilization at 1 and 6 months was compared between the cohorts using multivariable logistic regression additionally controlling for age, sex, and Charlson Comorbidity Index. RESULTS: The percent of LSFs that were robot-assisted rose by 169% from 2011 to 2017, increasing linearly each year (p = 0.0007). Matching resulted in 2528 patients in each cohort for analysis. Robot-assisted LSF patients experienced higher risk of revision (adjusted odds ratio [aOR] = 2.35, P ≤ 0.0001), 30-day readmission (aOR = 1.39, P = 0.0002), and total 30-day complications (aOR = 1.50, P < 0.0001), specifically respiratory (aOR = 1.56, P = 0.0006), surgical site infection (aOR = 1.56, P = 0.0061), and implant-related complications (aOR = 1.74, P = 0.0038). The risk of revision due to infection after robot-assisted LSF was an estimated 4.5-fold higher (aOR = 4.46, 95% confidence interval [CI] 1.95-12.04, P = 0.0011). Furthermore, robot-assisted LSF had increased risk of revision due to instrument failure (aOR = 1.64, 95% CI 1.05-2.58, P = 0.0300), and pseudarthrosis (aOR = 2.24, 95%CI = 1.32-3.95, P = 0.0037). A higher percentage of revisions were due to infection in robot-assisted LSF (19.0%) than in conventional LSF (9.2%) (P = 0.0408). CONCLUSION: Robotic-assisted posterior LSF is independently associated with increased risk of revision surgery, infection, instrumentation complications, and postoperative opioid utilization compared to conventional fusion techniques. Further research is needed to investigate long-term postoperative outcomes following robot-assisted LSF. Spine surgeons should be cautious when considering immediate adoption of this emerging surgical technology. LEVEL OF EVIDENCE: 3.

Surgical Treatment of Patients With Dual Hip and Spinal Degenerative Disease: Effect of Surgical Sequence of Spinal Fusion and Total Hip Arthroplasty on Postoperative Complications.

STUDY DESIGN: Retrospective study. OBJECTIVE: To determine how lumbar spinal fusion-total hip arthroplasty (LSF-THA) operative sequence would affect THA outcomes. SUMMARY OF BACKGROUND DATA: Outcomes following THA in patients with a history of lumbar spinal degenerative disease and fusion are incompletely understood. METHODS: The PearlDiver Research Program (http://www.pearldiverinc.com) was used to identify patients undergoing primary THA. Patients were divided into four cohorts: 1) Primary THA without spine pathology, 2) remote LSF prior to hip pathology and THA, and patients with concurrent hip and spinal pathology that had 3) THA following LSF, and 4) THA prior to LSF. Postoperative complications and opioid use were assessed with multivariable logistic regression to determine the effect of spinal degenerative disease and operative sequence. RESULTS: Between 2007 and 2017, 85,595 patients underwent primary THA, of whom 93.6% had THA without lumbar spine degenerative disease, 0.7% had a history of remote LSF, and those with concurrent hip and spine pathology, 1.6% had THA prior to LSF, and 2.4% had THA following LSF. Patients with hip and lumbar spine pathology who underwent THA prior to LSF had significantly higher rates of dislocation (aOR = 2.46, P < 0.0001), infection (aOR = 2.65, P < 0.0001), revision surgery (aOR = 1.91, P < 0.0001), and postoperative opioid use at 1 month (aOR: 1.63, P < 0.001), 3 months (aOR = 1.80, P < 0.001), 6 months (aOR: 2.69, P < 0.001), and 12 months (aOR = 3.28, P < 0.001) compared with those treated with THA following LSF. CONCLUSION: Patients with degenerative hip and lumbar spine pathology who undergo THA prior to LSF have a significantly increased risk of postoperative dislocation, infection, revision surgery, and prolonged opioid use compared with THA after LSF. Surgeons should consider the surgical sequence of THA and LSF on outcomes for patients with this dual pathology. Shared decision making between patients, spine surgeons, and arthroplasty surgeons is necessary to optimize outcomes in patients with concomitant hip and spine pathology. LEVEL OF EVIDENCE: 3.

Spine Surgery Outcomes in Workers' Compensation Patients.

Occupational spine injuries place a substantial burden on employees, employers, and the workers' compensation system. Both temporary and permanent spinal conditions contribute substantially to disability and lost wages. Numerous investigations have revealed that workers' compensation status is a negative risk factor for outcomes after spine injuries and spine surgery. However, positive patient outcomes and return to work are possible in spine-related workers' compensation cases with proper patient selection, appropriate surgical indications, and realistic postoperative expectations. Quality improvement measures aimed at optimizing outcomes and minimizing permanent disability are crucial to mitigating the burden of disability claims.

An Anatomic Evaluation of Arthroscopic Access to the Radial Head.

PURPOSE: To determine the area of the radial head accessible for visualization and screw placement from the standard anteromedial and anterolateral portals used in elbow arthroscopy. METHODS: Five cadaveric elbows were arthroscopically evaluated using standard anteromedial and anterolateral portals. Markers (pins) were placed into the accessible portions of the radial head at maximal pronation and supination. Specimens were then evaluated by computed tomography, and the arc of the radial head accessible from each portal was determined. RESULTS: A continuous 220.04° ± 37.58° arc of the radial head was accessible from the combination of the anterolateral and anteromedial portals. From the anteromedial portal, the arc obtained measured 147.96° ± 21.81°, and from the anterolateral portal, the arc obtained measured 156.02° ± 33.32°. Using the radial styloid as a marker for 0°, the mean total arc ranged from 92.3° ± 34.06° dorsal to 127.74° ± 23.65° volar relative to the radial styloid. CONCLUSIONS: Standard anteromedial and anterolateral portals used for elbow arthroscopy allow access to an average 220° area of the radial head. CLINICAL RELEVANCE: This study defines the area of the radial head that can be contacted using commonly used, safe, and simple portals.