Learning by drawing and modeling: Teaching modalities for spinal anatomy in medical students.

Ongoing research has attempted to discern the optimal way to teach surgical anatomy. This study investigated the relative effectiveness of drawing and clay modeling on learning spinal anatomy among medical students. Participants were recruited from a first-year medical school class to participate in an optional educational session in their regular course schedule. Seventy-eight students participated, and 62 completed pre- and post-session tests. Participants were randomized to one of three groups, either learning spinal anatomy by (1) drawing, (2) clay modeling, or (3) reviewing a 3D anatomy application (control). All groups referenced the anatomy application; the control group had no additional learning modality. Students had 15 min to learn major anatomical structures in the lumbar spine according to their assigned modality. Learning was evaluated in terms of score differential on pre- and post-session anatomy tests, with questions focused on anatomy applied in different contexts such as pathophysiology and radiology. Improved pre- to posttest scores were expected for the drawing and modeling groups compared to control. On average, the drawing group's scores significantly improved by 11% from pre- to posttest. Scores in the clay and control groups did not significantly improve. Drawing is thus an effective strategy for learning basic and applied spinal anatomy, and drawing and clay modeling (with adequate time) may be useful for teaching medical students to apply surgical anatomical knowledge in various contexts. These modalities are generalizable to any surgical anatomical education, and should be further explored among surgical residents given their efficacy, feasibility, and minimal use of resources.

The positive prediction of single photon emission computed tomography/ computed tomography (SPECT/CT) in the outcome of intervention for cervical facet pain.

BACKGROUND CONTEXT: Previous studies have reported that magnetic resonance imaging (MRI) and computed tomography (CT) do not predict response to facet blocks. However, single photon emission computed tomography (SPECT) uptake within facet joints has been shown to correlate with pain relief after intervention in the lumbar spine. There is minimal data regarding the predictive value of single photon emission computed tomography/computed tomography (SPECT/CT) for neck pain. PURPOSE: The aim of this study was to evaluate the utility of SPECT/CT in patients with axial neck pain for the identification of specific facet joints that would benefit from diagnostic and therapeutic facet joint steroid injections and/or medial branch block/RFA treatments. STUDY DESIGN: A retrospective cohort study. PATIENT SAMPLE: One hundred seventy-nine patients at a single institution pain center with neck pain and a SPECT/CT scan between 2009 and 2015. One hundred twelve patients had no prior intervention at the level of interest and met inclusion criteria. OUTCOME MEASURES: Pain reduction at 50% and 80% thresholds within 24 hours of facet intervention. Concordance of facet intervention with the focus of maximal uptake on SPECT/CT scan. METHODS: All patients were referred to our institution's Center for Pain Medicine and were treated with facet interventions. The site of facet intervention was determined by pain center providers based on their clinical examination and interpretation of images. Groups were formed based on whether the facet intervention included the level of maximal uptake on SPECT/CT scan. A positive response to intervention was defined at both 50% and 80% thresholds for reduction in pain within 24 hours of facet injection with steroid and local anesthetic or medial branch block with local anesthetic only. These were the facet interventions used for our data collection. A Chi-square statistic was used to analyze categorical data and a Student's t-test was used to analyze non-categorical data. SPSS (IBM Corp. IBM SPSS Version 24.0) was used for all analyses. RESULTS: Of our 112 patients, Group 1 consisted of 89 with an intervention occurring at the level with increased uptake on SPECT/CT. Group 2 consisted of 23 patients with an intervention at a level without uptake on SPECT/CT. Demographic data did not significantly differ between cohorts. A Chi-square test of independence demonstrated that intervention at a level concordant with SPECT/CT was significantly correlated with self-reported pain relief thresholds of both 50% and 80% (p=.0002). CONCLUSIONS: Facet interventions based on SPECT/CT scan uptake were more successful in pain reduction than those which were not. This suggests a role for SPECT/CT in diagnosing therapeutic targets for neck pain.

The Role of High School Football Coverage in Resident Education.

Athletic team coverage experience varies widely across orthopedic surgery residency programs in the United States. There is a paucity of literature regarding whether serving as a team physician contributes to resident education and whether it can be performed within the bounds of current work-hour restrictions. Residents consider coverage of high school football games a valuable educational experience that does not adversely affect their 80-hour work week. Sixty-one orthopedic residents who served as high school football team physicians as part of their residency curriculum completed an 11-question survey. Responses ranged from strongly agree (1) to strongly disagree (5) on a Likert scale. The majority of residents agreed that serving as a team physician was an overall valuable experience (85%), that it enhanced their orthopedic sports medicine education (89%), and that it increased their awareness of the role played by athletic trainers (97%). The majority of respondents disagreed only with the statement that serving as a team physician had negatively affected their 80-hour work week (54%), and an additional 26% neither agreed nor disagreed. The vast majority of participating orthopedic residents consider high school football team coverage a valuable experience that enhances education and can be performed within work-hour limitations. [Orthopedics. 2020;43(6):e574-e578.].

Use of Fondaparinux Following Elective Lumbar Spine Surgery Is Associated With a Reduction in Symptomatic Venous Thromboembolism.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess the impact of fondaparinux on venous thromboembolism (VTE) following elective lumbar spine surgery in high-risk patients. METHODS: Matched patient cohorts who did or did not receive inpatient fondaparinux starting postoperative day 2 following elective lumbar spine surgery were compared. All patients received 1 month of acetyl salicylic acid 325 mg following discharge. The primary outcome was a symptomatic DVT (deep vein thrombosis) or PE (pulmonary embolus) within 30 days of surgery. Secondary outcomes included prolonged wound drainage, epidural hematoma, and transfusion. RESULTS: A significantly higher number of DVTs were diagnosed in the group that did not receive inpatient VTE prophylaxis (3/102, 2.9%) compared with the fondaparinux group (0/275, 0%, P = .02). Increased wound drainage was seen in 18.5% of patients administered fondaparinux, compared with 25.5% of untreated patients (P = .15). Deep infections were equivalent (2.2% with fondaparinux vs 4.9% control, P = .18). No epidural hematomas were noted, and the number of transfusions after postoperative day 2 and 90-day return to operating room rates were equivalent. CONCLUSIONS: Patients receiving fondaparinux had lower rates of symptomatic DVT and PE and a favorable complication profile when compared with matched controls. The retrospective nature of this work limits the safety and efficacy claims that can be made about the use of fondaparinux to prevent VTE in elective lumbar spine surgery patients. Importantly, this work highlights the potential safety of this regimen, permitting future high-quality trials.

Meniscal repair using an all-inside, rapidly absorbing, tensionable device.

PURPOSE: The purpose of this study was to evaluate the clinical success rate of all-inside meniscal repairs using a rapidly absorbing device in patients undergoing concurrent anterior cruciate ligament (ACL) reconstructions. METHODS: Patients with menisci repaired using the polydioxanone Mitek RapidLoc (Depuy Mitek, Raynham, MA) during concurrent ACL reconstruction were evaluated clinically 2 years following index surgery. We performed examinations on 38 meniscal tears in 30 patients using the International Knee Documentation Committee form and the Knee Disorders Subjective History visual analog scale. We also performed physical examinations for an effusion, joint line tenderness, McMurray's testing, and KT-1000 arthrometry (MEDmetric, San Diego, CA). RESULTS: The clinical success rate for meniscal repair was 86.8% (33 of 38) at a mean follow-up of 30.4 months (range, 21 to 56 months). Univariate analysis revealed sex as the only predictive variable for failure; all failures occurred in male patients. Nonpredictive variables included tear length, type, and configuration; a duration of more than 3 months, compartment, zone, ligament graft choice, age, follow-up, Tegner score, and visual analog scale score. CONCLUSIONS: The polydioxanone RapidLoc device was found to have a clinical success rate of 86.8%. These data suggest that the more rapidly absorbing polydioxanone device is effective for all-inside meniscal repair during concurrent ACL reconstruction. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Vertebral artery injuries in cervical spine surgery.

BACKGROUND CONTEXT: Vertebral artery injuries (VAIs) are rare but serious complications of cervical spine surgery, with the potential to cause catastrophic bleeding, permanent neurologic impairment, and even death. The present literature regarding incidence of this complication largely comprises a single surgeon or small multicenter case series. PURPOSE: We sought to gather a large sample of high-volume surgeons to adequately characterize the incidence and risk factors for VAI, management strategies used, and patient outcomes after VAI. STUDY DESIGN: The study was constructed as a cross-sectional study comprising all cervical spine patients operated on by the members of the international Cervical Spine Research Society (CSRS). PATIENT SAMPLE: All patients who have undergone cervical spine surgery by a current member of CSRS as of the spring of 2012. OUTCOME MEASURES: For each surgeon surveyed, we collected self-reported measures to include the number of cervical cases performed in the surgeon's career, the number of VAIs encountered, the stage of the case during which the injury occurred, the management strategies used, and the overall patient outcome after injury. METHODS: An anonymous 10-question web-based survey was distributed to the members of the CSRS. Statistical analysis was performed using Student t tests for numerical outcomes and chi-squared analysis for categorical variables. RESULTS: One hundred forty-one CSRS members (of 195 total, 72%) responded to the survey, accounting for a total of 163,324 cervical spine surgeries performed. The overall incidence of VAI was 0.07% (111/163,324). Posterior instrumentation of the upper cervical spine (32.4%), anterior corpectomy (23.4%), and posterior exposure of the cervical spine (11.7%) were the most common stages of the case to result in an injury to the vertebral artery. Discectomy (9%) and anterior exposure of the spine (7.2%) were also common time points for an arterial injury. One-fifth (22/111) of all VAI involved an anomalous course of the vertebral artery. The most common management of VAI was by direct tamponade. The outcomes of VAIs included no permanent sequelae in 90% of patients, permanent neurologic sequelae in 5.5%, and death in 4.5%. Surgeons at academic and private centers had nearly identical rates of VAIs. However, surgeons who had performed 300 or fewer cervical spine surgeries in their career had a VAI incidence of 0.33% compared with 0.06% in those with greater than 300 lifetime cases (p=.028). CONCLUSIONS: The overall incidence of VAI during cervical spine surgery reported from this survey was 0.07%. Less experienced surgeons had a higher rate of VAI compared with their more experienced peers. The results of VAI are highly variable, resulting in no permanent harm most of the time; however, permanent neurologic injury or death occur in 10% of cases.

Safety of thromboembolic chemoprophylaxis in spinal trauma patients requiring surgical stabilization.

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine the incidence of thromboembolic events, bleeding complications such as epidural hematomas, and wound complications in patients with spinal trauma requiring surgical stabilization. SUMMARY OF BACKGROUND DATA: Literature addressing the safety and efficacy of chemoprophylactic agents in postoperative patients with spinal trauma is sparse. As a result, significant variability exists regarding administration of thromboembolic chemoprophylaxis in this population. The risk of bleeding complications is particularly concerning. METHODS: Patients with spinal trauma who underwent surgical stabilization in 2009 and 2010 at a single level 1 trauma center were retrospectively reviewed. Exclusion criteria included patients who underwent solely decompressive procedures, noninstrumented fusions, kyphoplasty, or had incomplete medical records. Patients who received chemoprophylaxis were compared with patients who did not. Demographical information and injury data were collected. Primary outcome measures were prevalence of thromboembolic events, epidural hematomas, and persistent wound drainage requiring irrigation and debridement. RESULTS: Two hundred twenty-seven of 373 patients were included (56 in the untreated group, 171 in the treated group). Eight patients in the untreated group (14.3%) and 12 patients in the treated group (7%) developed postoperative thromboembolism (P = 0.096). There was 1 pulmonary embolism in the untreated group (1.8%), and 4 pulmonary embolisms in the treated group (2.3%). Surgical irrigation and debridement for wound drainage was required for 1.8% of patients in the untreated group and for 5.3% of patients in the treated group. No epidural hematomas were noted in either group. The treated group had more spinal levels fused (P = 0.46), higher injury severity scores (0.001), and longer hospitalizations (0.018). Patients who developed postoperative thromboembolism had significantly higher body mass indexes (P = 0.01), injury severity scores (0.001), number of spinal levels fused (P = 0.004), incidence of neurological deficits (0.001), and longer hospitalizations (0.16) compared with those who did not. CONCLUSION: The use of chemoprophylaxis appears to be safe in at-risk patients in the immediate postoperative period after spinal trauma surgery. No epidural hematomas occurred, and the risk of wound drainage is small. Body mass index, injury severity score, presence of neurological deficits, and number of spinal levels fused should be considered when determining which patients should receive chemoprophylaxis after surgical stabilization.