Provider confidence in the telemedicine spine evaluation: results from a global study.

PURPOSE: To utilize data from a global spine surgeon survey to elucidate (1) overall confidence in the telemedicine evaluation and (2) determinants of provider confidence. METHODS: Members of AO Spine International were sent a survey encompassing participant's experience with, perception of, and comparison of telemedicine to in-person visits. The survey was designed through a Delphi approach, with four rounds of question review by the multi-disciplinary authors. Data were stratified by provider age, experience, telemedicine platform, trust in telemedicine, and specialty. RESULTS: Four hundred and eighty-five surgeons participated in the survey. The global effort included respondents from Africa (19.9%), Asia Pacific (19.7%), Europe (24.3%), North America (9.4%), and South America (26.6%). Providers felt that physical exam-based tasks (e.g., provocative testing, assessing neurologic deficits/myelopathy, etc.) were inferior to in-person exams, while communication-based aspects (e.g., history taking, imaging review, etc.) were equivalent. Participants who performed greater than 50 visits were more likely to believe telemedicine was at least equivalent to in-person visits in the ability to make an accurate diagnosis (OR 2.37, 95% C.I. 1.03-5.43). Compared to in-person encounters, video (versus phone only) visits were associated with increased confidence in the ability of telemedicine to formulate and communicate a treatment plan (OR 3.88, 95% C.I. 1.71-8.84). CONCLUSION: Spine surgeons are confident in the ability of telemedicine to communicate with patients, but are concerned about its capacity to accurately make physical exam-based diagnoses. Future research should concentrate on standardizing the remote examination and the development of appropriate use criteria in order to increase provider confidence in telemedicine technology.

COVID-19 and the rise of virtual medicine in spine surgery: a worldwide study.

PURPOSE: The COVID-19 pandemic forced many surgeons to adopt "virtual medicine" practices, defined as telehealth services for patient care and online platforms for continuing medical education. The purpose of this study was to assess spine surgeon reliance on virtual medicine during the pandemic and to discuss the future of virtual medicine in spine surgery. METHODS: A comprehensive survey addressing demographic data and virtual medicine practices was distributed to spine surgeons worldwide between March 27, 2020, and April 4, 2020. RESULTS: 902 spine surgeons representing seven global regions responded. 35.6% of surgeons were identified as "high telehealth users," conducting more than half of clinic visits virtually. Predictors of high telehealth utilization included working in an academic practice (OR = 1.68, p = 0.0015) and practicing in Europe/North America (OR 3.42, p < 0.0001). 80.1% of all surgeons were interested in online education. Dedicating more than 25% of one's practice to teaching (OR = 1.89, p = 0.037) predicted increased interest in online education. 26.2% of respondents were identified as "virtual medicine surgeons," defined as surgeons with both high telehealth usage and increased interest in online education. Living in Europe/North America and practicing in an academic practice increased odds of being a virtual medicine surgeon by 2.28 (p = 0.002) and 1.15 (p = 0.0082), respectively. 93.8% of surgeons reported interest in a centralized platform facilitating surgeon-to-surgeon communication. CONCLUSION: COVID-19 has changed spine surgery by triggering rapid adoption of virtual medicine practices. The demonstrated global interest in virtual medicine suggests that it may become part of the "new normal" for surgeons in the post-pandemic era.

Telemedicine in research and training: spine surgeon perspectives and practices worldwide.

PURPOSE: To utilize a global survey to elucidate spine surgeons' perspectives towards research and resident education within telemedicine. METHODS: A cross-sectional, anonymous email survey was circulated to the members of AO Spine, an international organization consisting of spine surgeons from around the world. Questions were selected and revised using a Delphi approach. A major portion of the final survey queried participants on experiences with telemedicine in training, the utility of telemedicine for research, and the efficacy of telemedicine as a teaching tool. Responses were compared by region. RESULTS: A total of 485 surgeons completed the survey between May 15, 2020 and May 31, 2020. Though most work regularly with trainees (83.3%) and 81.8% agreed that telemedicine should be incorporated into clinical education, 61.7% of respondents stated that trainees are not present during telemedicine visits. With regards to the types of clinical education that telemedicine could provide, only 33.9% of respondents agreed that interpretation of physical exam maneuvers can be taught (mean score = - 0.28, SD = ± 1.13). The most frequent research tasks performed over telehealth were follow-up of imaging (28.7%) and study group meetings (26.6%). Of all survey responses provided by members, there were no regional differences (p > 0.05 for all comparisons). CONCLUSIONS: Our study of spine surgeons worldwide noted high agreement among specialists for the implantation of telemedicine in trainee curricula, underscoring the global acceptance of this medium for patient management going forward. A greater emphasis towards trainee participation as well as establishing best practices in telemedicine are essential to equip future spine specialists with the necessary skills for navigating this emerging platform.

Spine surgeon perceptions of the challenges and benefits of telemedicine: an international study.

INTRODUCTION: While telemedicine usage has increased due to the COVID-19 pandemic, there remains little consensus about how spine surgeons perceive virtual care. The purpose of this study was to explore international perspectives of spine providers on the challenges and benefits of telemedicine. METHODS: Responses from 485 members of AO Spine were analyzed, covering provider perceptions of the challenges and benefits of telemedicine. All questions were optional, and blank responses were excluded from analysis. RESULTS: The leading challenges reported by surgeons were decreased ability to perform physical examinations (38.6%), possible increased medicolegal exposure (19.3%), and lack of reimbursement parity compared to traditional visits (15.5%). Fewer than 9.0% of respondents experienced technological issues. On average, respondents agreed that telemedicine increases access to care for rural/long-distance patients, provides societal cost savings, and increases patient convenience. Responses were mixed about whether telemedicine leads to greater patient satisfaction. North Americans experienced the most challenges, but also thought telemedicine carried the most benefits, whereas Africans reported the fewest challenges and benefits. Age did not affect responses. CONCLUSION: Spine surgeons are supportive of the benefits of telemedicine, and only a small minority experienced technical issues. The decreased ability to perform the physical examination was the top challenge and remains a major obstacle to virtual care for spine surgeons around the world, although interestingly, 61.4% of providers did not acknowledge this to be a major challenge. Significant groundwork in optimizing remote physical examination maneuvers and achieving legal and reimbursement clarity is necessary for widespread implementation.

Correction to: Learning from the past: did experience with previous epidemics help mitigate the impact of COVID-19 among spine surgeons worldwide?

Unfortunately, the 13th author name has been incorrectly published in the original publication. The complete correct name is given below.

Impact of dietary aromatic amino acids on osteoclastic activity.

We had shown that aromatic amino acid (phenylalanine, tyrosine, and tryptophan) supplementation prevented bone loss in an aging C57BL/6 mice model. In vivo results from the markers of bone breakdown suggested an inhibition of osteoclastic activity or differentiation. To assess osteoclastic differentiation, we examined the effects of aromatic amino acids on early /structural markers as vitronectin receptor, calcitonin receptor, and carbonic anhydrase II as well as, late/functional differentiation markers; cathepsin K and matrix metalloproteinase 9 (MMP-9). Our data demonstrate that the aromatic amino acids down-regulated early and late osteoclastic differentiation markers as measured by real time PCR. Our data also suggest a link between the vitronectin receptor and the secreted cathepsin K that both showed consistent effects to the aromatic amino acid treatment. However, the non-attachment related proteins, calcitonin receptor, and carbonic anhydrase II, demonstrated less consistent effects in response to treatment. Our data are consistent with aromatic amino acids down-regulating osteoclastic differentiation by suppressing remodeling gene expression thus contributing initially to the net increase in bone mass seen in vivo.

Comparative analysis of sodium coupled vitamin C transporter 2 in human osteoarthritis grade 1 and grade 3 tissues.

BACKGROUND: Nutrient levels are known to influence the development of osteoarthritis (OA), presumably by modulating levels of matrix biosynthesis and degradation. These processes may be affected by ascorbic acid (AA), an antioxidant which acts as a cofactor for numerous biochemical reactions and is essential for post-translational modifications of collagen. In this study we examined the expression of SVCT2, the only known Sodium coupled vitamin C transporter isoform present in articular cartilage, in human articular cartilage explants derived from both normal and osteoarthritis articular cartilage. METHODS: OA1 and OA3 human articular cartilage was carefully dissected and macroscopically graded for degeneration via the Collins scale. The tissue samples were histologically examined by Hematoxylin and Eosin and Safranin O and Fast Green staining. SVCT2 expression analysis was performed at mRNA level by quantitative real time PCR and at a protein level by immunohistochemistry. RESULTS: Our quantitative real time PCR showed marked variation in the expression of SVCT2 in human osteoarthritic articular cartilage. SVCT2 expression was significantly down-regulated (p = 0.0001) in the Collins grade 3 (OA3) compared to Collins grade 1 (OA1) tissue. Furthermore, slides stained with fluorescent antibodies to SVCT2 demonstrated greatly reduced fluorescence for the SVCT2 transporter on the chondrocyte plasma membrane in the osteoarthritic tissue samples. CONCLUSIONS: These findings demonstrate that the expression of SVCT2 transporter is significantly altered in human osteoarthritic tissues (OA3). The modulation of this transporter could therefore potentially influence the prevention, management and treatment of osteoarthritis.

Regulation of vitamin C transporter in the type 1 diabetic mouse bone and bone marrow.

A number of studies have revealed that Type I diabetes (T1D) is associated with bone loss and an increased risk of fractures. T1D induces oxidative stress in various tissues and organs. Vitamin C plays an important role in the attenuation of oxidative stress; however, little is known about the effect of T1D induced oxidative stress on the regulation of vitamin C transporter in bone and bone marrow cells. To investigate this, T1D was induced in mice by multiple low dose injections of streptozotocin. We have demonstrated that endogenous antioxidants, glutathione peroxidase (GPx) and superoxide dismutase (SOD) are down-regulated in the bone and bone marrow of T1D. The vitamin C transporter isoform SVCT2, the only known transporter expressed in bone and bone marrow stromal cells (BMSCs), is negatively regulated in the bone and bone marrow of T1D. The µCT imaging of the bone showed significantly lower bone quality in the 8 week T1D mouse. The in-vitro study in BMSCS showed that the knockdown of SVCT2 transporter decreases ascorbic acid (AA) uptake, and increases oxidative stress. The significant reversing effect of antioxidant vitamin C is only possible in control cells, not in knockdown cells. This study suggested that T1D induces oxidative stress and decreases SVCT2 expression in the bone and bone marrow environment. Furthermore, this study confirms that T1D increases bone resorption, decreases bone formation and changes the microstructure of bones. This study has provided evidence that the regulation of the SVCT2 transporter plays an important role not only in T1D osteoporosis but also in other oxidative stress-related musculoskeletal complications.

Telemedicine in Spine Surgery: Global Perspectives and Practices.

STUDY DESIGN: Cross-sectional, anonymous, international survey. OBJECTIVES: The COVID-19 pandemic has resulted in the rapid adoption of telemedicine in spine surgery. This study sought to determine the extent of adoption and global perspectives on telemedicine in spine surgery. METHODS: All members of AO Spine International were emailed an anonymous survey covering the participant's experiences with and perceptions of telemedicine. Descriptive statistics were used to depict responses. Responses were compared among regions. RESULTS: 485 spine surgeons participated in the survey. Telemedicine usage rose from <10.0% to >39.0% of all visits. A majority of providers (60.5%) performed at least one telemedicine visit. The format of "telemedicine" varied widely by region: European (50.0%) and African (45.2%) surgeons were more likely to use phone calls, whereas North (66.7%) and South American (77.0%) surgeons more commonly used video (P < 0.001). North American providers used telemedicine the most during COVID-19 (>60.0% of all visits). 81.9% of all providers "agreed/strongly agreed" telemedicine was easy to use. Respondents tended to "agree" that imaging review, the initial appointment, and postoperative care could be performed using telemedicine. Almost all (95.4%) surgeons preferred at least one in-person visit prior to the day of surgery. CONCLUSION: Our study noted significant geographical differences in the rate of telemedicine adoption and the platform of telemedicine utilized. The results suggest a significant increase in telemedicine utilization, particularly in North America. Spine surgeons found telemedicine feasible for imaging review, initial visits, and follow-up visits although the vast majority still preferred at least one in-person preoperative visit.

Spine Surgery and COVID-19: The Influence of Practice Type on Preparedness, Response, and Economic Impact.

STUDY DESIGN: Cross-sectional observational cohort study. OBJECTIVE: To investigate preparation, response, and economic impact of COVID-19 on private, public, academic, and privademic spine surgeons. METHODS: AO Spine COVID-19 and Spine Surgeon Global Impact Survey includes domains on surgeon demographics, location of practice, type of practice, COVID-19 perceptions, institutional preparedness and response, personal and practice impact, and future perceptions. The survey was distributed by AO Spine via email to members (n = 3805). Univariate and multivariate analyses were performed to identify differences between practice settings. RESULTS: A total of 902 surgeons completed the survey. In all, 45.4% of respondents worked in an academic setting, 22.9% in privademics, 16.1% in private practice, and 15.6% in public hospitals. Academic practice setting was independently associated with performing elective and emergent spine surgeries at the time of survey distribution. A majority of surgeons reported a >75% decrease in case volume. Private practice and privademic surgeons reported losing income at a higher rate compared with academic or public surgeons. Practice setting was associated with personal protective equipment availability and economic issues as a source of stress. CONCLUSIONS: The current study indicates that practice setting affected both preparedness and response to COVID-19. Surgeons in private and privademic practices reported increased worry about the economic implications of the current crisis compared with surgeons in academic and public hospitals. COVID-19 decreased overall clinical productivity, revenue, and income. Government response to the current pandemic and preparation for future pandemics needs to be adaptable to surgeons in all practice settings.

The Impact of COVID-19 Pandemic on Spine Surgeons Worldwide: A One Year Prospective Comparative Study.

STUDY DESIGN: Survey. OBJECTIVE: In March of 2020, an original study by Louie et al investigated the impact of COVID-19 on 902 spine surgeons internationally. Since then, due to varying government responses and public health initiatives to the pandemic, individual countries and regions of the world have been affected differently. Therefore, this follow-up study aimed to assess how the COVID-19 impact on spine surgeons has changed 1 year later. METHODS: A repeat, multi-dimensional, 90-item survey written in English was distributed to spine surgeons worldwide via email to the AO Spine membership who agreed to receive surveys. Questions were categorized into the following domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions. RESULTS: Basic respondent demographics, such as gender, age, home demographics, medical comorbidities, practice type, and years since training completion, were similar to those of the original 2020 survey. Significant differences between groups included reasons for COVID testing, opinions of media coverage, hospital unemployment, likelihood to be performing elective surgery, percentage of cases cancelled, percentage of personal income, sick leave, personal time allocation, stress coping mechanisms, and the belief that future guidelines were needed (P<.05). CONCLUSION: Compared to baseline results collected at the beginning of the COVID-19 pandemic in 2020, significant differences in various domains related to COVID-19 perceptions, hospital preparedness, practice impact, personal impact, and future perceptions have developed. Follow-up assessment of spine surgeons has further indicated that telemedicine and virtual education are mainstays. Such findings may help to inform and manage expectations and responses to any future outbreaks.

Shape Loss of Autoclaved, Machine-Bent Cobalt-Chrome and Titanium Spine Surgery Rods.

STUDY DESIGN: This was a biomechanical study. OBJECTIVE: Shape loss of surgical spine rods has been implicated as a factor leading to postsurgical loss of alignment correction. Our objective was to compare the degree of shape loss in surgical spine rods of different compositions under physiological conditions that were bent before or after being autoclaved. METHODS: 10 CoCr and 10 commercially pure titanium (CPTi) surgical spine rods were contoured using a machine press. Five CoCr and 5 CPTi rods were bent before being autoclaved (preoperative bent group); 5 CoCr and 5 CPTi rods were bent after being autoclaved (intraoperative bent group). All rods were immersed in a phosphate-buffered saline bath at body temperature (37.2°C ± 2°C). Changes in radius of curvature were measured at different time intervals over an 8-week course using a high-definition scanner. RESULTS: Each rod demonstrated shape loss in radius of curvature (range = 1.04-9.99 mm) over the duration of the study. Intraoperatively bent CPTi rods demonstrated the largest shape loss (range = 8.73-9.99 mm; median 9.33 mm; P < .01). Preoperatively bent CPTi (range = 1.04-1.71 mm; median = 1.39 mm; P < .01) and intraoperatively bent CoCr (range = 1.11-2.11 mm; median = 2.01 mm; P < .01) rods underwent the least amount of shape loss. CONCLUSION: CPTi spinal rods bent after autoclave may lead to considerable loss of alignment correction. In addition, our results suggest that preautoclave bent CPTi and CoCr spinal rods bent after autoclave may be a more ideal choice of implant because they may provide more resistance to shape loss over time.

The Clinical Impact of Image Guidance and Robotics in Spinal Surgery: A Review of Safety, Accuracy, Efficiency, and Complication Reduction.

Image guidance (IG) and robotic-assisted (RA) surgery are modern technological advancements that have provided novel ways to perform precise and accurate spinal surgery. These innovations supply real-time, three-dimensional imaging information to aid in instrumentation, decompression, and implant placement. Although nothing can replace the knowledge and expertise of an experienced spine surgeon, these platforms do have the potential to supplement the individual surgeon's capabilities. Specific advantages include more precise pedicle screw placement, minimally invasive surgery with less reliance on intraoperative fluoroscopy, and lower radiation exposure to the surgeon and staff. As these technologies have become more widely adopted over the years, novel uses such as tumor resection have been explored. Disadvantages include the cost of implementing IG and robotics platforms, the initial learning curve for both the surgeon and the staff, and increased patient radiation exposure in scoliosis surgery. Also, given the relatively recent transition of many procedures from inpatient settings to ambulatory surgery centers, access to current devices may be cost prohibitive and not as readily available at some centers. Regarding patient-related outcomes, much further research is warranted. The short-term benefits of minimally invasive surgery often bolster the perioperative and early postoperative outcomes in many retrospective studies on IG and RA surgery. Randomized controlled trials limiting such confounding factors are warranted to definitively show potential independent improvements in patient-related outcomes specifically attributable to IG and RA alone. Nonetheless, irrespective of these current unknowns, it is clear that these technologies have changed the field and the practice of spine surgery. Surgeons should be familiar with the potential benefits and tradeoffs of these platforms when considering adopting IG and robotics in their practices.

An Update on Wrong-Site Spine Surgery.

STUDY DESIGN: Broad narrative review of current literature and adverse event databases. OBJECTIVE: The aim of this review is to report the current state of wrong-site spine surgery (WSSS), whether the Universal Protocol has affected the rate, and the current trends regarding WSSS. METHODS: An updated review of the current literature on WSSS, the Joint Commission sentinel event statistics database, and other state adverse event statistics database were performed. RESULTS: WSSS is an adverse event that remains a potentially devastating problem, and although the incidence is difficult to determine, the rate is low. However, given the potential consequences for the patient as well as the surgeon, WSSS remains an event that continues to be reported alarmingly as often as before the implementation of the Universal Protocol. CONCLUSIONS: A systems-based approach like the Universal Protocol should be effective in preventing wrong-patient, wrong-procedure, and wrong-sided surgeries if the established protocol is implemented and followed consistently within a given institution. However, wrong-level surgery can still occur after successful completion of the Universal Protocol. The surgeon is the sole provider who can establish the correct vertebral level during the operation, and therefore, it is imperative that the surgeon design and implement a patient-specific protocol to ensure that the appropriate level is identified during the operation.

Inpatient Outcomes in Dialysis Dependent Patients Undergoing Elective Cervical Spine Surgery for Degenerative Cervical Conditions.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate inpatient outcomes in dialysis dependent patients undergoing elective cervical spine surgery. METHODS: A total of 1605 dialysis dependent patients undergoing elective primary or revision cervical spine surgery for degenerative conditions were identified from the National Inpatient sample from 2002 to 2012 and compared to 1 450 642 nondialysis-dependent patients undergoing the same procedures. The National Inpatient Sample is a de-identified database; thus, no institutional review board approval was needed. RESULTS: Dialysis dependence was associated with higher inpatient mortality rates (7.5% vs 1.9%; P < .001) as well as both major (17.3% vs 0.6%; P < .001) and minor (36.8% vs 10.5%; P < .001) complication rates as compared with nondialysis-dependent patients. Dialysis-dependent patients had substantially increased mean lengths of stay (9.8 days compared with 2.0 days; P < .001) and total hospital charges ($141 790 compared with $46 562; P < .001). CONCLUSION: Dialysis-dependence is associated with drastically increased complication rates, risk of mortality, and represent a significant financial and psychosocial burden to patients undergoing elective cervical spine surgery. Both surgeons and patients should be aware of these risks while planning elective surgeries.

The Impact of COVID-19 Pandemic on Spine Surgeons Worldwide.

STUDY DESIGN: Cross-sectional, international survey. OBJECTIVES: The current study addressed the multi-dimensional impact of COVID-19 upon healthcare professionals, particularly spine surgeons, worldwide. Secondly, it aimed to identify geographical variations and similarities. METHODS: A multi-dimensional survey was distributed to surgeons worldwide. Questions were categorized into domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions. RESULTS: 902 spine surgeons representing 7 global regions completed the survey. 36.8% reported co-morbidities. Of those that underwent viral testing, 15.8% tested positive for COVID-19, and testing likelihood was region-dependent; however, 7.2% would not disclose their infection to their patients. Family health concerns were greatest stressor globally (76.0%), with anxiety levels moderately high. Loss of income, clinical practice and current surgical management were region-dependent, whereby 50.4% indicated personal-protective-equipment were not adequate. 82.3% envisioned a change in their clinical practice as a result of COVID-19. More than 33% of clinical practice was via telemedicine. Research output and teaching/training impact was similar globally. 96.9% were interested in online medical education. 94.7% expressed a need for formal, international guidelines to manage COVID-19 patients. CONCLUSIONS: In this first, international study to assess the impact of COVID-19 on surgeons worldwide, we identified overall/regional variations and infection rate. The study raises awareness of the needs and challenges of surgeons that will serve as the foundation to establish interventions and guidelines to face future public health crises.

Personal Health of Spine Surgeons Can Impact Perceptions, Decision-Making and Healthcare Delivery During the COVID-19 Pandemic - A Worldwide Study.

OBJECTIVE: To determine if personal health of spine surgeons worldwide influences perceptions, healthcare delivery, and decision-making during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A cross-sectional study was performed by distributing a multidimensional survey to spine surgeons worldwide. Questions addressed demographics, impacts and perceptions of COVID-19, and the presence of surgeon comorbidities, which included cancer, cardiac disease, diabetes, obesity, hypertension, respiratory illness, renal disease, and current tobacco use. Multivariate analysis was performed to identify specific comorbidities that influenced various impact measures. RESULTS: Across 7 global regions, 36.8% out of 902 respondents reported a comorbidity, of which hypertension (21.9%) and obesity (15.6%) were the most common. Multivariate analysis noted tobacco users were more likely to continue performing elective surgery during the pandemic (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.46-4.72; p = 0.001) and were less likely to utilize telecommunication (OR, 0.51; 95% CI, 0.31-0.86; p = 0.011), whereas those with hypertension were less likely to warn their patients should the surgeon become infected with COVID-19 (OR, 0.57; 95% CI, 0.37-0.91; p = 0.017). Clinicians with multiple comorbidities were more likely to cite personal health as a current stressor (OR, 1.32; 95% CI, 1.07-1.63; p = 0.009) and perceived their hospital's management unfavorably (OR, 0.74; 95% CI, 0.60-0.91; p = 0.005). CONCLUSION: This is the first study to have mapped global variations of personal health of spine surgeons, key in the development for future wellness and patient management initiatives. This study underscored that spine surgeons worldwide are not immune to comorbidities, and their personal health influences various perceptions, healthcare delivery, and decision-making during the COVID-19 pandemic.

COVID-19: Current and future challenges in spine care and education - a worldwide study.

BACKGROUND: The COVID-19 pandemic has impacted spine care around the globe. Much uncertainty remains regarding the immediate and long-term future of spine care and education in this COVID-19 era. STUDY DESIGN: Cross-sectional, international study of spine surgeons. METHODS: A multi-dimensional survey was distributed to spine surgeons around the world. A total of 73 questions were asked regarding demographics, COVID-19 observations, personal impact, effect on education, adoption of telemedicine, and anticipated challenges moving forward. Multivariate analysis was performed to assess factors related to likelihood of future conference attendance, future online education, and changes in surgical indications. RESULTS: A total of 902 spine surgeons from seven global regions completed the survey. Respondents reported a mean level of overall concern of 3.7 on a scale of one to five. 84.0% reported a decrease in clinical duties, and 67.0% reported a loss in personal income. The 82.5% reported being interested in continuing a high level of online education moving forward. Respondents who personally knew someone who tested positive for COVID-19 were more likely to be unwilling to attend a medical conference 1 year from now (OR: 0.61, 95% CI: [0.39, 0.95], P = .029). The 20.0% reported they plan to pursue an increased degree of nonoperative measures prior to surgery 1 year from now, and respondents with a spouse at home (OR: 3.55, 95% CI: [1.14, 11.08], P = .029) or who spend a large percentage of their time teaching (OR: 1.45, 95% CI: [1.02, 2.07], P = .040) were more likely to adopt this practice. CONCLUSIONS: The COVID-19 pandemic has had an adverse effect on surgeon teaching, clinical volume, and personal income. In the future, surgeons with family and those personally affected by COVID-19 may be more willing to alter surgical indications and change education and conference plans. Anticipating these changes may help the spine community appropriately plan for future challenges.

Minimizing Blood Loss in Spine Surgery.

STUDY DESIGN: Broad narrative review. OBJECTIVE: To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery. METHODS: A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery. RESULTS: There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements. CONCLUSION: As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain.

BACKGROUND CONTEXT: The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016. PURPOSE: The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN: This is a guideline summary review. METHODS: This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors. RESULTS: Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature. CONCLUSIONS: The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.