Invasive dental procedures as risk factors for postoperative spinal infection and the effect of antibiotic prophylaxis.

AIM: To identify invasive dental procedures as a risk factor for postoperative spinal infection (PSI) and evaluate the effectiveness of antibiotic prophylaxis. MATERIALS AND METHODS: We analysed 229,335 patients who underwent spinal surgery with instrumentation from 2010 to 2017, using the nationwide database. The incidence of spinal infection 2 years after surgery was determined. Invasive dental procedures as a risk factor for PSI and the effects of antibiotic prophylaxis during this period were also analysed. RESULTS: A total of 15,346 patients (6.69%) were diagnosed with PSI. It was found that advanced age, male sex, and a high Charlson Comorbidity Index were risk factors for PSI. The risk of PSI did not increase following dental procedures (adjusted hazard ratio [HR] 0.850; 95% confidence interval [CI], 0.793-0.912) and was not affected by antibiotics (adjusted HR 1.097; 95% CI, 0.987-1.218). Patients who received dental treatment as early as 3 months after spinal surgery had the lowest risk of postoperative infection (adjusted HR 0.869; 95% CI, 0.795-0.950). CONCLUSIONS: Invasive dental procedure does not increase the risk of PSI, and antibiotic prophylaxis before dental procedure was not effective in preventing spinal infection.

Is There an Association Between Psychiatric Disorders and Adolescent Idiopathic Scoliosis? A Large-database Study.

BACKGROUND: Children with adolescent idiopathic scoliosis (AIS) have reduced quality of life related to poor self-image, perhaps because of cosmetic concerns. However, there has not been a large-database epidemiologic study on the association between psychiatric disorders and scoliosis. QUESTIONS/PURPOSES: Using the Korean National Health Insurance database, we asked: (1) How common are psychiatric disorders among children with AIS? (2) After controlling for gender, age, insurance type, and residential district, are psychiatric disorders more common among children with AIS than among age-matched controls? METHODS: A retrospective analysis was conducted using sample datasets from the Health Insurance Review and Assessment Service from 2012 to 2016, which is a 10% randomly extracted sample of total inpatients and outpatients each year. The mean number of total patients in each dataset was 1,047,603 ± 34,534. The mean number of children with AIS was 7409 ± 158 for each year. The age criteria was 10 to 19 years for the matching. Mood disorders, anxiety disorders, and behavioral disorders were selected as disorders possibly associated with AIS. We identified children with AIS who had any of the disorders above, and we obtained the prevalence of these disorders based on diagnostic codes. As an exploratory analysis, clinically meaningful variables were selected among the available codes in the dataset, and a univariable logistic regression test was performed for each variable. A multivariable logistic regression test with advanced variables was performed to identify the adjusted odds ratios of psychiatric disorders in children with AIS. RESULTS: The median (range) prevalence of psychiatric disorders in children with AIS from 2012 to 2016 was 7% (6% to 7%). Compared with children who did not have AIS, and after controlling for gender, age, insurance type, and residential district, children with AIS were more likely to have psychiatric disorders in all 5 years. The adjusted ORs of psychiatric disorders in children with AIS compared with children who did not have AIS ranged from 1.47 to 1.74 (2012: OR 1.60 [95% CI 1.46 to 1.75]; p < 0.001; 2013: OR 1.73 [95% CI 1.58 to 1.89]; p < 0.001; 2014: OR 1.74 [95% CI 1.59 to 1.91]; p < 0.001; 2015: OR 1.71 [95% CI 1.56 to 1.88]; p < 0.001; 2016: OR 1.47 [95% CI 1.33 to 1.62]; p < 0.001). CONCLUSION: Considering the higher prevalence of psychiatric disorders in children with AIS compared with children who did not have AIS, children with AIS and their parents should be counseled about the increased risk of deteriorating mental health of the patients, and surgeons should provide early referral to pediatric psychiatrists. Further studies should investigate the effect of the factors related to AIS, such as curve type, Cobb angle, and treatment modality. LEVEL OF EVIDENCE: Level III, prognostic study.

Which Factors Affect the Stress of Intraoperative Orthopedic Surgeons by Using Electroencephalography Signals and Heart Rate Variability?

Can we recognize intraoperative real-time stress of orthopedic surgeons and which factors affect the stress of intraoperative orthopedic surgeons with EEG and HRV? From June 2018 to November 2018, 265 consecutive records of intraoperative stress measures for orthopedic surgeons were compared. Intraoperative EEG waves and HRV, comprising beats per minute (BPM) and low frequency (LF)/high frequency (HF) ratio were gathered for stress-associated parameters. Differences in stress parameters according to the experience of surgeons, intraoperative blood loss, and operation time depending on whether or not a tourniquet were investigated. Stress-associated EEG signals including beta 3 waves were significantly higher compared to EEG at rest for novice surgeons as the procedure progressed. Among senior surgeons, the LF/HF ratio reflecting the physical demands of stress was higher than that of novice surgeons at all stages. In surgeries including tourniquets, operation time was positively correlated with stress parameters including beta 1, beta 2, beta 3 waves and BPM. In non-tourniquet orthopedic surgeries, intraoperative blood loss was positively correlated with beta 1, beta 2, and beta 3 waves. Among orthopedic surgeons, those with less experience demonstrated relatively higher levels of stress during surgery. Prolonged operation time or excessive intraoperative blood loss appear to be contributing factors that increase stress.

Association of Functional Gastrointestinal Disorders with Adolescent Idiopathic Scoliosis.

Numerous adolescents diagnosed with adolescent idiopathic scoliosis (AIS) often manifest symptoms indicative of functional gastrointestinal disorders (FGIDs). However, the precise connection between FGIDs and AIS remains unclear. The study involved adolescents drawn from sample datasets provided by the Korean Health Insurance Review and Assessment Service spanning from 2012 to 2016, with a median dataset size of 1,446,632 patients. The AIS group consisted of individuals aged 10 to 19 with diagnostic codes for AIS, while the control group consisted of those without AIS diagnostic codes. The median prevalence of FGIDs in adolescents with AIS from 2012 to 2016 was 24%. When accounting for confounding factors, the analysis revealed that adolescents with AIS were consistently more prone to experiencing FGIDs each year (2012: adjusted odds ratio (aOR), 1.21 [95% confidence interval (CI), 1.10-1.35], p < 0.001; 2013: aOR, 1.31 [95% CI, 1.18-1.46], p < 0.001; 2014: aOR, 1.24 [95% CI, 1.12-1.38], p < 0.001; 2015: aOR, 1.34 [95% CI, 1.21-1.49], p < 0.001; and 2016: aOR, 1.35 [95% CI, 1.21-1.50], p < 0.001). These findings suggest that AIS is correlated with an elevated likelihood of FGIDs, indicating that AIS may function as a potential risk factor for these gastrointestinal issues. Consequently, it is recommended to provide counseling to adolescents with AIS, alerting them to the heightened probability of experiencing chronic gastrointestinal symptoms.

Biomechanical Comparison and Three-Dimensional Analysis of Cement Distribution Patterns for Different Pedicle Screw Designs.

The purpose of this study to explore strategies for reducing cement leakage during cement-augmented pedicle screw fixation, we compared the cement distribution patterns and biomechanical strengths of different types of cement-augmented fenestrated screws and traditional cement-augmented techniques. We compared five screw groups in this study: (1) Cannulated screws (Cann); (2) distal one-hole screws (D1); (3) distal two-hole screws (D2); (4) middle two-hole screws (M2); and (5) traditional screws with a traditional cement injection technique (Trad). The screws were inserted into cancellous bone blocks using a controlled, adequate cement injection pressure (1.6-2.0 kg), and an appropriate cement viscosity. Center to screw tip distance, three-dimensional distribution, and pull-out strength for cement were compared between groups. The average distance between the cement center and the screw tip was highest in the M2 group, suggesting a higher risk of cement leakage into the spinal canal. The Trad group had the highest migration distance in the z-axis, also reflecting a higher risk of leakage into the spinal canal. The D1 group had the highest pull-out strength (253 ± 48.82 N and 797 ± 58.31 N) in bone blocks representing different degrees of osteoporosis, and the D2 group had the second highest pull-out strength in the severe osteoporosis model. Overall, D1 screws appeared to be the best option for optimizing biomechanical function and minimizing the risk of cement leakage into the spinal canal in patients with osteoporotic bone undergoing spinal surgery.

Medial Pedicle Pivot Point Using Preoperative Computed Tomography Morphometric Measurements for Cervical Pedicle Screw Insertion: A Novel Technique and Case Series.

This study describes a new and safe freehand cervical pedicle screw insertion technique using preoperative computed tomography (CT) morphometric measurements as a guide and a medial pedicle pivot point (MPPP) during the procedure. This study included 271 pedicles at 216 cervical spine levels (mean: 4.75 pedicles per patient). A pedicle diameter (PD) ≥ 3.5 mm was the cut-off for pedicle screw fixation. The presence and grade of perforation were detected using postoperative CT scans, where perforations were graded as follows: 0, no perforation; 1, perforation < 0.875 mm; 2, perforation 0.875-1.75 mm; and 3, perforation > 1.75 mm. The surgical technique involved the use of an MPPP, which was the point at which the lines representing the depth of the lateral mass and total length of the pedicle intersected, deep in the lateral mass. The overall success rate was 96.3% (261/271, Grade 0 or 1 perforations). In total, 54 perforations occurred, among which 44 (81.5%) were Grade 1 and 10 (18.5%) were Grade 2. The most common perforation direction was medial (39/54, 72.2%). The freehand technique for cervical pedicle screw fixation using the MPPP may allow for a safe and accurate procedure in patients with a PD ≥3.5 mm.

Incidence rate of congenital scoliosis estimated from a nationwide health insurance database.

To investigate the epidemiology of congenital scoliosis (CS) and treatment trends. An age-matched, nationwide, population-based study was conducted using the National Health Insurance and Health Insurance Review and Assessment databases from 2010 to 2015. Data regarding the diagnosis and treatment of scoliosis were extracted using International Classifications of Diseases, 10th revision codes. The age-matched normal population was determined from the Korean Statistical Information Service database. We analyzed the incidence rate of CS according to age and sex, as well as the proportion of surgically treated patients. A total of 1664 patients (aged 0-19 years) were diagnosed with CS. The overall average incidence rate of CS over the 5-year period was 3.08 per 100,000 persons, with the highest and second highest rates at 0 years and 12-16 years of age, respectively. The incidence rate stratified by age ranged from 1.5 to 20.1 per 100,000 persons among the age-matched normal population, with peaks at 0 years of age and the second growth spurt in adolescence (12-16 years for males; 10-14 years for females). Anterior surgery was rarely performed; posterior surgery was performed in 92 patients (5.5% of all patients), with the highest prevalence (56.5%) in patients diagnosed at 10-14 years of age. The overall average incidence rate of CS over a 5-year period was 3.08 per 100,000 persons. Only 5.5% of patients underwent surgery within 5 years after the initial diagnosis.

Incidence and Surgery Rate of Idiopathic Scoliosis: A Nationwide Database Study.

Idiopathic scoliosis is the most common cause of three-dimensional deformities of the spine. Most of the previous studies have been cross-sectional studies to estimate the prevalence in the general population. An age-matched, population-based study is performed using nationwide databases between 2011 and 2015. The incidence rates of idiopathic scoliosis by age group, sex, and region are identified. We also investigate the pattern of medical institution use and the surgery rate of patients with idiopathic scoliosis. Our results show that a total of 268,372 patients were diagnosed with idiopathic scoliosis. The overall incidence was 0.497%, and the incidence for females was 1.44 times higher than for males. By age group, the incidence of adolescent idiopathic scoliosis in patients aged 10-14 years was 0.821% compared to 0.029%, 0.192%, and 0.709% for those patients aged 0-2, 3-9, and 15-19 years, respectively. Both male and female urban populations had higher incidences than rural populations with no age differences at diagnosis. Survival analysis confirmed that 0.7% of diagnosed patients underwent surgical treatment within five years. Understanding the epidemiology of idiopathic scoliosis is helpful in diagnosing high risk patients and monitoring surgical interventions.

Risk Factors of Clostridium Difficile Infection After Spinal Surgery: National Health Insurance Database.

The purpose of this study was to evaluate risk factors of Clostridium Difficile infection (CDI) after spinal surgery using the Health Insurance Review and Assessment Service (HIRA) data. The incidence of postoperative CDI was investigated using HIRA data from 2012 to 2016. Cases involving CDI that occurred within a 30-day postoperative period were identified. Risk factors, including age, sex, comorbidities, postoperative infection, spinal surgery procedure, type of antibiotic, and duration of antibiotic use, were evaluated. Duration of hospital stay, medical cost, and mortality were also evaluated. In total, 71,322 patients were included. Presumed cases of CDI were identified in 57 patients, with CDI rate of 0.54 per 10,000 patient days. Advanced age, staged operation, postoperative infection, and the use of multiple antibiotics were significant risk factors. First-generation cephalosporins were shown to be associated with a lower incidence of CDI. CDI was also associated with longer hospital stays and increased medical cost, and it was an independent risk factor for increased mortality. Extra attention should be paid to patients at high risk for the development of postoperative CDI, and unnecessary use of multiple antibiotics should be avoided. Level of Evidence: Level III, retrospective cohort study.

Intraoperative real-time stress in degenerative lumbar spine surgery: simultaneous analysis of electroencephalography signals and heart rate variability: a pilot study.

BACKGROUND CONTEXT: Interest in intraoperative stress has increased due to its potentially detrimental impact on surgical performance and burnout among spine surgeons. PURPOSE: The purpose of this study was to analyze intraoperative stress in real time in terms of electroencephalography signals and heart rate variability using a wearable device during spine surgery. STUDY DESIGN: Prospective observational study. PATIENT SAMPLE: Five orthopedic spine surgeons with experience ranging from 1 to 30 years were included. OUTCOME MEASURES: The outcome measures included stress levels among the spine surgeons and differences in stress parameters between novice and expert surgeons and between assistants and operators. METHODS: From June 2018 to November 2018, 179 consecutive records of intraoperative stress measures, including intraoperative electroencephalography signals and heart rate variability, comprising beats per minute (BPM) and low frequency/high frequency ratio, for the orthopedic spine surgeons were prospectively gathered, compared, and analyzed. RESULTS: Among all measures, sensory-motor rhythm (SMR) waves, gamma waves, and BPM differed significantly during surgery (analysis of variance; p=.040, .013, .002, respectively). Surgery duration and intraoperative bleeding were positively correlated with stress parameters, including gamma waves and tension. For operators, surgeon experience was negatively correlated with concentration, tension, and SMR, gamma, M-beta, and H-beta waves (Pearson correlation, p<.05). However, for assistants, surgeon experience was positively correlated with concentration, tension, BPM, and SMR, M-beta, H-beta, and gamma waves. Bleeding amounts were correlated positively with gamma waves and tension for both operators and assistants (Pearson correlation, p<.05). Stress among operators was higher than that among assistants in terms of low frequency/high frequency ratio. CONCLUSIONS: Operators and surgeons with low experience exhibited higher stress levels during surgery, which should be addressed when scheduling elective surgery to ensure optimal conditions among spine surgeons.

Hand grip strength as a surrogate marker for postoperative changes in spinopelvic alignment in patients with lumbar spinal stenosis.

There are a few studies on the postoperative changes in sagittal alignment and corresponding factors, including hand grip strength (HGS) and muscle performance tests for lumbar spinal stenosis (LSS). Thus, we aimed to determine whether HGS can be a surrogate marker for global sagittal alignment changes after decompression with fusion surgery for LSS. This retrospective observational study included 91 patients who underwent spine fusion surgery for LSS. Radiological spinopelvic parameters, including sagittal vertical axis (SVA), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), global tilt (GT), and T1 pelvic angle (T1PA), were analyzed preoperatively and 1 year after posterior decompression and fusion surgery. To assess muscle performance, the 6-m walk (SMT), timed up and go (TUGT), and sit-to-stand (STS) tests were conducted. The relationship between HGS and postoperative SVA was examined through multiple linear regression analysis. Additionally, the relationship between HGS and preoperative/postoperative radiologic spinopelvic parameters and muscle performance test results was analyzed through Pearson's correlation. HGS was significantly correlated with age, preoperative and postoperative SVA, and the muscle performance tests. Furthermore, HGS was a factor that can significantly influence postoperative SVA changes in multiple linear regression analyses. Therefore, HGS may be a good predictor of postoperative SVA change.

Emphysematous osteomyelitis of the spine: A rare case report.

RATIONALE: Emphysematous osteomyelitis is a rare disease caused by gas-forming bacteria. But only 45 cases have been reported in the literature since then. PATIENT CONCERNS: A 72-year-old female presented to our hospital with severe lower back pain that aggravated 4 days ago. DIAGNOSES: Computed tomography (CT) revealed intraosseous mottled air in the T12 and L1 vertebral bodies and epidural space. The enhanced T1 and T2 magnetic resonance imaging scans showed heterogeneous signal intensity of vertebral bodies, suggestive of emphysematous osteomyelitis. INTERVENTIONS: Surgery was performed to identify culture strains and to remove emphysematous lesions of the vertebral body using extensive transpedicular irrigation. OUTCOMES: Escherichia coli (E coli) was identified in the surgical specimen, and intravenous antibiotic therapy was continued with cefotaxime. The patient had a significant decrease in lower back pain after the surgery and the final CT scan before discharge revealed significantly decreased air at T12 and L1 vertebral bodies and no air density in the epidural space. LESSONS: We present a patient diagnosed with emphysematous osteomyelitis in vertebral bodies caused by E coli and successfully treated with surgical intervention.

Hand grip strength can predict clinical outcomes and risk of falls after decompression and instrumented posterolateral fusion for lumbar spinal stenosis.

BACKGROUND CONTEXT: There has been limited research on the association between hand grip strength (HGS) as one of the diagnostic criteria for sarcopenia and surgical outcomes of lumbar spinal stenosis (LSS). PURPOSE: We aimed to determine the effect of HGS on surgical outcomes and risk of fall in patients with LSS. STUDY DESIGN: This is a retrospective observational study. PATIENT SAMPLE: We included 200 patients who underwent spinal surgery for LSS. OUTCOME MEASURES: We recorded clinical outcome parameters, including Oswestry Disability Index (ODI), Euro-QOL (EQ-5D), and visual analog scale (VAS) scores for back or leg pain. To assess the risk of fall we used HGS and four functional mobility tests (alternative step test, six-meter walk test, timed up and go test, sit-to-stand test). MATERIALS AND METHODS: ODI, EQ-5D, and VAS scores for back and leg pain were assessed preoperatively and 1 year after surgery. The four functional mobility tests were assessed at each time point during the 1-year follow-up period to assess the risk of fall in patients with LSS. We divided the patient cohort according to sex and allocated them into two different groups based on HGS: high HGS (≥26 kg for men, n=26; ≥18 kg for women, n=35), and low HGS (<26 kg for men, n=48; <18 kg for women, n=91). The pre- and postoperative ODI, EQ-5D, and VAS scores for back and leg pain, as well as the functional mobility test results, and demographic data were compared between the two groups using independent t tests. Correlations between HGS and clinical outcome parameters were analyzed using Pearson correlation. RESULTS: In women and men, HGS correlated with the preoperative/postoperative ODI (r1=-0.217/r2=-0.345 in women, and r1=-0.384/r2=-0.411 in men) and EQ-5D scores (r1=0.190/r2=0.309 in women, and r1=0.373/r2=0.467 in men). HGS also correlated with the four postoperative results for the functional mobility tests: alternative step test (r=-0.238 in women, r=-0.431 in men), six-meter walk test (r=-0.232 in women, r=-0.282 in men), timed up and go test (r=-0.285 in women, r=-0.359 in men), and sit-to-stand test (r=-0.238 in women, r=-0.251 in men). The preoperative and postoperative ODI and EQ-5D scores in the high HGS group were superior to those in the low HGS group. Among the four functional mobility tests, preoperative and postoperative six-meter walk test results showed improvements in the high HGS group. CONCLUSIONS: Considering the multifactorial nature of falls, HGS may be a useful surrogate marker for predicting the risk of falls and clinical outcomes in patients with LSS.