The changing epidemiology of traumatic spine injuries: a trends analysis of 26 years of patients at a major level 1 trauma center in the United States.

BACKGROUND CONTEXT: Traumatic spinal injuries (TSI) are associated with high morbidity, mortality, and resource utilization. The epidemiology of TSI varies greatly across different countries and regions and is impacted by national income levels, infrastructure, and cultural factors. Further, there may be changes over time. It is essential to investigate TSI to gain useful epidemiologic information. However, there have been no recent studies on trends for TSI in the US, despite the changing population demographics, healthcare policy, and technology. As a result, re-examination is warranted to reflect how the modern era has affected the epidemiology of US spine trauma patients and their management. PURPOSE: To determine epidemiologic trends in traumatic spine injuries over time. STUDY DESIGN/SETTING: Retrospective analysis; level 1 trauma center in the United States. PATIENT SAMPLE: A total of 21,811 patients, between the years of 1996 and 2022, who presented with traumatic spine injury. OUTCOME MEASURES: Age, sex, race, Injury Severity Score, mechanism of injury, injury diagnosis, injury level, rate of operative intervention, hospital length of stay, intensive care unit length of stay, discharge disposition, in-hospital mortality. METHODS: Data was collected from our institutional trauma registry over a 26-year period. Inclusion criteria involved at least one diagnosis of vertebral fracture, spinal cord injury, spinal subluxation, or intervertebral disc injury. Exclusion criteria consisted of patients with no diagnosed spine injury or a diagnosis of strain only. A total of 21,811 patients were included in the analysis. Descriptive statistics were tabulated and ordinary least squares linear regression was conducted for trends analysis. RESULTS: Regression analysis showed a significant upward trend in patient age (+13.83 years, ß=+0.65/year, p<.001), female sex (+2.7%, ß=+0.18%/year, p=.004), falls (+10.5%, ß=+0.82%/year, p<.001), subluxations (+12.8%, ß=+0.35%/year, p<.001), thoracic injuries (+1.5%, ß=+0.28%/year, p<.001), and discharges to subacute rehab (+15.9%, ß=+0.68%/year, p<.001). There was a significant downward trend in motor vehicle crashes (-7.8%, ß=-0.47%/year, p=.016), firearms injuries (-3.4%, ß=-0.19%/year, p<.001), sports/recreation injuries (-2.9%, ß=-0.18%/year, p<.001), spinal cord injuries (-11.25%, ß=-0.37%, p<.001), complete spinal cord injuries (-7.6%, ß=-0.24%/year, p<.001), and discharges to home (+4.5%, ß=-0.27%/year, p=.011). CONCLUSIONS: At our institution, the average spine trauma patient has trended toward older females. Falls represent an increasing proportion of the mechanism of injury, on a trajectory to become the most common cause. With time, there have been fewer spinal cord injuries and a lower proportion of complete injuries. At discharge, there has been a surge in the utilization of subacute rehabilitation facilities. Overall, there has been no significant change in injury severity, rate of operative intervention, length of stay, or mortality.

Feasibility of a novel augmented reality overlay for cervical screw placement in phantom spine models.

STUDY DESIGN: Feasibility study. PURPOSE: A phantom model was used to evaluate the accuracy of a novel augmented reality (AR) system for cervical screw placement. OVERVIEW OF LITERATURE: The use of navigation systems is becoming increasingly common in spine procedures. However, numerous factors limit the feasibility of regular and widespread use of navigation tools during spine surgery. AR is a new technology that has already demonstrated utility as a navigation tool during spine surgery. However, advancements in AR technology are needed to increase its adoption by the medical community. METHODS: AR technology that uses a fiducial-less registration system was tested in a preclinical cervical spine phantom model study for accuracy during spinal screw placement. A three-dimensional reconstruction of the spine along with trajectory lines was superimposed onto the phantom model using an AR headset. Participants used the AR system to guide screw placement, and post-instrumentation scans were compared for accuracy assessment. RESULTS: Twelve cervical screws were placed under AR guidance. All screws were placed in an acceptable anatomic position. The average distance error for the insertion point was 2.73±0.55 mm, whereas that for the endpoint was 2.71±0.69 mm. The average trajectory angle error for all insertions was 2.69°±0.59°. CONCLUSIONS: This feasibility study describes a novel registration approach that superimposes spinal anatomy and trajectories onto the surgeon's real-world view of the spine. These results demonstrate reasonable accuracy in the preclinical model. The results of this study demonstrate that this technology can assist with accurate screw placement. Further investigation using cadaveric and clinical models is warranted.

Diagnosis and Management of Thoracic Myelopathy.

Thoracic myelopathy can be a challenging condition to diagnose and treat. Successful outcomes depend on early recondition of the pathology and appropriate surgical referral in cases of progressive neurologic deterioration. The thoracic cord is tethered in kyphosis by the dentate ligaments and contains a tenuous blood supply. These conditions make the thoracic cord particularly susceptible to external compression and ischemic damage. Careful preoperative planning with specific attention to the location and source of thoracic stenosis is critical to successful decompression and complication avoidance. The purpose of this discussion is to outline the common sources of thoracic myelopathy and current recommendations regarding diagnosis and management. The review concludes with an overview of the most up-to-date literature regarding clinical outcomes.

Superinfections of the Spine: A Single-Institution Experience.

Background/Objectives: A superinfection occurs when a new, secondary organism colonizes an existing infection. Spine infections are associated with high patient morbidity and sometimes require multiple irrigations and debridements (I&Ds). When multiple I&Ds are required, the risk of complications increases. The purpose of this study was to report our experience with spine superinfections and determine which patients are typically affected. Methods: A retrospective case series of spine superinfections and a retrospective case-control analysis were conducted. Data were collected manually from electronic medical records. Spine I&Ds were identified. Groups were created for patients who had multiple I&Ds for (1) a recurrence of the same causative organism or (2) a superinfection with a novel organism. Preoperative demographic, clinical, and microbiologic data were compared between these two outcomes. A case series of superinfections with descriptive data was constructed. Lastly, two illustrative cases were provided in a narrative format. Results: A total of 92 patients were included in this analysis. Superinfections occurred after 6 out of the 92 (7%) initial I&Ds and were responsible for 6 out of the 24 (25%) repeat I&Ds. The preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) of the patients with a superinfection were significantly lower than those in the control group (p = 0.022 and p = 0.032). Otherwise, the observed differences in the preoperative variables were not statistically different. In the six cases of superinfection, the presence of high-risk comorbidities, a history of substance abuse, or a lack of social support were commonly observed. The superinfecting organisms included Candida, Pseudomonas, Serratia, Klebsiella, Enterobacter, and Staphylococcus species. Conclusions: Superinfections are a devastating complication requiring reoperation after initial spine I&D. Awareness of the possibility of superinfection and common patient archetypes can be helpful for clinicians and care teams. Future work is needed to examine how to identify, help predict, and prevent spine superinfections.

The Utility of the Validated Intraoperative Bleeding Scale in Thoracolumbar Spine Surgery: A Single-Center Prospective Study.

STUDY DESIGN: Prospective, single-center study. OBJECTIVE: To evaluate the clinical relevance of the validated intraoperative bleeding severity scale (VIBe) in thoracolumbar spine surgery. METHODS: Adult patients aged 18 through 88 undergoing elective decompression, instrumentation, and fusion of the thoracolumbar spine were prospectively enrolled after informed consent was provided and written consent was obtained. Validated intraoperative bleeding severity scores were recorded intraoperatively. Univariate analysis consisted of Student T-tests, Pearson's χ2 Tests, Fisher's Exact Tests, linear regression, and binary logistic regression. Multivariable regression was conducted to adjust for baseline characteristics and potential confounding variables. RESULTS: A total of N = 121 patients were enrolled and included in the analysis. After adjusting for confounders, VIBe scores were correlated with an increased likelihood of intraoperative blood transfusion (ß = 2.46, P = .012), postoperative blood transfusion (ß = 2.36, P = .015), any transfusion (ß = 2.49, P < .001), total transfusion volume (ß = 180.8, P = .020), and estimated blood loss (EBL) (ß = 409, P < .001). Validated intraoperative bleeding severity scores had no significant association with length of hospital stay, 30-day readmission, 30-day reoperation, 30-day emergency department visit, change in pre- to post-op hemoglobin and hematocrit, total drain output, or length of surgery. CONCLUSION: The VIBe scale is associated with perioperative transfusion rates and EBL in patients undergoing thoracolumbar spine surgery. Overall, the VIBe scale has clinically relevant meaning in spine surgery, and shows potential utility in clinical research. LEVEL OF EVIDENCE: Level II.

Lower Extremity Somatosensory Evoked Potentials Predict Functional Outcomes in Complete Traumatic Cervical Spinal Cord Injury.

BACKGROUND: Traumatic cervical spinal cord injury (tCSCI) is often a debilitating injury, making early prognosis important for medical and surgical planning. Currently, the best early predictors of prognosis are physical examination, imaging studies, and patient demographics. Despite these factors, patient outcomes continue to vary significantly. The purpose of this study was to evaluate the prognostic value of somatosensory evoked potentials (SSEPs) with functional outcomes in tCSCI patients. METHODS: A retrospective study was conducted on prospectively collected data from 2 academic institutions. Patients 18 years and older who had tCSCI and underwent posterior cervical decompression and stabilization with intraoperative neuromonitoring were reviewed. The outcomes of interest were the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade and ASIA motor score at follow-up. Outcomes measures were assessed via student t-tests, chi-squared tests, and multivariable regression analysis. RESULTS: A total of 79 patients were included. In complete injuries, detectable lower extremity SSEPs were associated with higher ASIA motor scores at follow-up (P = 0.002), greater increases in ASIA motor scores at follow-up (P = 0.009), and a greater likelihood of clinically important improvement in ASIA motor score (P = 0.024). Incomplete, AIS grade C injuries has higher rates of grade conversion (P = 0.019) and clinically important improvement in ASIA motor score (P = 0.010), compared to AIS grade A or B injuries. CONCLUSIONS: The detection of lower extremity SSEP signals during initial surgical treatment of tCSCI is associated with greater improvement in ASIA motor scores postoperatively. The association is most applicable to patients with complete injury.

A 10-Year Retrospective Review on the Use of Prophylactic Spinal Reconstruction in Spinal Surgery Involving High-Risk Patients.

BACKGROUND: Spinal surgeries are being offered to a broader patient population who are both medically and surgically complex. History of prior spinal surgery, advanced age, and presence of comorbidities, such as obesity, malnutrition, steroid use, and tobacco use, are risk factors for postoperative complications. Prophylactic spinal reconstruction at the time of spinal surgery has been shown to have improved outcomes and decreased wound complications; however, outcomes focusing specifically on complex patients with a history of previous spinal surgery (or surgeries) have not been well described. METHODS: This is a retrospective study performed at the University of Maryland Medical Center (Baltimore, MD) of high-risk patients who underwent complex spinal surgery with prophylactic spinal reconstruction from 2011 to 2022. One hundred forty-three consecutive surgeries from 136 patients were included in the study. Patients younger than 17 years or who had an incomplete medical record were excluded. RESULTS: Most patients were female (63.6%) versus male (31.5%). The average American Society of Anesthesiologists score was 3. All but 6 patients (11%) had a history of at least 1 spinal surgery, with nearly half of patients having had between 2 and 5 spinal surgeries. Reconstruction was performed with paraspinous flaps in most cases (n = 133 [93%]). The overall complication rate was 10.5%, with surgical site infection being the most common complication. Seventeen patients (12.5%) underwent reoperation within 90 days of initial surgery. Average length of follow-up was 4.18 months (range, 0.03-40.53 months). CONCLUSIONS: In appropriately selected patients, prophylactic spinal reconstruction offers improved outcomes with decreased wound complications compared with salvage. For large defects, paraspinous flaps are recommended over other reconstructive options. Prolonged drain placement is felt to be protective against complications.

FLOSEAL Versus SURGIFLO in Lumbar Surgery: Similar Outcomes, Different Costs in a Matched Cohort Analysis.

OBJECTIVE: Flowable gelatin-based matrices with thrombin for hemostatic control are commercially available as Floseal (Baxter International Inc.) and Surgiflo (Ethicon Inc.). The objective of this study is to compare the rate of blood transfusions following the use of Floseal and Surgiflo in lumbar spine surgery. METHODS: Elective lumbar spine surgery patients between September 2019 and March 2021 were identified via CPT codes. Floseal 10 mL (N=102) and Surgiflo matrix 8 mL (N=108) cohorts excluded those younger than 18 years or those who underwent surgeries for infection, trauma, or tumor. The primary outcome was blood transfusion. Surgical complexity was controlled using the Surgical Invasiveness Index and Adult Spinal Deformity Invasiveness Score. The 1:1 propensity score matching was performed using demographic information, Surgical Invasiveness Index, Adult Spinal Deformity Invasiveness Score, and tranexamic acid use. RESULTS: A total of 77 Floseal patients were propensity score matched with 77 Surgiflo patients. There was no difference in the rate of blood transfusion (p=0.441). There was also no difference in operative time, estimated blood loss, or postoperative hemoglobin levels. The Surgiflo cohort used more units per surgery (p=0.004) and cost $102.45 more per surgery. Switching to Floseal saves $102,450 per year per 1000 surgeries. CONCLUSIONS: There was no difference in transfusion rates between using Floseal or Surgiflo for lumbar spine surgery. Surgiflo had higher usage per surgery and costs than Floseal.

Lower socioeconomic status is not associated with severity of adolescent idiopathic scoliosis: a matched cohort analysis.

PURPOSE: Assessing the influence of socioeconomic status (SES) on the severity of adolescent idiopathic scoliosis (AIS) on initial presentation to the spinal surgeon remains a challenge. The area deprivation index (ADI) is a validated measure of SES that abstracts multiple domains of disadvantage into a single score. We hypothesized that patients with low SES (high ADI) present to the orthopedic clinic with more advanced curve pathology. METHODS: We retrospectively reviewed patients diagnosed with AIS. Subjects were assigned ADI scores based on Zip codes. Matched cohorts of high and low ADI were generated using propensity scores. Bivariate and multivariate analyses were performed to identify factors impacting the magnitude of the curve at presentation. RESULTS: A total of 425 patients with appropriate imaging were included. After matching, the study population was 69.2% female and 92.3% Black. The mean BMI percentile was 61.9. Medicaid covered 57.3% of subjects, and 42.7% had commercial insurance. The mean ADI was 55.5. The mean Cobb angle at presentation was 33.6 degrees. Cobb angle was significantly greater among female patients (36.0 degrees vs 28.0) and among patients with greater BMI percentile (ß = 0.127), but was not significantly associated with ADI, race, or insurance type. ADI was not associated with the rate of surgery. CONCLUSION: ADI is not predictive of curve severity in pediatric patients presenting to the clinic for AIS. Female sex and BMI are independently associated with advanced curvature. Public health workers, primary care providers, and surgeons should remain aware of the complex interactions of socioeconomic factors, BMI and sex when addressing barriers to timely care. LEVEL OF EVIDENCE: Prognostic Level III.

Comparison of Outcomes in Percutaneous Fixation of Traumatic Fractures between Ankylosing Spondylitis and Diffuse Idiopathic Skeletal Hyperostosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study aims to analyze outcomes and complications of patients with thoracic and lumbar fractures in the setting of ankylosing spinal disorders (ASD) treated with minimally invasive surgery (MIS). METHODS: The operative logs from 2012 to 2019 from one academic, Level I trauma center were reviewed for cases of thoracic and lumbar spinal fractures in patients with ASD treated with a MIS approach. Variables were compared between patients with ankylosing spondylitis (AS), diffuse idiopathic skeletal hyperostosis (DISH), and advanced spondylosis. RESULTS: A total of 48 patients with ASD and concomitant thoracic or lumbar spinal fracture managed with an MIS approach were identified. A total of 11 patients were identified with AS, 21 with DISH, and 16 with advanced spondylosis. A total of 27 (56.3%) patients experienced complications. Complications differed between groups; DISH patients experienced a greater number of post-operative complications compared to AS and advanced spondylosis patients (P = .009). There was no significant difference in length of surgery, estimated blood loss, length of stay, readmission, and reoperation rates between AS and DISH patients. There were 3 mortalities unrelated to the surgery. CONCLUSION: Percutaneous stabilization of patients with ankylosing spinal disorder fractures remains a viable management method. Operative characteristics were similar between AS, DISH, and advanced spondylosis patients; however, DISH patients experienced a greater number of post-operative complications.

Retrospective Analysis of Causes and Risk Factors of 30-Day Readmission After Spine Surgery for Thoracolumbar Trauma.

STUDY DESIGN: Retrospective Case Series. OBJECTIVE: This study aims to evaluate readmission rates, risk factors, and reason for unplanned 30-day readmissions after thoracolumbar spine trauma surgery. METHODS: A retrospective chart review was conducted for patients undergoing operative treatment for thoracic or lumbar trauma with open or minimally invasive surgical approach at a Level 1 urban trauma center. Patients were divided into two groups based on 30-day readmission status. Reason for readmission, reoperation rates, injury type, trauma severity, and incidence of polytrauma were compared between the two groups. RESULTS: A total of 312 patients, 69.9% male with an average age of 47 ± 19 years were included. The readmitted group included 16 patients (5.1%) of which 9 (56%) were readmitted for medical complications and 7 for surgical complications. Wound complications (31.3% of readmissions) were the most common cause of readmission, followed by non-wound related sepsis (18.9% of readmissions). A total of 6 patients (37.5%) required reoperation; 2 instrumentation failures underwent revision surgery, and 4 wound complications underwent irrigation and debridement. Patients with higher Injury Severity Scale (ISS) were more likely to be readmitted (27.8% vs 22.1%, P = .045). Concomitant lower limb surgery increased odds of readmission (OR, 4.40; 95% CI, 1.10-17.83; P = .037). CONCLUSION: Spine trauma 30-day readmission rate was 5.1%, comparable to those reported in the elective spine surgery literature. Readmitted patients were more likely to sustain concomitant operative lower limb trauma. Wound complications were the most common cause of readmission, and almost half of the patients were readmitted due to surgery-related complications.

Intraoperative Sensory Signals Predict Prognosis for Patients with Traumatic Cervical Spinal Cord Injury.

OBJECTIVE: In patients with traumatic cervical spinal cord injury (tCSCI), the potential role of intraoperative neuromonitoring as a prognostic tool has been insufficiently studied. This study aimed to determine if detectable signals during intraoperative neuromonitoring portend a greater likelihood of recovery for patients with tCSCI. METHODS: Patients who underwent decompression and surgical fixation following tCSCI were retrospectively reviewed through previously prospectively collected data from the Surgical Timing in Acute Spinal Cord Injury Study. Improvement in American Spinal Injury Association (ASIA) motor score and ASIA Impairment Scale grade conversion rates at final follow-up were compared between patients with detectable intraoperative neuromonitoring somatosensory evoked potential (SSEP) signals and those without detectable signals. RESULTS: Forty-nine patients had intraoperative neuromonitoring. Patients with incomplete tCSCI had detectable lower extremity SSEPs more often than patients with complete tCSCI (56.3% vs. 23.5%, P = 0.028). There was no difference in detectable upper extremity SSEPs between complete and incomplete tCSCI (65.6% vs. 58.8%, P = 0.638). Of the 17 patients with complete tCSCI, patients with detectable lower extremity SSEPs had ASIA motor scores similar to the nondetectable cohort on admission (21.5 vs. 16.2, P = 0.609) but higher ASIA motor scores at final follow-up (57.5 vs. 27.1, P = 0.041). Of the 32 patients with incomplete spinal cord injury, there was no difference in grade conversion or motor scores between detectable and nondetectable SSEP cohorts. CONCLUSIONS: The presence of upper extremity SSEP signals in patients who present with complete tCSCI portends greater improvement in ASIA motor scores and likelihood of American Spinal Injury Association Impairment Scale grade conversion at final follow-up.

Open vs Percutaneous Pedicle Instrumentation for Kyphosis Correction in Traumatic Thoracic and Thoracolumbar Spine Injuries.

OBJECTIVES: Percutaneous pedicle instrumentation (PPI) has been used for the treatment of thoracic and thoracolumbar (TL) trauma. However, the ability of PPI to correct significant post-traumatic kyphosis requires further investigation. The objective of this study is to compare the amount of kyphosis correction achieved by PPI vs the traditional open posterior approach in patients presenting with significant kyphotic deformity following traumatic thoracic and TL spine injuries. METHODS: Following Institutional Review Board approval, patients who underwent surgery for thoracic (T1-T9) or TL (T10-L2) fractures with at least 15° of focal kyphosis in a 5-year period were included in this study. Patients were separated into 2 cohorts based on surgical technique: traditional open posterior approach and minimally invasive PPI. Kyphosis correction was measured using Cobb angle 1 vertebrae above and 1 below the level of injury on sagittal preoperative computed tomography image, immediate and follow-up postoperative upright lateral radiographs. Initial degree of correction and loss of correction at the final follow-up were compared. RESULTS: Of 91 patients included, 65 (71%) underwent open surgery and 26 (29%) underwent PPI. Open patients had 11° (95% CI, 9°-13°) of immediate correction compared with 11° (95% CI, 6°-15°) for PPI (P = 0.81). Follow-up data were available for 70 patients with a median of 105.5 days. Both groups had 1° (95% CI, 0°-2°) of loss of correction at follow-up (P = 0.82). Regardless of surgical technique, obesity (>30 kg/m2) and AO type-A compression fractures had significantly less correction. For each unit of body mass index, there was a 0.75° decrease in correction achieved (P < 0.0001). Other factors did not influence the degree of correction. CONCLUSIONS: PPI techniques provide equivalent postoperative angular correction and maintenance of correction compared with open surgery in thoracic and TL trauma patients. CLINICAL RELEVANCE: This study provides evidence for spine surgeons to utilize either technique for treating significant traumatic kyphotic deformity. LEVEL OF EVIDENCE: Therapeutic 3.

Predicting Length of Stay After Thoracolumbar Trauma: A Single-Center, Retrospective Analysis.

BACKGROUND: Length of stay (LOS) is a meaningful outcome measure for more efficient and effective quality of care. However, algorithms to predict LOS have yet to be created for patients who undergo surgical management for traumatic spinal fractures. OBJECTIVES: The objectives of this study were to (1) identify preoperative, perioperative, and postoperative factors associated with increased LOS and (2) create predictive formulas to estimate LOS in thoracolumbar trauma patients who undergo surgical correction. METHODS: This is a retrospective case series of 196 patients operated for thoracolumbar spine trauma from January 2012 to December 2017 at a level 1 trauma and academic institution. Bivariate analysis between LOS and various preoperative, perioperative, and postoperative factors was conducted to identify significant associations. Multivariate analysis was conducted to create models capable of predicting LOS. RESULTS: LOS was significantly associated with various preoperative (eg, Charlson Comorbidity Index, Glasgow Coma Scale [GCS], injury severity score), operative (eg, length of surgery, number of instrumented segments, surgical technique), and postoperative variables (eg, complications, discharge location). Multivariate analysis of preoperative variables identified 5 significant independent predictors that could predict LOS with strong correlation with observed LOS (ρ = 0.63). With all variables considered, multivariate analysis identified 8 variables (GCS, American Society of Anesthesiologists score, neurological status, polytrauma, packed red blood cell transfusion, number of unique postoperative complications, skin complications, and discharge facility) that could predict LOS with strong correlation (ρ = 0.80). CONCLUSIONS: Various preoperative, perioperative, and postoperative factors are significantly associated with LOS in traumatic thoracolumbar spine patients. We developed models with good predictive capacity for LOS. If validated, these models should help in risk stratifying patients for increased LOS and consequently improve perioperative patient counseling. CLINICAL RELEVANCE: This article contributes to identifying and predicting patients who are high risk for extended LOS after traumatic thoracolumbar injuries.

Similar Accuracy of Surgical Plans After Initial In-Person and Telemedicine Evaluation of Spine Patients.

OBJECTIVE: The aim of this study was to compare accuracy of surgical plans generated from in-person and telemedicine evaluations and assess the reasons for surgical plan changes between initial evaluation and surgery. The secondary objective was to assess the effect of changes in surgical planning on postoperative outcomes. METHODS: In this retrospective cohort study, consecutive patients who were evaluated as new patients by orthopaedic spine faculty between 2019 and 2021 were divided by appointment type: telemedicine (n = 39) and in-person (n = 92). Patients were included if the surgeon documented a definitive surgical plan at the initial visit. The primary outcome was change in surgical plan from initial assessment to actual procedure performed. RESULTS: There was no significant difference in the accuracy of initial surgical plans between the telemedicine and in-person cohorts (79.5% vs. 82.6%, P = 0.673). The most common modification in the surgical plan (79%) was change in the number of operated levels, of which 18 of 19 patients had 1 added operated level. Less common reasons were change in approach (13%) and change in procedure (8%). Patients with changes to their surgical plan experienced longer length of stay (3.1 vs. 2.0 days, P = 0.027) than patients with consistent surgical plans. CONCLUSIONS: Telemedicine and in-person evaluations generated similarly accurate surgical plans. Changes to the initial surgical plans most often involved adding operative levels. Our findings show that telemedicine visits are an acceptable option for preoperative assessment to generate surgical plans; however, further research is needed.

Postoperative outcomes of minimally invasive pedicle screw fixation for treatment of unstable pathologic neoplastic fractures.

STUDY DESIGN: Retrospective Case Series. OBJECTIVES: Minimally invasive techniques have emerged as a useful tool in the treatment of neoplastic spine pathology due to decrease in surgical morbidity and earlier adjuvant treatment. The objective of this study was to analyze outcomes and complications in a cohort of unstable, symptomatic pathologic fractures treated with percutaneous pedicle screw fixation (PPSF). METHODS: A retrospective review was performed on consecutive patients with spinal stabilization for unstable pathologic neoplastic fractures between 2007 and 2017. Patients who underwent PPSF through a minimally invasive approach were included. Surgical indications included intractable pain, mechanical instability, and neurologic compromise with radiologic visualization of the lesion. RESULTS: 20 patients with mean Tomita Score of 6.3 ± 2.1 points [95% CI, 5.3-7.2] were treated with constructs that spanned a mean of 4.7 ± 1.4 [95% CI, 4.0-5.3] instrumented levels. 10 (50%) patients were augmented with vertebroplasty. Majority of patients (65%) had no complications during their hospital stay and were discharged home (60%). Four patients received reoperation: two extracavitary corpectomies, one pathologic fracture at a different level, and one adjacent segment disease. CONCLUSION: Minimally invasive PPSF is a safe and effective option when treating unstable neoplastic fractures and may be a viable alternative to the traditional open approach in select cases. LEVEL OF EVIDENCE: 4.

Appropriate Telemedicine Utilization in Spine Surgery: Results From a Delphi Study.

STUDY DESIGN: Delphi expert panel consensus. OBJECTIVE: To obtain expert consensus on best practices for appropriate telemedicine utilization in spine surgery. SUMMARY OF BACKGROUND DATA: Several studies have shown high patient satisfaction associated with telemedicine during the COVID-19 peak pandemic period as well as after easing of restrictions. As this technology will most likely continue to be employed, there is a need to define appropriate utilization. METHODS: An expert panel consisting of 27 spine surgeons from various countries was assembled in February 2021. A two-round consensus-based Delphi method was used to generate consensus statements on various aspects of telemedicine (separated as video visits or audio visits) including themes, such as patient location and impact of patient diagnosis, on assessment of new patients. Topics with ≥75% agreement were categorized as having achieved a consensus. RESULTS: The expert panel reviewed a total of 59 statements. Of these, 32 achieved consensus. The panel had consensus that video visits could be utilized regardless of patient location and that video visits are appropriate for evaluating as well as indicating for surgery multiple common spine pathologies, such as lumbar stenosis, lumbar radiculopathy, and cervical radiculopathy. Finally, the panel had consensus that video visits could be appropriate for a variety of visit types including early, midterm, longer term postoperative follow-up, follow-up for imaging review, and follow-up after an intervention (i.e., physical therapy, injection). CONCLUSION: Although telemedicine was initially introduced out of necessity, this technology most likely will remain due to evidence of high patient satisfaction and significant cost savings. This study was able to provide a framework for appropriate telemedicine utilization in spine surgery from a panel of experts. However, several questions remain for future research, such as whether or not an in-person consultation is necessary prior to surgery and which physical exam maneuvers are appropriate for telemedicine.Level of Evidence: 4.

Surgical fixation of pathologic and traumatic spinal fractures using single position surgery technique in lateral decubitus position.

STUDY DESIGN: Retrospective Case Series. OBJECTIVES: This study aims to determine complications, readmission, and revision surgery rates in patients undergoing single position surgery (SPS) for surgical treatment of traumatic and pathologic thoracolumbar fractures. METHODS: A multi-center review of patients who underwent SPS in the lateral decubitus position (LSPS) for surgical management of traumatic or pathologic thoracolumbar fractures between January 2016 and May 2020 was conducted. Operative time, estimated blood loss (EBL), intraoperative complications, postoperative complications, readmissions, and revision surgeries were collected. RESULTS: A total of 12 patients with a mean age of 45 years (66.67% male) were included. The majority of patients underwent operative treatment for acute thoracolumbar trauma (66.67%) with a mean injury severity score (ISS) of 16.71. Mean operative time was 175.5 min, mean EBL of 816.67 cc. Five patients experienced a complication, two of which required revision surgery for additional decompression during the initial admission. All ambulatory patients were mobilized on postoperative day 1. The mean hospital length of stay (LOS) was 9.67 days. CONCLUSION: The results of this case series supports LSPS as a feasible alternative to the traditional combined anterior-posterior approach for surgical treatment of pathologic and thoracolumbar fractures. These results are similar to reductions in operative time, EBL, and LOS seen in the elective spine literature with LSPS. LEVEL OF EVIDENCE: IV.

Anterior longitudinal ligament release from a posterior approach: an alternative to three-column osteotomy.

PURPOSE: Expansion of the anterior column and compression of the posterior column restores lordosis and sagittal imbalance. Anterior longitudinal ligament (ALL) release has been described from lateral and anterior approaches as a technique to improve lumbar lordosis; however, posterior approach to release the ALL has not been adequately assessed. METHODS: We demonstrate a case series of ALL release using a posterior approach performed in conjunction with posterior column osteotomy (PCO), with or without transforaminal lumbar interbody fusion (TLIF) for spinal deformity. Eleven cases were identified from billing records between 2010 and 2019. Retrospective review was conducted for perioperative complications and revision surgery. Overall and segmental lumbar lordosis (LL) correction was measured from pre- and postoperative imaging. RESULTS: Eleven patients underwent ALL release with a PCO. Kyphosis, scoliosis, and flat back syndrome were the most common spinal deformities. On average, patients had 9 ± 3 levels fused and a single level ALL release. ALL release was most commonly performed at L1-L2 and L2-L3 levels. An overall LL correction of 28.6° ± 19.8o was achieved; ALL release introduced 16.7° ± 11.9° of lordotic correction and accounted for 49.2 ± 30.4% of the overall lordotic correction. Average blood loss was 1030 ± 573 mL. CONCLUSIONS: ALL release as an adjunct to PCO and TLIF is a viable technique for providing increased deformity correction without subjecting the patient to a more invasive three-column osteotomy. While this approach may not be appropriate for all patients, it represents a useful option in spinal deformity correction while limiting blood loss and additional anterior surgery. LEVEL OF EVIDENCE: IV.

The Orthopaedic Match: Defining the Academic Profile of Successful Candidates.

BACKGROUND: Research productivity forms a vital part of the resident selection process and can markedly affect the chance of a successful match. Current reports regarding the publication record among prospective orthopaedic surgery residents are likely inaccurate. Potential applicants have a poor understanding of the strength of their research credentials in comparison to other candidates. METHODS: We identified matched applicants from the 2013 to 2017 orthopaedic surgery residency application cycles. We performed a bibliometric analysis of these residents using Scopus, PubMed, and Google Scholar to identify published articles and calculate the h-index of each applicant at the time of application. Details were collected on medical school, advanced degrees, publication type, first authorship, and article relatedness to orthopaedic surgery. RESULTS: We included 3,199 matched orthopaedic surgery applicants. At the time of application, the median h-index was 0, the median number of publications was 1, and 40% of successful candidates did not hold any publications. The h-index (R 0.08, P < 0.0001) and median number of publications of matched orthopaedic surgery residency candidates significantly increased (R 0.09, P < 0.0001) across application cycles. Furthermore, the proportion of matched applicants without publications at the time of application significantly decreased (R -0.90, P = 0.0350). Conversely, the percentage of articles first-authored by applicants decreased (R -0.96, P = 0.0093), but article relatedness to orthopaedic surgery remained constant (R 0.82, P = 0.0905). Strikingly, notable changes were observed in the type of articles published by successful applicants: the proportion of preclinical studies decreased (R -0.07, P = 0.0041), whereas clinical research articles increased (R 0.07, P = 0.0024). CONCLUSION: The publication count held by successful orthopaedic surgery applicants is substantially lower than the nationally reported average. Matched orthopaedic surgery candidates demonstrate increasingly impressive research achievements each application cycle. However, increased academic productivity comes at the cost of reduced project responsibility and a shift toward faster-to-publish articles.