Single position lumbar fusion: a systematic review and meta-analysis.

BACKGROUND CONTEXT: Recently, a single position lumbar fusion has been described in which both the anterior or lateral interbody fusion as well as posterior percutaneous pedicle screw fixation are performed in a single position. PURPOSE: The purpose of this study was to present and analyze the current evidence for single position lumbar fusion. STUDY DESIGN/SETTING: This is a systematic review and meta-analysis. PATIENT SAMPLE: Prospective or retrospective studies published in English that assessed outcomes of single position lumbar fusion surgery for patients with lumbar degenerative disease, spondylolisthesis, or radiculopathy were included. OUTCOME MEASURES: Outcome measures included operative time, estimated blood loss, hospital length of stay, X-Ray exposure time, and postoperative outcomes including leg numbness or pain, leg weakness, lumbar lordosis, and segmental lordosis. METHODS: This systematic review was performed in accordance with PRISMA guidelines. Two separate meta-analyses were performed. The first compared single position (SP) surgery, both lateral and prone, to dual position or flipped (F) surgery. The second meta-analysis compared lateral single position (LSP) surgery to prone single position (PSP) surgery. Variables were included if (1) they were a mean with a reported standard deviation or (2) if they were a categorical variable. For calculating standard error of the mean, we used sample size, mean, and standard deviation. A random effects model was used. The heterogeneity among studies was assessed with a significance level of <0.05. RESULTS: Twenty-one articles were included for analysis. Three studies were prospective nonrandomized studies, while 18 were retrospective. Seven articles studied lateral single position only, 10 articles compared lateral single position to traditional repositioning surgery, three articles studied prone single position surgery, and one article compared prone single position surgery to traditional repositioning surgery. A detailed review is provided for all 21 articles. Seventeen studies were included for meta-analysis comparing the SP versus F groups, for a total of 942 patients in the SP group and 254 in the F group. Mean operative time was significantly less for the SP group compared with the F group (SP: 127.5±7.9, F: 188.7±15.5, p<.001). Average hospital length of stay was 2.87±0.3 days in the SP group and 6.63±0.6 days in the F group (p<.001). Complication rates did not significantly differ between groups. Pedicle screws placed in the lateral position had a higher rate of complication as compared with those placed in a prone position (L: 10.2±2%, P: 1.6±1%, p=.015). Seventeen studies were included in the LSP versus PSP analysis, including 13 in the LSP group and four in the PSP group, with a total of 785 patients in the LSP group and 85 patients in the PSP group. Operative time and X-Ray exposure was significantly less in the LSP compared with the PSP group (117.1±5.5 minutes vs. 166.9±21.9 minutes, p<.001; 43.7±15.5 minutes vs. 171.0±25.8 minutes, p<.001). Postoperative segmental lordosis was greater in the prone single position group (p<.001). CONCLUSIONS: Single position surgery decreases operative times and hospital length of stay, while maintaining similar complication rates and radiographic outcomes. PSP surgery was found to be longer in duration and have increased radiation exposure time compared with LSP, while increasing postoperative segmental lordosis.

Trends of Ulnar Collateral Ligament Reconstruction in the United States from 2003 to 2014: Analysis of 3,133 Patients.

PURPOSE: The purpose of this study is to investigate the trends concerning ulnar collateral ligament (UCL) reconstruction (UCLR) for athletic injuries within the United States over the years 2003 to 2014. METHODS: A retrospective review of the Truven Health Marketscan® Commercial Database was conducted for patients undergoing UCLR. Data was reviewed for patients treated between 2003 and 2014, and the cohort of patients undergoing UCLR was queried using Common Procedural Terminology code 24346. Patients ages 11 to 40 years were included and divided into 6 different age groups, with the rate of UCLR calculated for each group. RESULTS: The overall rate of UCLR increased from 4.4 per million in 2003 to 11.9 per million in 2014 (p < .01). Throughout the same time period, the rate per million increased from 3.3 to 22.1 in 11- to 15-year-olds (p < .01), from 105.4 to 293.2 in 16- to 20-year-olds (p < .01), from 23.1 to 67.0 in 21- to 25-year-olds (p < .01), and from 2.1 to 5.7 in 31- to 35-year-olds (p < .01). There was no significant increase in the rate of UCLR in the age groups of 26 to 30 and 36 to 40 years. CONCLUSION: UCLR was mostly performed in patients aged 11 to 25 years (96.6%), and specifically most common in those patients aged 16 to 20 years (67.4%). The rate of UCLR procedures increased over time for younger age groups significantly more than for their older counterparts. CLINICAL RELEVANCE: UCLR rates are increasing in young patients despite efforts addressing injury risk reduction strategies and education for coaches, players, and parents regarding risk factors for UCL injury.

Differing perceptions of preoperative communication among surgical team members.

BACKGROUND: Although preoperative communication is an emerging means through which surgical teams prepare for cases, little is known regarding its current state. This study investigated this topic in a survey of surgical team members. METHODS: An 11-question survey regarding the current state of and barriers to preoperative communication among surgical team members (surgeons, anesthesiologists, and surgical nurses and technologists) was distributed at a United States academic medical center utilizing the SurveyMonkey online questionnaire tool. Statistical analyses depended on variable type. RESULTS: The response rate was 49.4% (170 of 344 potential responses). All groups strongly agreed that preoperative communication contributes to health care quality and patient outcomes. Surgeons rated their satisfaction with the current state of preoperative communication more favorably than anesthesiologists (p < 0.05). Satisfaction ratings of the current state were suboptimal across groups. The most common selection for the current timing of preoperative communication across groups was before each case (29.4% of respondents) and for optimal timing, the day before a case (31.2%). The most frequently discussed topic across groups was reported to be operating room and nursing details (72.4% of respondents). The greatest barriers to preoperative communication across groups were thought to be a lack of a standard method of communication (52.4% of respondents), lack of time (51.8%), and difficulty in determining the assigned staff for a given case (50.0%). CONCLUSIONS: There exist differing perceptions of preoperative communication among surgical team members, which conveys an opportunity for improvement across groups. Coordination of the timing of preoperative communication and standardization of the discussed content could help mitigate current barriers.

Thromboprophylaxis in Spinal Surgery.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Determine the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in spinal surgery patients receiving no thromboprophylaxis, mechanoprophylaxis, and chemoprophylaxis. SUMMARY OF BACKGROUND DATA: The incidence of thromboembolic complications after spinal surgery is not well established. Although a variety of effective mechanical and chemical thromboprophylaxis interventions exist, their role in spinal surgery remains unclear. Spine surgeons are faced with the difficult decision of balancing the risk of death from a thromboembolic complication against the risk of permanent neurological damage from an epidural hematoma (EDH). METHODS: The Medline database was queried using combinations of the terms related to the aforementioned subject matter. Articles meeting our predetermined inclusion criteria were reviewed and relevant data extracted. Meta-analyses were created using a random-effects model for incidence of DVT and PE by type of thromboprophylaxis, method of screening, and study type. RESULTS: Twenty-eight articles were included in the final analyses. The higher mean incidence of DVT and PE in the mechanoprophylaxis group (DVT: 1%, PE: 0.81%) compared to the chemoprophylaxis group (DVT: 0.85%, PE: 0.58%) was not observed to be statistically significant. Six percent of PEs was fatal; the rate of EDHs was 0.3%. The incidence of DVT was higher in prospective studies (1.4%) compared to retrospective studies (0.61%); the incidence of DVT was not affected by whether the study screened only symptomatic patients. CONCLUSION: Although the incidence of DVT and PE was relatively low regardless of prophylaxis type, the true incidence is difficult to determine given the heterogeneous nature of the small number of studies available in the literature. Our findings suggest there may be a role for chemoprophylaxis given the relatively high rate of fatal PE. Future studies are needed to determine which patient population would benefit most from chemoprophylaxis. LEVEL OF EVIDENCE: 2.

Preferably Not My Surgery: A Survey of Patient and Family Member Comfort with Concurrent and Overlapping Surgeries.

BACKGROUND: Concurrent and overlapping surgical procedures are a timely topic. The 2 largest publications on the topic were limited to a journalistic overview and a government committee report. Since then, a recent survey of paid individuals found that they disapprove of overlapping surgical procedures in many cases. Still, we are aware of no work that specifically polled patients and their family members about their beliefs on concurrent and overlapping surgical procedures. We hypothesized that patients and family members will be uncomfortable with 1 surgeon performing overlapping or concurrent surgical procedures. METHODS: A survey about concurrent and overlapping surgical procedures was given to 200 patients and their family members at a single, urban academic medical center. Participants were asked to respond to questions about their knowledge of concurrent and overlapping surgical procedures, their comfort with different surgical scenarios, and their beliefs on possible reasons for such surgical scenarios. Individuals were approached about the survey until 200 patients and family members responded. RESULTS: On average, respondents were neutral with surgical procedures involving overlap of 2 noncritical portions and were not comfortable with overlap involving a critical portion of 1 or both surgical procedures. They agreed that hospitals allow overlapping surgical procedures to increase revenue. CONCLUSIONS: Patients undergoing a surgical procedure at an academic medical center and their family members were neutral or uncomfortable with concurrent or overlapping surgical procedures, affirming the hypothesis. Knowing these preferences is relevant to surgeons' practices and to informed consent discussions. It appears beneficial for surgeons to address the advantages and disadvantages of overlapping surgical procedures with their patients if applicable.

It All Depends on Who Does What: A Survey of Patient and Family Member Comfort With Surgical Trainees Operating.

OBJECTIVE: To measure patient and family member comfort with surgical trainees of varying levels performing different portions of surgery. DESIGN, SETTING, AND PARTICIPANTS: An electronic survey dividing surgery into 6 steps (prepping and positioning, initial incision, deep dissection, critical portions, deep suturing, and closing incision), differentiating surgical trainees by 4 levels of experience (medical student, intern, resident, and fellow), and specifying whether or not an attending surgeon is in the operating room (OR) was given to 200 patients and family members in the surgical waiting area of a single academic medical center. Responses were on a 7-point Likert scale from "Not Comfortable at All" to "Completely Comfortable". RESULTS: Patient and family member comfort significantly increased as trainee experience increased. It reached a nadir for all trainees performing "critical portions" of surgery. However, their average response was "Comfortable" for residents and fellows performing any surgical step when the attending surgeon is present in the OR. The percentage of "Comfortable" responses was significantly lower for all trainee levels performing any surgical step when the attending surgeon is absent from the OR. CONCLUSIONS: Patient and family member comfort with surgical trainees operating varies based on the trainee's level of experience, the step the trainee performs, and whether or not the attending surgeon is present in the OR. Patients and family members are on average "Comfortable" with surgical residents and fellows performing any surgical step when the attending surgeon is present.

Trend of Spine Surgeries in the Outpatient Hospital Setting Versus Ambulatory Surgical Center.

STUDY DESIGN: Retrospective database review. OBJECTIVE: The aim of the present study was to examine how often spine surgery is being performed in an outpatient hospital setting versus a more "true" ambulatory setting, specifically ambulatory surgery centers (ASCs) in which admission and discharge are required on the same calendar day. SUMMARY OF BACKGROUND DATA: Recent studies have assessed the safety, satisfactory clinical outcomes, and increasing utilization of both cervical and lumbar spinal surgeries performed in the outpatient setting. No studies have delineated between true ambulatory settings and outpatient hospitals when assessing the rates of these procedures. METHODS: A retrospective review of the Truven Health Marketscan Research Databases was conducted for patients undergoing spine operations between 2003 and 2014. The frequency of each Common Procedural Terminology code was identified per year, and then categorized into each of "inpatient hospital," "outpatient hospital," or "ASC" in states that clearly define ASCs as facilities in which patients are discharged on the same calendar day of the operation, and do not stay overnight. RESULTS: During the period between 2003 and 2014, the procedures that had the most dramatic increase as an outpatient hospital procedure included lumbar decompression laminotomy first level (18.7%-68.5%) and posterior cervical decompression laminectomy without facetectomy discectomy first level (0%-46.7%). ASC procedures had more modest increases during this time period with the most significant increases in lumbar decompression laminotomy first level (0.7%-10.6%) and posterior cervical decompression laminotomy first level (0%-23.4%). CONCLUSION: "True" ambulatory surgeries are not increasing at the same rate as outpatient procedures with 23-hour observation capacity. Although prior studies have demonstrated the safety of outpatient spine surgery, one possible reason for this trend may be that surgeons feel that this safety may not be comparable to that of other outpatient procedures. LEVEL OF EVIDENCE: 3.

Insulin-like growth factor (IGF) signaling in tumorigenesis and the development of cancer drug resistance.

One of the greatest obstacles to current cancer treatment efforts is the development of drug resistance by tumors. Despite recent advances in diagnostic practices and surgical interventions, many neoplasms demonstrate poor response to adjuvant or neoadjuvant radiation and chemotherapy. As a result, the prognosis for many patients afflicted with these aggressive cancers remains bleak. The insulin-like growth factor (IGF) signaling axis has been shown to play critical role in the development and progression of various tumors. Many basic science and translational studies have shown that IGF pathway modulators can have promising effects when used to treat various malignancies. There also exists a substantial body of recent evidence implicating IGF signaling dysregulation in the dwindling response of tumors to current standard-of-care therapy. By better understanding both the IGF-dependent and -independent mechanisms by which pathway members can influence drug sensitivity, we can eventually aim to use modulators of IGF signaling to augment the effects of current therapy. This review summarizes and synthesizes numerous recent investigations looking at the role of the IGF pathway in drug resistance. We offer a brief overview of IGF signaling and its general role in neoplasia, and then delve into detail about the many types of human cancer that have been shown to have IGF pathway involvement in resistance and/or sensitization to therapy. Ultimately, our hope is that such a compilation of evidence will compel investigators to carry out much needed studies looking at combination treatment with IGF signaling modulators to overcome current therapy resistance.

Bone Morphogenetic Protein (BMP) signaling in development and human diseases.

Bone Morphogenetic Proteins (BMPs) are a group of signaling molecules that belongs to the Transforming Growth Factor-ß (TGF-ß) superfamily of proteins. Initially discovered for their ability to induce bone formation, BMPs are now known to play crucial roles in all organ systems. BMPs are important in embryogenesis and development, and also in maintenance of adult tissue homeostasis. Mouse knockout models of various components of the BMP signaling pathway result in embryonic lethality or marked defects, highlighting the essential functions of BMPs. In this review, we first outline the basic aspects of BMP signaling and then focus on genetically manipulated mouse knockout models that have helped elucidate the role of BMPs in development. A significant portion of this review is devoted to the prominent human pathologies associated with dysregulated BMP signaling.