Feasibility of C2 Lamina Screw Placement in a New Zealand Cohort: Computed Tomography Analysis According to Ethnicity and Gender.

BACKGROUND: Previous analyses have suggested variations in cervical spine canal morphology according to ethnicity, possibly in part due to variations in the posterior elements. The potential for these variations to affect the placement of instrumentation is uncertain. The aim of this study was to report on the feasibility of C2 lamina screw insertion in a New Zealand cohort including analysis of Maori, the indigenous people of New Zealand. METHODS: A trauma computed tomography database was accessed to identify suitable images. On axial images, where the isthmus was at its widest, the outer diameter (OD) and inner diameter (ID) of the lamina were measured. Screw length was measured from a proposed entry point to the contralateral junction of the lamina and lateral mass. The spinolaminar angle was measured as the angle subtended by the screw trajectory and midsagittal plane. A 5.5-mm OD was accepted as a threshold for the feasibility of lamina screw placement. RESULTS: One hundred eighty-seven images were assessed: 115 New Zealand European and 72 Maori. The mean age of the cohort was 41.9 years (SD 19.6), and most patients (64%) were men. For the entire cohort, mean OD was 6.6 and 6.8 mm on the right and left, respectively; the mean inner diameter was 3.5 and 3.8 mm; mean screw length was 31.5 and 31.5 mm; and mean spinolaminar angle was 46.0° and 46.1°. C2 lamina screw placement was feasible in a majority of patients. Considering only Maori patients, placement was feasible in 96% of right and 94% of left laminae in men but 72% of right and 72% of left laminae in women. CONCLUSIONS: In a majority of patients, C2 lamina screw placement is feasible. However, advanced imaging must be carefully assessed preoperatively because data suggest that Maori women may not necessarily have optimal anatomy.Clinical RelevanceCare needs to be taken when assessing and planning surgery inpatients of different ethnicities because variations may exist in the morphology of the posterior elements of C2, leading to variation in optimal fixation strategy.Level of Evidence3.

External Validation of the Spinal Orthopedic Research Group Index for Spinal Epidural Abscess 90-day Mortality in a Geographically Remote Population.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To externally validate the Spinal Orthopaedic Research Group (SORG) index for predicting 90-day mortality from Spinal Epidural Abscess (SEA) and compare its utility to the 11-item modified frailty index (mFI-11) and Charlson Comorbidity Index (CCI). SUMMARY OF BACKGROUND DATA: Providing a mortality estimate may guide informed patient and clinician decision-making. A number of prognostic tools and calculators are available to help predict the risk of mortality from SEA, including the SORG index, which estimates ninety-day post discharge mortality. External validation is essential before wider use of any clinical prediction tool. METHODS: Patients were identified using hospital coding. Medical and radiological records were used to confirm the diagnosis. Mortality data, and data to calculate the SORG index, mFI-11 and CCI was collected. Area under the curve (AUC) and calibration plots were used to analyse. RESULTS: 150 patients were included: 58 female (39%), with median age 63 years. Fifteen deaths (10%) at 90-days post discharge and 20 (13%) at one-year. The mean SORG index was 13.6%, mean CCI 2.75, and mean mFI-11 was 1.34. The SORG index (P=0.0006) and mFI-11 (P<0.0001) were associated with 90-day mortality. AUC for SORG, mFI-11, and CCI were 0.81, 0.84, and 0.49, respectively. The calibration slope for the SORG index showed slight overestimation in the middle ranges of the predicted probability, more so than mFI-11, and was not well-calibrated over the higher ranges of predicted probability. CONCLUSIONS: This study externally validated the SORG index, demonstrating its utility in our population at predicting 90-day mortality, however, it was less well calibrated than the mFI-11. Variations in algorithm performance may be a result of difference in socioethnic composition and health resource between development and validation centres. Continued multicentre data input may help improve such algorithms and improve their generalisability.

An exploratory study of acute analgesia in tibial shaft fractures: a comparison between Maori and Non-Maori.

BACKGROUND: Published research suggests Indigenous peoples are less likely to receive analgesia in acute pain settings however there is limited data on the indigenous New Zealand Maori population. The aim of this exploratory pilot study was to compare management between Maori and non-Maori for acute fracture pain in a regional trauma centre. METHODS: A retrospective review was undertaken for 120 patients with isolated tibial shaft fractures presenting at a tertiary level trauma center between 2015 and 2020. Outcome measures reflected the patient journey including type of analgesia charted pre-hospital, in the ED and on the ward. RESULTS: Out of 104 matched patients, 48 (46%) were Maori and 65% were male. Fewer Maori received pre-hospital analgesia compared with non-Maori (odds ratio 0.29, p = 0.006). Pain scores were similar on arrival to ED (6.1 ± 3.5 versus 5.4 ± 2.7, p = 0.2). Once at hospital, there were similar rates of prescribed analgesia (paracetamol, NSAIDs, synthetics, or opioids) both in ED and the ward. Time to analgesia were also similar for both groups (72 ± 71 min versus 65 ± 63 min, P > 0.9). DISCUSSION: We found differences in pre-hospital administration of analgesia between Maori and non-Maori patients with tibial shaft fractures. However once in hospital although there was a trend towards lower prescribing for Maori, there were no significant differences. Exploring the reasons underpinning this difference and the development of robust analgesic guidelines for tibial shaft fractures may help in reducing this inequity in care, particularly in the pre-hospital setting.

Keeping It Simple: Developing a Prognostic Tool for Spinal Epidural Abscess.

STUDY DESIGN: A retrospective study. OBJECTIVE: To develop a prognostic score for mortality and treatment failure in Spinal epidural abscess (SEA), based on simplicity and multidimensional assessment principles. METHODS: One-hundred-fifty patients were reviewed. Variables assessed included comorbidities, functional status, clinical presentation, Frankel classification, and biochemical and radiological parameters. The main outcomes were the 90-day mortality and treatment failure, corresponding to any intensification of the initial treatment plan. Variables were sorted out with a factorial analysis. Logistic regressions were performed, and the new score was derived from the coefficients. ROC curves with Area Under Curve, calibration plots, and cross-validation were performed. RESULTS: Forty-three patients (29%) had treatment failure, and 15 died (10%) by 90 days. Factorization created 3 groups: Comorbidities (C), Severity (S), and Function (F). For 90-day mortality, Odds ratios were 1.20 (P = .0002), 1.15, (P = .03), 1.36, (P < 10-4) for C, S, F, respectively. The new score 'CSF' had 1 point per item, ranging from zero to 3. OR increased by 1.2/point for 90-day mortality (P < 10-4), AUC was .86. For failures OR increased by 1.15/point (P = .014), AUC was .58, and increased to .64 for patients who survived after 90 days, probably due to competing risks. CONCLUSIONS: Comorbidities, Severity, and Function is a new simplistic tool, easy to use in daily practice; its performances were excellent for 90-day mortality, and acceptable for failures. Simple tools are more likely to be adopted into practice. External validation of this technique is desirable.

Plasma concentration of prophylactic cefazolin best correlates with lean body mass measured by bioimpedance analysis in lumbar spine surgery: Results of a pilot study.

The aim of this study was to determine the association between measures of body composition and the concentration of plasma and paraspinal muscle cefazolin. Secondly, we aimed to confirm the efficacy of our hospital dosing regimen in achieving the minimum inhibitory concentration (MIC) at the surgical site. Patients undergoing posterior-based lumbar spine surgery had body composition analysed using bioimpedance analysis. All received 2 g of cefazolin at anaesthetic induction in line with hospital guidelines. Cefazolin concentration was measured in plasma (30-minites) and muscle (30- and 60-minuites) using high-performance liquid chromatography. 20 patients were recruited (mean age 61.5 years; 12 female). Mean plasma cefazolin concentrations were 34.1 +/- 10.2 mg/L; mean muscle concentrations 44.4 +/- 18.6 mg/kg and 43.8 +/- 20.4 mg/kg at 30- and 60-minutes respectively. Univariate analysis showed significant correlation between plasma cefazolin concentration and lean mass weight, absolute body weight, height, dry lean mass, total water, total body water, extracellular and intracellular water volume. Linear regression analysis showed lean mass weight the best predictor of plasma cefazolin concentration. Muscle cefazolin concentration was dependent on the plasma concentration. Using a MIC of 2 mg/L and 2 mg/kg for Staphylococcus aureus, MIC was achieved in all samples. In summary, plasma cefazolin concentration was best predicted by lean body mass. Further work should consider the influence of body composition on antibiotic delivery in extremes of body mass index. Local hospital guidelines are effective at achieving MIC against S. aureus.

Hindfoot nailing for displaced ankle fractures in the elderly: A case-control analysis.

INTRODUCTION: Management of fragility ankle fractures in the elderly poses a surgical dilemma. An alternative to open reduction and internal fixation (ORIF) with screw and plate construct in selected elderly patients who may be significantly frail and comorbid is a tibio-talo-calcaneal (TTC) or hindfoot nail. Hindfoot nailing potentially reduces the risk of wound infection and increases likelihood of earlier return to function by allowing earlier weightbearing. The aim of this study was to examine the outcomes and complications of patients who received a hindfoot nail compared to patients who underwent an ORIF. METHODS: A retrospective review identified patients who underwent hindfoot nailing from Jan 2010 to Dec 2021. Patients aged >65-years who underwent ORIF in the same time period were concurrently identified. The patients in the ORIF group were matched with patients in the hindfoot nail group by age, gender, comorbidity according to their Charlson Comorbidity Index (CCI) and their pre-injury function by Karnofsky Performance Scale (KPS). Clinical Frailty Scale (CFS) was also collected as part of patient demographics. Outcomes examined include mortality, length of stay, operation time, return to previous mobility, wound complications, metalware failure and infections. RESULTS: Twenty-six patients were identified in the hindfoot nail group and matched to 26 patients who underwent ORIF. Mean age was 84 and 83 years in the nail and ORIF group respectively. Overall, there were 12 and 11 complications from the hindfoot nail and ORIF group respectively with seven and two requiring return to theatre in the nail group and ORIF group (P = 0.07). The hindfoot nail group waited an average of 22 days after the operation for weightbearing compared to 59 days in the ORIF group (P < 0.001). There were no significant differences in length of stay (P = 0.58) and operation time (P = 0.19). CONCLUSION: Hindfoot nailing was associated with an increased risk of complications and higher risk of return to the operating theatre. Despite the potential attraction of earlier weightbearing, surgeons and patients need to be aware of these potential pitfalls.

Ten-year Review of Acute Pediatric Hematogenous Osteomyelitis at a New Zealand Tertiary Referral Center.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) remains a cause of severe illness among children with the possibility of long-term consequences for growth and development. Recent research has highlighted an unusually high burden of disease in the New Zealand population compared with other Western regions. We have sought to identify trends in presentation, diagnosis, and management of AHO, with added focus on ethnicity and access to health care. METHODS: A 10-year retrospective review of all patients <16 years with presumed AHO presenting to a tertiary referral center between 2008 and 2018 was performed. RESULTS: One hundred fifty-one cases met inclusion criteria. The median age was 8 years with a male predominance (69.5%). Staphylococcus aureus was the most common pathogen using traditional laboratory culture method (84%). The number of cases per year decreased from 2008 to 2018. Assessment using New Zealand deprivation scores showed Maori children were most likely to experience socioeconomic hardship ( P ≤0.01). Median distance traveled by families to first hospital consult was 26 km (range 1 to 178 km). Delayed presentation was associated with need for prolonged antibiotic therapy. Incidence of disease varied by ethnicity with 1:9000 cases per year for New Zealand European, 1:6500 for Pacific, and 1:4000 for Maori. Overall recurrence rate was 11%. CONCLUSIONS: The incidence of AHO in New Zealand is concerningly high within Maori and Pacific populations. Future health interventions should consider environmental, socioeconomic, and microbiological trends in the burden of disease. LEVEL OF EVIDENCE: Retrospective study, Level III.

The Associative Pattern Between Segmental Arterial Damage and Complete Neurological Disorder After Spinal Cord Injury: A Case-Control Study.

INTRODUCTION: The prevalence of vascular trauma surrounding the thoracic spine following Spinal Cord Injury (SCI) is unknown. The potential for neurologic recovery is uncertain in many cases; in some cases, neurologic assessment is not possible, for example, in severe head injury or early intubation, and detection of segmental artery injury may help as a predictive factor. OBJECTIVE: To assess the prevalence of segmental vessel disruption in two groups, with and without neurologic deficit. MATERIAL AND METHODS: This is a retrospective cohort study, with a group SCI American Spinal Injury Association (ASIA) E and a group SCI ASIA A. All patients had a high-energy thoracic or thoracolumbar fracture from T1 to L1. Patients were matched 1:1 (one ASIA A matched with one ASIA E) according to the fracture type, age, and level. The primary variable was the assessment of the presence/disruption of the segmental arteries, bilaterally, around the fracture. Analysis was performed twice by two independent surgeons in a blinded fashion. RESULTS: Both groups had 2 type A, 8 type B, and 4 type C fractures. The right segmental artery was detected in 14/14 (100%) of the patients with ASIA E and in 3/14 (21%) or 2/14 (14%) of the patients with ASIA A, according to the observers, p=0.001. The left segmental artery was detectable in 13/14 (93%) or 14/14 (100%) of the patients ASIA E and in 3/14 (21%) of the patients ASIA A for both observers. All in all, 13/14 of the patients with ASIA A had at least one segmental artery undetectable. The sensibility varied between 78%to 92%, and the specificity from 82% to 100%. The Kappa Score varied between 0.55 and 0.78. CONCLUSION: Segmental arteries disruption was common in the group ASIA A. This may help to predict the neurological status of patients with no complete neurological assessment or potential for recovery post-injury.

Early Reduction in C-Reactive Protein Following Treatment for Spinal Epidural Abscess: A Potential Treatment Guide.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: To assess the predictive value of early C-reactive protein (CRP) trends following diagnosis of spinal epidural abscess (SEA). Non-operative management with intravenous antibiotics has not demonstrated equivalent outcomes with regard to mortality and morbidity. Knowledge of specific patient and disease factors associated with worse outcomes may predict treatment failure. METHODS: All patients treated for spontaneous SEA in a tertiary centre in New Zealand over a 10-year period were followed for at least 2 years. CRP at diagnosis and day 4-5 following treatment initiation was analyzed to determine predictors of CRP reduction of at least 50%. Proportional Cox hazards regression investigated mortality over 2 years. RESULTS: 94 patients met inclusion criteria and with CRP values available for analysis. Median age was 62 years (+/- 17.7) and 59 (63%) were treated operatively. Kaplan-Meier analysis estimate of 2-year survival was .81 (95% CI .72-.88). CRP reduction by 50% was seen in 34 patients. Patients who did not experience a 50% reduction were more likely to have thoracic infection (27 vs 8, P = .02) or multifocal sepsis (41 vs 13, P = .002). Failure to achieve a 50% reduction by day 4-5 was associated with worse post-treatment Karnofsky scores (70 vs 90, P = .03) and longer hospital stay (25 days vs 17.5 days, P = .04). Cox regression model showed mortality predicted by Charlson Comorbidity Index, thoracic location of infection, pre-treatment Karnofsky score, and failure to achieve a 50% CRP reduction by day 4-5. CONCLUSIONS: Patients who fail to reduce CRP values by 50% at day 4-5 following treatment initiation are more likely to experience prolonged hospital stay, have poorer functional outcome and have greater mortality risk at 2 years. This group has severe illness regardless of treatment type. Failure to achieve a biochemical response to treatment should prompt reassessment.

Septic arthritis of the native hip joint: a multi-pattern, multi-outcome disease.

PURPOSE: Septic arthritis of the native hip joint (SANH) is an uncommon surgical and medical emergency with few reports. The aim of this study was to determine predictors of return to theatre (RTT), complications and mortality. METHODS: Patients with SANH were identified from January 2009 to June 2022; 50 patients and three subgroups were identified: Pyogenic (surgical washout without systemic inflammatory disease), Systemic (surgical washout with SIDs) and patients managed non-surgically. Patterns of these groups were assessed with a principal component analysis. The cumulative incidences for death, any complication and RTT for repeat washout were calculated. The predictive variables associated with outcomes were selected with univariable models and then incorporated in multivariable CoxPH regressions. RESULTS: The 1-year cumulative incidence was 14% for mortality and 48.5% for any complication. Amongst patients managed surgically, 1-year risk of RTT was 46% in Pyogenic subgroup and 21% in Systemic subgroup. Systemic subgroup had lower complications and RTT and higher rate of sterile aspirate, compared to Pyogenic. Charlson comorbidity index (CCI) (HR = 1.41, P value = 0.03), preoperative albumin (HR = 0.81, P value = 0.009) and preoperative haemoglobin (HR = 0.95, P value = 0.02) were significantly associated with 1-year mortality. Time between symptom onset and admission > 7 days (HR = 3.15, P value = 0.042), preoperative Hb (HR = 1.05, P value = 0.016), socioeconomic deprivation (HR = 1.18, P value = 0.04) and Systemic subgroup (HR = 0.25, P value = 0.04) were significantly associated with RTT. CONCLUSION: Mortality was well predicted by the usual parameters including CCI, albumin, but also low haemoglobin. Patients presenting in a delayed fashion were more likely to have multiple lavages.

Quality of life in children up to 13 years following acute haematogenous osteomyelitis.

Acute haematogenous osteomyelitis (AHO) remains a cause of severe illness among children with the possibility of long-term consequences for growth and development. Previous research on sequelae from AHO rarely considers outcomes more than 2 years following treatment. This study aims to establish the quality of life of patients diagnosed with AHO in childhood up to 13 years after diagnosis, evaluating the impact on social, emotional, physical, and school function. Children treated for AHO between 2008 and 2018 at a tertiary referral centre in New Zealand were identified. Paediatric Quality of Life Inventory (PedsQL) questionnaires were conducted via phone with either the child or primary caregiver and responses analysed. Forty patients met inclusion criteria, were contactable by phone, and consented to participate. The mean age was 7 years (range 0-15) and most were female (60%). Health-related quality of life (HRQOL) was scored as a percentage with most participants scoring >80% ( n = 27). Those who do experience reduced quality of life following treatment for AHO were likely to complain of pain, stiffness, or anxiety. The impact of significant childhood illness on mental health was not adequately captured by the PedsQL but was highlighted in qualitative feedback. The majority of children treated for AHO reported excellent HRQOL up to 13 years following treatment although a negative impact on mental health was reported using qualitative analysis. A refined scoring system is needed to assess the long-term impact of musculoskeletal infection. Patient case series, Level IV.

Early CRP Trends in Childhood Osteomyelitis Predict Complicated Disease.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) remains a cause of severe illness among children. Contemporary research aims to identify predictors of acute and chronic complications. Trends in C-reactive protein (CRP) after treatment initiation may predict disease course. We have sought to identify factors associated with acute and chronic complications in the New Zealand population. METHODS: A retrospective review of all patients younger than16 years with presumed AHO presenting to a tertiary referral centre between 2008 and 2018 was performed. Multivariate was analysis used to identify factors associated with an acute or chronic complication. An "acute" complication was defined as the need for 2 or more surgical procedures, a hospital stays longer than 14 days, or recurrence despite intravenous antibiotics. A "chronic" complication was defined as growth or limb length discrepancy, avascular necrosis, chronic osteomyelitis, pathologic fracture, frozen joint, or dislocation. RESULTS: One hundred fifty-one cases met the inclusion criteria. The median age was 8 years (69.5% male). Within this cohort, 53 (34%) experienced an acute complication and 18 (12%) a chronic complication. Regression analysis showed that contiguous disease, delayed presentation, and failure to reduce CRP by 50% at day 4/5 predicted an acutely complicated disease course. Chronic complication was predicted by the need for surgical management and failed CRP reduction by 50% at day 4/5. CONCLUSIONS: CRP trends over 96 hours after the commencement of treatment differentiate patients with AHO likely to experience severe disease. LEVEL OF EVIDENCE: Level II, retrospective study.

Utility of Surgical Risk Calculators in Spine Surgery in Patients Aged Over 80 Years: Analysis of SpineSage and ACS NSQIP.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To validate the predictive accuracy of both the SpineSage and ACS-NSQIP surgical risk calculators in patients over the age of 80 years, undergoing spine surgery for any reason. METHODS: We included 210 consecutive patients treated with single-stage spine surgery at our institution between 2009 and 2019. The demographic details and preoperative characteristics of each patient were collected and reviewed for entry into both the SpineSage and ACS risk calculators. The estimated risk supplied by these calculators was compared to the observed rate of complications post-surgery. The main method of comparison was using receiver operating characteristic (ROC) curve analysis. RESULTS: Complications were identified in 51 patients (24%). Most patients underwent surgery for a degenerative cause (71%), with the majority of procedures performed on the lumbosacral spine (66%). Receiver operating characteristic (ROC) curves were calculated to compare the outcomes of each tool. Area under the curve (AUC) analysis showed similar predictive accuracy between SpineSage and ACS when predicting overall complications (0.688; P < .001 vs 0.634; P = .021). AUC analysis demonstrated that SpineSage had better predictive accuracy when estimating risk of major complications (0.778; P = .037 vs 0.675; P = .001). CONCLUSION: For the prediction of risks associated with spine surgery in those aged >80 years, SpineSage appears to be preferable to the ACS-NSQIP surgical risk calculator in this single centre cohort, SpineSage was more accurate in predicting the risk of serious medical complications. The accuracy of both of these tools could still be improved upon.

Analysis of Sagittal Thoracic Inlet Measures in Relation to Anterior Access to the Cervicothoracic Junction.

STUDY DESIGN: Retrospective radiographic study. OBJECTIVE: The aim of this study was to define the association between thoracic inlet measures in relation to anterior access to the cervicothoracic junction. METHODS: Trauma CT scans in patients >16 years were analyzed. The projection angle (PA), defined as the angle subtended by a line along the superior endplate of the vertebral body and the line from the anterosuperior corner of the vertebral body to the manubrium, was measured at C7, T1 and T2; angles were positive if the projection was above the manubrium. Thoracic inlet angle (TIA), thoracic inlet distance (TID) and pelvic incidence (PI) were measured. RESULTS: 65 scans were assessed (33 males; mean age 47.7 years (s.d. 8.7)). The mean TIA 79.9° (s.d. 13.4°; range 52.6° - 112.2°), mean TID 66.1 mm (s.d. 6.6 mm) and mean PI was 50.5° (s.d. 10.2°). Mean values for the projection angles at C7, T1 and T2 were 24.2°, 7.6° and -8.3° respectively. PA were positive in 95% at C7, 73% at T1 and 30% at T2. PA at each level correlated significantly with age (mean r=-0.371; P = .015) and TIA (mean r=-0.916; P < .001) but neither TID nor PI. TIA correlated with age (r = 0.328; P = .008). CONCLUSIONS: The projection angles of the CTJ vertebrae are influenced by thoracic inlet angle and a lesser degree age. Understanding sagittal spinal parameters in the CTJ can aid in planning surgical strategy and approach.

Readability of online patient educational materials for common orthopaedic paediatric conditions within Australasia.

BACKGROUND: The role of patient educational materials for paediatric patients is increasing. A reading grade level of eighth-grade (USA) or year nine (Australia and New Zealand) is recommended as acceptable. The aim of this paper was to assess the reading grade levels of paediatric online patient educational materials, within Australasia. METHODS: The online Google® search engine was used with a variety of keyword combinations, filtered to the location of Australia and New Zealand. Suitable websites were explored for webpages related to slipped upper femoral epiphysis, septic arthritis, osteomyelitis, talipes equinovarus and developmental dysplasia of the hip. Readability was assessed using the online readability software WEB FX®. RESULTS: Seventy-six patient educational webpages were analysed: 66 from Australia and 10 from New Zealand. Only eight of the 76 webpages (10.5%) had reading grade levels below the recommended eighth-grade (US)/year nine (AUS/NZ) level. Webpages from private healthcare providers and pages related to septic arthritis had the significantly highest reading grades. CONCLUSIONS: Australasian families have limited online patient educational materials available to them, which are mostly set at reading grade levels above recommended standards. Healthcare providers should be incentivized to improve the readability of their patient educational materials to reduce health disparities and improve health literacy moving forward.

Predicting complications of spine surgery: external validation of three models.

BACKGROUND CONTEXT: Numerous prediction tools are available for estimating postoperative risk following spine surgery. External validation and comparison of these tools is critical prior to clinical use. No model for adverse events after spine surgery has undergone decision curve analysis. PURPOSE: External validation, comparison, and decision curve analysis of 3 previously described models [SpineSage, Risk Assessment Tool (RAT), National Surgical Quality Improvement Program Risk Calculator (NSQIP)] for predicting 30-day postoperative complications after spine surgery STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Three hundred fifteen patients who underwent spine surgery at a tertiary academic surgical center in New Zealand between January 2019 and April 2020. OUTCOME MEASURES: As defined by each risk prediction tool and objectively using the Comprehensive Complication Index. METHODS: We retrospectively reviewed risk of postoperative complication was calculated for each patient according to the 3 models. Overall model fit, calibration, discrimination, and decision curve analysis for each model were assessed in line with the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines. RESULTS: 100 (35%) patients experienced complications. SpineSage and RAT were well calibrated, NSQIP systematically underestimated risk. Area under the curve was greatest for SpineSage (0.75) compared with the NSQIP (0.72) and the RAT (0.69). Decision curve analysis showed SpineSage resulted in greatest net benefit across all risk thresholds. CONCLUSIONS: Of the models studied, SpineSage most accurately predicted risk and can be expected to perform better than a strategy of treating all patients if patient or surgeon deem complication risk >10% significant. NSQIP may not be suitable for the clinical use in our local population.

Development of a Prediction Model for Significant Adverse Outcome After Spine Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Development, validation, and decision curve analysis of a novel tool (NZSpine) for modelling risk of complications within 30 days of spine surgery. METHODS: Data was gathered retrospectively from medical records of patients who underwent spine surgery at a single tertiary centre between January 2019 and December 2020 (n = 488). Postoperative adverse events were classified objectively using the Comprehensive Complication Index (CCI). The model was derived using backward stepwise logistic regression. Validation was undertaken using bootstrap resampling. Discrimination was determined by calculating the area under the receiver operating characteristic (AUC). Calibration was assessed graphically. Clinical utility of the model was assessed using decision curve analysis (DCA). Performance measures were compared to an existing tool, SpineSage. RESULTS: Overall complication rate was 34%. Modelling showed higher age, surgical invasiveness and preoperative anemia were most strongly predictive of any complication (OR = 1.03, 1.09, 2.1 respectively, P < .001), whereas the occurrence of a major complication (CCI >26) was most strongly associated with the presence of respiratory disease (OR = 2.82, P < .001). At validation, the model showed good discrimination with an AUC of .73 (.71 - .75) and excellent calibration. SpineSage had an AUC of .71, while DCA showed the novel model had greater expected benefit at all risk thresholds. CONCLUSION: NZSpine is a novel risk assessment tool for patients undergoing acute and elective spine surgery and may help inform clinicians and patients of their perioperative risk.

Analysis of Upper Cervical Spine Measurements in the Uninjured Pediatric Spine.

BACKGROUND: Only a small number of studies have offered normative data for the upper cervical spine in children and with some variation in findings. OBJECTIVE: The aim of this study was to determine normal values for upper cervical spine measurements used in the assessment of upper cervical spine trauma in the pediatric population. METHODS: One-hundred computed tomographic images of the cervical spine of children aged ≤16 years were included for analysis. All children were cleared of spinal injury. Anterior atlanto-dens interval (ADI), posterior atlanto-dens interval (PADI), basion-dens interval (BDI), Powers ratio, condylar-C1 interval (CCI), and lateral mass interval (LMI) were measured on the relevant sagittal or coronal images. Measurements for CCI and LMI were taken on each side. RESULTS: Mean age was 111 months (range 11-196 months). Sixty-two were male. Mean values (and ranges) of the measurements were as follows: BDI: 7.1 mm (3.6-12.2); ADI 2.8 mm (0.8-4.8); PADI 18.7 mm (14.1-23.2); Powers ratio 0.72 (0.59-1.0); CCI 2.0 and 2.0 (0.5-4.2); and LMI 3.2 and 3.3 mm (1.7-4.8). BDI (r = -0.488), ADI (r = -0.201), PADI (r = 0.264), and CCI (r = -0.468 and -0.454) all showed significant correlation with age. The Powers ratio was the most stable measurement across all age groups. CONCLUSIONS: Normal values were reported from a local pediatric population with a wide age range. Most values correlate with age to a degree, and so normal values may vary throughout childhood. A multicenter study is desirable to advance knowledge in this field. CLINICAL RELEVANCE: Current radiographic measures used to assess for possible ligamentous injury in the pediatric upper cervical spine correlate with age. Caution must be held when analyzing the upper cervical spine across a range of age groups in children.

Analysis of Lumbar Fusion and Lumbar Arthroplasty Videos on YouTube.

BACKGROUND: Patients often use the internet for information on their spinal surgeries. The goal of this study was to assess and compare the quality of lumbar fusion and arthroplasty videos on YouTube and to identify predictors of video quality. STUDY DESIGN: Cross-sectional. METHODS: YouTube was searched utilizing 3 search terms for both lumbar fusion and lumbar arthroplasty. Fifty videos from each search were categorized and analyzed. Videos were analyzed using 3 scoring systems: JAMA, informative, and clinical scores. The JAMA score rates online information based on 4 factors: authorship, attribution, disclosure, and currency. The informative score previously devised by Zhang et al was also applied to each video. Finally, 2 surgery-specific scores were created for lumbar fusion and lumbar arthroplasty based on peer-reviewed information. These were modeled on the informed consent procedure. Data analysis was conducted using the Jamovi 1.1.9.0. RESULTS: Eighty-four unique lumbar fusion videos and 82 lumbar arthroplasty videos were analyzed. Educational videos were the most common in fusion (78%) and arthroplasty (47%) groups; however, arthroplasty videos were more likely to be commercial (17%, P = 0.01). Fusion videos were more viewed (P < 0.001); however, arthroplasty videos had higher positivity ratings (P < 0.01). Overall, quality was poor for videos in both categories. Mean JAMA scores were 1.57 and 1.70 for fusion and arthroplasty, respectively, and did not differ significantly (P = 0.32). Fusion videos had higher informative scores (1.57 vs 1.23, P = 0.02) and higher clinical scores (21.8% vs 15.9%, P = 0.06). CONCLUSION: Information on YouTube for lumbar fusion and arthroplasty is poor. However, information on fusion is better than arthroplasty. Metadata can be used to help patients pick higher quality videos. CLINICAL RELEVANCE: This paper provides clinicians with an oversight of what their patients may accessing on the internet. Patients may have incorrect information regarding the surgical proceedure they are being offered. These misconceptions must be resovled in order to gain true informed consent from the patient and avoid damage to the surgeon-patient relationship.