Elevated preoperative blood pressure and its relationship to intraoperative mean arterial pressure and blood loss in posterior spinal fusion for adolescent idiopathic scoliosis.

PURPOSE: The relationship between preoperative blood pressure (BP) and intraoperative mean arterial pressure (MAP) and estimated blood loss (EBL) in pediatric spine surgery is currently unknown. The objectives of this study were to determine if elevated preoperative BP is associated with elevated intraoperative MAP, EBL, and percentage estimated blood volume (EBV) lost, and to determine if intraoperative MAP is associated with percentage of EBV lost during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: This is a retrospective cohort analysis of 209 patients undergoing PSF for AIS between 2016 and 2019 by a single surgeon. Data extracted included demographic characteristics, preoperative systolic and diastolic BP, continuous intraoperative MAP measured by arterial line, EBL, radiographic, and surgical characteristics. Time points of interest for MAP included incision and exposure. Elevated BP was defined as > 1 standard deviation above the mean BP of patients included in the study, and elevated MAP was defined as > 65 mmHg. RESULTS: Elevated preoperative systolic BP was associated with elevated MAP at incision (p = 0.002). Patients with elevated preoperative diastolic BP had significantly higher MAP at exposure and throughout the procedure (p = 0.04). MAP > 65 at incision was associated with a 5% increase in EBV lost (p < 0.001). CONCLUSIONS: Patients with elevated preoperative BP parameters have increased MAPs at incision, exposure, and throughout surgery. Elevated MAP at incision is associated with an increased percentage of EBV lost in a small number of patients undergoing PSF for AIS.

Turf Toe Injuries in the Athlete: an Updated Review of Treatment Options, Rehabilitation Protocols, and Return-to-Play Outcomes.

PURPOSE OF REVIEW: First metatarsophalangeal joint sprains or turf toe (TT) injuries occur secondary to forceful hyperextension of the great toe. TT injuries are common among athletes, especially those participating in football, soccer, basketball, dancing, and wrestling. This review summarizes the current treatment modalities, rehabilitation protocols, and return-to-play criteria, as well as performance outcomes of patients who have sustained TT injuries. RECENT FINDINGS: Less than 2% of TT injuries require surgery, but those that do are typically grade III injuries with damage to the MTP joint, evidence of bony injury, or severe instability. Rehabilitation protocols following non-operative management consist of 3 phases lasting up to 10 weeks, whereas protocols following operative management consist of 4 phases lasting up 20 weeks. Athletes with low-grade injuries typically achieve their prior level of performance. However, among athletes with higher grade injuries, treated both non-operatively and operatively, about 70% are expected to maintain their level of performance. The treatment protocol, return-to-play criteria, and overall performance outcomes for TT injuries depend on the severity and classification of the initial sprain. For grade I injuries, players may return to play once they experience minimal to no pain with normal weightbearing, traditionally after 3-5 days. For grade II injuries, or partial tears, players typically lose 2-4 weeks of play and may need additional support with taping when returning to play. For grade III injuries, or complete disruption of the plantar plate, athletes lose 4-6 weeks or more depending upon treatment strategy.

Review of Enhanced Handheld Surgical Drills.

The handheld drill has been used as a conventional surgical tool for centuries. Alongside the recent successes of surgical robots, the development of new and enhanced medical drills has improved surgeon ability without requiring the high cost and consuming setup times that plague medical robot systems. This work provides an overview of enhanced handheld surgical drill research focusing on systems that include some form of image guidance and do not require additional hardware that physically supports or guides drilling. Drilling is reviewed by main contribution divided into audio-, visual-, or hardware-enhanced drills. A vision for future work to enhance handheld drilling systems is also discussed.

Surgical Setting in Achilles Tendon Repair: How Does It Relate to Costs and Complications?

Background: Primary Achilles tendon repair (ATR) can be performed in ambulatory surgery centers (ASCs) or hospitals. We compared costs and complication rates of ATR performed in these settings. Methods: We retrospectively queried the electronic medical record of our academic health system and identified 97 adults who underwent primary ATR from 2015 to 2021. Variables were compared between patients treated at ASCs vs those treated in hospitals. We compared continuous variables with Wilcoxon rank-sum tests and categorical variables with χ2 tests. We used an α of 0.05. Multivariable logistic regression was performed to determine associations between surgical setting and costs. Linear regression was performed between each charge subtype and total cost to identify which charge subtypes were most associated with total cost. Results: Patients who underwent ATR in hospitals had a higher rate of unanticipated postoperative hospital admission (13%) than those treated in ASCs (0%) (P = .01). We found no differences with regard to postoperative complications, emergency department visits, readmission, rerupture, reoperation/revision, or death. Patients treated in hospitals had a higher mean (±SD) implant cost ($664 ± $810) than those treated in ASCs ($175 ± $585) (P < .01). We found no differences between settings with regard to total cost, supply costs, operating room charges, or anesthesia charges. Higher implant cost was associated with hospital setting (odds ratio = 16 [95% CI: 1.7-157]) and body mass index > 25 (odds ratio = 1.2 [95% CI: 1.0-1.5]). Operating room costs were strongly correlated with total costs (R2 = .94). Conclusion: The overall cost and complication rate of ATRs were not significantly different between ASCs and hospitals. ATRs performed in hospitals had higher implant costs and higher rates of postoperative admission than those performed in ASCs. Level of Evidence: Level III, retrospective comparative study.

Prevention of Proximal Junctional Kyphosis Using Proximal Fixation Techniques.

BACKGROUND: Adult spinal deformity (ASD) is a disorder characterized by abnormal curvature of the spine resulting from progressive degeneration of spinal elements. Although operative intervention for ASD is commonplace, it is associated with several complications, including proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). The objective of this review is to outline the role of proximal fixation in preventing PJK and PJF. METHODS: We conducted a literature search using the Embase, Scopus, Web of Science, CINHAL, Cochrane Library, and PubMed MEDLINE databases. We considered only studies focusing on adult patients and selected clinical studies investigating proximal fixation techniques. RESULTS: There was mixed evidence of the efficacy of hooks and other instrumentation methods in preventing PJK, although most studies supported the use of hooks. Selection of lower thoracic vertebrae was associated with higher rates of PJK and PJF in several studies, although the relationship was inconsistent, and many studies reported no significant difference in rates of PJK or PJF between different upper instrumented vertebra (UIV) levels. Other techniques that are not related to specific instrumentation or vertebral selection, such as adjusting UIV screw trajectory, were also referenced. However, the evidence supporting these techniques was limited. DISCUSSION: Despite the presence of numerous studies in the literature discussing proximal fixation strategies to reduce the incidence of PJK/PJF, the lack of prospective studies and high variability in study methods make direct comparison challenging. We could not draw strong conclusions regarding the superiority of any one technique, despite promising clinical results with a strong biomechanical basis in several studies. CLINICAL RELEVANCE: This systematic literature review showed that a variety of proximal fixation techniques have been used to prevent PJK/PJF without clear evidence in favor of any particular technique.

Association of Neighborhood Socioeconomic Deprivation With Utilization and Costs of Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: A retrospective analysis. OBJECTIVE: The aim of our study was to analyze the association of Area Deprivation Index (ADI) with the utilization and costs of elective anterior cervical discectomy and fusion (ACDF) surgery. SUMMARY OF BACKGROUND DATA: ADI, a comprehensive neighborhood-level measure of socioeconomic disadvantage, has been shown to be associated with worse perioperative outcomes in a variety of surgical settings. MATERIALS AND METHODS: The Maryland Health Services Cost Review Commission Database was queried to identify patients who underwent primary elective ACDF between 2013 and 2020 in the state. Patients were stratified into tertiles by ADI, from least disadvantaged (ADI1) to most disadvantaged (ADI3). The primary endpoints were ACDF utilization rates per 100,000 adults and episode-of-care total costs. Univariable and multivariable regression analyses were performed. RESULTS: A total of 13,362 patients (4984 inpatient and 8378 outpatient) underwent primary ACDF during the study period. In our study, there were 2,401 (17.97%) patients residing in ADI1 neighborhoods (least deprived), 5974 (44.71%) in ADI2, and 4987 (37.32%) in ADI3 (most deprived). Factors associated with increased surgical utilization were increasing ADI, outpatient surgical setting, non-Hispanic ethnicity, current tobacco use, and diagnoses of obesity and gastroesophageal reflux disease. Factors associated with lower surgical utilization were: non-white race, rurality, Medicare/Medicaid insurance status, and diagnoses of cervical disk herniation or myelopathy. Factors associated with higher costs of care were increasing ADI, older age, Black/African American race, Medicare or Medicaid insurance, former tobacco use, and diagnoses of ischemic heart disease and cervical myelopathy. Factors associated with lower costs of care were outpatient surgical setting, female sex, and diagnoses of gastroesophageal reflux disease and cervical disk herniation. CONCLUSIONS: Neighborhood socioeconomic deprivation is associated with increased episode-of-care costs in patients undergoing ACDF surgery. Interestingly, we found greater utilization of ACDF surgery among patients with higher ADI. LEVEL OF EVIDENCE: 3.

Operative vs Nonoperative Management of Achilles Tendon Rupture: A Cost Analysis.

Background: Achilles tendon rupture (ATR) is a common injury with a growing incidence rate. Treatment is either operative or nonoperative. However, evidence is lacking on the cost comparison between these modalities. The objective of this study is to investigate the cost differences between operative and nonoperative treatment of ATR using a large national database. Methods: Patients who received treatment for an ATR were abstracted from the large national commercial insurance claims database, Marketscan Commercial Claims and Encounters Database (n = 100 825) and divided into nonoperative (n = 75 731) and operative (n = 25 094) cohorts. Demographics, location, and health care charges were compared using multivariable regression analysis. Subanalysis of costs for medical services including clinic visits, imaging studies, opioid usage, and physical therapy were conducted. Patients who underwent secondary repair were excluded. Results: Operative treatment was associated with increased net and total payments, coinsurance, copayment, deductible, coordination of benefits (COB) / savings, greater number of clinic visits, radiographs, magnetic resonance imaging (MRI) scans, and physical therapy (PT) sessions, and with higher net costs due to clinic visits, radiographs, MRIs, and PT (P < .001). Operative repair at an ambulatory surgical center was associated with a lower net and total payment, and a significantly higher deductible compared to in-hospital settings (P < .001). Both cohorts received similar numbers of opioid prescriptions during the study period. Yet, operative patients had a significantly shorter duration of opioid use. After controlling for confounders, operative repair was also independently associated with lower net costs due to opioid prescriptions. Conclusion: Compared with nonoperatively managed ATR, surgical repair is associated with greater costs partially because of greater utilization of clinic visits, imaging, and physical therapy sessions. However, surgical costs may be reduced when procedures are performed in ambulatory surgery centers vs hospital facilities. Nonoperative treatment is associated with higher prescription costs secondary to longer duration of opioid use. Level of Evidence: Level III, retrospective cohort study.

Hypoalbuminemia and the Higher Risk of Perioperative Sentinel Adverse Events in Patients Undergoing Total Shoulder Arthroplasty: A Propensity Score Matched Analysis.

Background: The purpose of this study is to examine the effect of hypoalbuminemia (HA) on sentinel adverse events after total shoulder arthroplasty (TSA). Methods: Patients who underwent primary TSA from 2015-2018 were collected from the National Surgical Quality Improvement Program (NSQIP) database. Patients with HA (serum albumin < 3.5 g/dL) were compared to patients with normal serum albumin. A probit regression model was used to estimate a propensity score. Logistic regression was performed to evaluate the effect of HA on sentinel adverse events after surgery. Results: A total of 4,337 patients were included, 8.2% of patients had HA. Patients with HA had higher rates of sentinel adverse events (14.0% vs 5.5%, P<0.01) compared with patients who had normal serum albumin. Reoperation (4.5% vs 1.5%, P<0.01), readmission (11.2% vs 3.9%, P<0.01), urinary tract infection (0.8% vs 0.03%, p <0.01) and pulmonary embolism (1.1% vs 0.2%, P=0.01) were higher in patients with HA. The odds ratio for a sentinel event for patients with HA was 2.6 (95% CI: 1.54, 4.44, P<0.01) when compared to a propensity score-matched control group. Conclusion: Patients with HA are at increased risk of sentinel adverse events following TSA compared to patients with normal serum albumin levels.

Cognitive impairment is associated with greater preoperative symptoms, worse health-related quality of life, and reduced likelihood of recovery after cervical and lumbar spine surgery.

Background: Cognitive impairment (CI) is associated with prolonged hospital stays and increased complications; however, its role in symptom severity and health-related quality of life (HRQoL) among spine patients is unknown. We determined 1) prevalence of preoperative CI; 2) associations between CI and preoperative pain, disability, and HRQoL; and 3) association between CI and postoperative improvements in HRQoL. Methods: This is a prospective cohort study of 453 consecutive adult spine surgery patients between October 2019 and March 2021. We compared pain (Numeric Rating Scale, NRS), pain-related disability (Oswestry/Neck Disability Index, O/NDI), and HRQoL (PROMIS-29 profile, version 2.0) among participants having severe (PROMIS-29 Cognitive Abilities score ≤30), moderate (31-35), or mild CI (36-40) or who were unimpaired (score >40), using analysis of variance. Likelihood of clinical improvement given the presence of any CI was estimated using logistic regression. All comparisons were adjusted for age, gender, comorbidity, and use of opioid medication during the last 30 days. Alpha=.05. Results: Eighty-five respondents endorsed CI (38 mild; 27 moderate; 20 severe). Preoperatively, those with CI had more severe back pain (p=.005) and neck pain (p=.025) but no differences in leg or arm pain. Those with CI had greater disability on ODI (p<.001) and NDI (p<.001) and worse HRQoL in all domains (all, p<.001). At 6 and 12 months postoperatively, those with CI were less likely to experience clinical improvement in disability and HRQoL (anxiety, pain interference, physical function, and satisfaction with ability to participant in social roles) (all, p<.05). Conclusions: CI was present in nearly 20% of spine patients before surgery and was independently associated with worse preoperative back and neck pain, disability, and HRQoL. Those with CI had approximately one-half the likelihood of achieving meaningful clinical improvement postoperatively. These results indicate a need to evaluate spine patients' cognitive impairment prior to surgery. Level of Evidence: III.

Worsening pain and quality of life for spine surgery patients during the COVID-19 pandemic: Roles of psychological distress and patient activation.

BACKGROUND: Public health measures during the COVID-19 pandemic have disrupted access to basic resources (income, food, housing, healthcare). The effects may impact patients differently based on socioeconomic status (SES), pre-existing psychological distress, and patient activation (knowledge, skills, and motivation to manage healthcare). We examined changes in access to basic resources and in pain and health-related quality of life (HRQoL) during the pandemic and determined how pre-existing psychological distress and patient activation are associated with exacerbation or mitigation of effects on pain and HRQoL. METHODS: This cross-sectional study assessed 431 patients in a longitudinal-outcomes registry who underwent or scheduled spine surgery at our institution and were surveyed about COVID-19 effects on accessing basic resources. We assessed pain (numeric rating scale) and HRQoL (PROMIS 29-Item Profile). Information on preoperative SES, psychological distress, patient activation, pain, and HRQoL was collected previously. We compared access to basic resources by SES. We compared changes from pre-COVID-19 to COVID-19 assessments of pain and HRQoL and proportions of patients reporting worsened pain and HRQoL stratified by psychological distress. We analyzed associations between patient activation and negative effects on HRQoL using multivariable linear regression. Alpha=0.05. RESULTS: Respondents reported minor disruptions in accessing basic resources (no difference by SES) but significant worsening of back (p=.027) and leg pain (p=.013) and HRQoL (physical function, fatigue, p<0.001; satisfaction with participation in social roles, p=0.048) during COVID-19. Psychological distress was associated with clinically relevant worsening of back, pain, leg pain, and physical function all, (p<0.05). High patient activation was associated with less impairment of physical function (p=0.03). CONCLUSION: Patients with pre-existing psychological distress experienced greater worsening of pain and HRQoL. High patient activation appeared to mitigate worsening of physical function. Providers should screen for psychological distress and patient activation and enhance supports to manage pain and maintain HRQoL in at-risk patients.Level of Evidence: III.

Synovectomy in juvenile idiopathic arthritis: A systematic review and meta-analysis.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is an inflammatory arthropathy with onset in children younger than 16 years. Treatment is primarily medical; however, surgical interventions, such as arthroscopic or open synovectomy, can be beneficial. Many studies have investigated synovectomy in JIA, but the results of these studies have not been synthesized to our knowledge. Therefore, we performed a systematic review of the literature reporting synovectomy as a treatment for JIA to provide clinical recommendations regarding its risks and benefits. METHODS: On March 8, 2022, we searched the Cochrane Library, Embase, PubMed, Scopus, and Web of Science for studies evaluating clinical outcomes of open or arthroscopic synovectomy to treat JIA in patients younger than 18 years. We included only studies published in English and excluded studies of synovectomy to treat other arthropathies, septic arthritis, hemophilia, or foreign body arthropathy. The level of evidence for included studies was determined by using the Oxford Centre for Evidence-Based Medicine criteria. We qualitatively analyzed clinical outcomes data, including patient-reported pain relief, rates of symptom recurrence, and postoperative complications. RESULTS: Of 428 articles assessed, 14 were included in our analysis. One was a randomized trial, 1 was a case-control study, and all others were case-series. Studies consistently reported that synovectomy was associated with improved function and decreased pain postoperatively. However, comparisons with modern medical therapy were lacking. Rates of arthritis recurrence varied, with increasing symptom recurrence with longer follow-up and re-synovectomy rates up to 15%. Oligoarticular disease and early disease course were associated with better response to synovectomy, whereas systemic and polyarticular disease were associated with poor response. Stiffness requiring manipulation under anesthesia was the most common complication (4% of all included patients). CONCLUSION: Although synovectomy is associated with positive functional outcomes and pain reduction postoperatively, there was inadequate comparison thus inadequate evidence to recommend it over modern medical therapy. The current literature suggests that synovectomy should be offered only to patients for whom medical management has failed, while noting the risks of decreased range of motion and symptom recurrence over time.

COVID-19 and the orthopaedic surgeon: who gets redeployed?

The COVID-19 pandemic has increased demand for physicians, leading to widespread redeployment of specialty physicians to care for patients with COVID-19. These redeployments highlight an important question: How do physicians balance competing obligations to their own health, their own patients, and society during a public health crisis? How can physicians, specifically subspecialists, navigate this tension? In this article, we analyse a clinical scenario in which an orthopaedic sports surgeon is redeployed to care for patients with COVID-19. This case raises questions about physicians' obligations to their own patients compared with society at large, the relative value of specialty physicians during a global pandemic, and the ethical permissibility of compulsory redeployment. Using the orthopaedic surgery specialty as a model, we build a redeployment framework for surgical specialists that is both ethical and equitable. We argue that although orthopaedic surgeons have a moral obligation to participate in physician redeployment schemes, the scope of this obligation is limited and contingent on the following conditions: (1) the number of local COVID-19 cases is high; (2) obligations to their own patients or orthopaedic patients requiring urgent or emergency care have been fulfilled; (3) their value as physicians exceeds their value as specialists because of the pandemic climate; (4) voluntary redeployments are exhausted before compulsory redeployments are implemented; and (5) redeployment would not put the physicians at unreasonable risk of harm.

Outcomes of Revision Surgery for Pseudarthrosis After Anterior Cervical Fusion: Case Series and Systematic Review.

STUDY DESIGN: Case series/systematic review. OBJECTIVES: To report on patients undergoing posterior cervical fusion for symptomatic pseudarthrosis following anterior cervical discectomy and fusion (ACDF), and to assess outcomes reporting in the literature. METHODS: Patients undergoing posterior instrumented fusion for pseudarthrosis after primary ACDF from 2013 to 2018 by a single surgeon were reviewed consecutively. Neck Disability Index (NDI) and visual analogue scale (VAS) arm/neck were recorded at preoperative, 6-month, and 1-year time points. A systematic review of the literature was performed, and outcomes reporting was recorded. RESULTS: NDI scores were 54.4 (SD 19.1), 36.6 (SD 18.1), and 41.2 (SD 19.2) at preoperative, 6-month, and 1-year time points, respectively, with improvement from preoperatively to 6 months (P = .004). VAS neck scores were 8.1 (SD 1.3), 5.0 (SD 2.9), and 5.8 (SD 2.2) at preoperative, 6-month, and 1-year time points, respectively, with improvement from preoperatively to 6 months (P = .038). VAS arm scores were 5.1 (SD 4.1), 3.5 (SD 3.2), and 3.6 (SD 2.7) at preoperative, 6-month, and 1-year time points, respectively, with improvement although these did not reach statistical significance (P = .145). The most common subjective outcomes reported in the literature were general symptoms assessments (43%), ordinal scales (43%), and VAS neck (19%) scales, with the majority of studies (67%) documenting one measure. CONCLUSIONS: Patient-reported outcomes demonstrate clinically meaningful improvement within the first 6 months after posterior fusion for pseudarthrosis. Studies demonstrate substantial variability and no standardization in outcomes reporting, limiting the ability to compare results across interventions and pathologies. Standardized reporting will enable comparisons to inform patients and physicians on the optimal approach to treat this difficult problem.

American Society of Anesthesiologists' Status Association With Cost and Length of Stay in Lumbar Laminectomy and Fusion: Results From an Institutional Database.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study was to characterize the costs associated with American Society of Anesthesiologists (ASA) class, and to determine the extent to which ASA status is a predictor of increased cost and LOS following lumbar laminectomy and fusion (LLF). SUMMARY OF BACKGROUND DATA: Spinal fusion accounts for the highest hospital costs of any surgical procedure performed in the United States, and ASA (American Society of Anesthesiologists) status is a known risk factor for cost and length of stay (LOS) in the orthopedic literature. There is a paucity of literature that directly addresses the influence of ASA status on cost and LOS following LLF. METHODS: This is a retrospective cohort study of an institutional database of patients undergoing single-level LLF at an academic tertiary care facility from 2006 to 2016. Univariate comparisons were made using χ tests for categorical variables and t tests for continuous variables. Multivariate linear regression was utilized to estimate regression coefficients, and to determine whether ASA status is an independent risk factor for cost and LOS. RESULTS: A total of 1849 patients met inclusion criteria. For every one-point increase in ASA score, intensive care unit (ICU) LOS increased by 0.518 days (P < 0.001), and hospital length of stay increased by 1.93 days (P < 0.001). For every one-point increase in ASA score, direct cost increased by $7474.62 (P < 0.001). CONCLUSION: ASA status is a predictor of hospital LOS, ICU LOS, and direct cost. Consideration of the ways in which ASA status contributes to increased cost and prolonged LOS can allow for more accurate reimbursement adjustment and more precise targeting of efficiency and cost effectiveness initiatives. LEVEL OF EVIDENCE: 3.

Synthetic Cages Associated With Increased Rates of Revision Surgery and Higher Costs Compared to Allograft in ACDF in the Nonelderly Patient.

OBJECTIVE: The aim of this study was to compare all-cause reoperation rates and costs in nonelderly patients treated with anterior cervical discectomy and fusion (ACDF) with structural allograft versus synthetic cages for degenerative pathology. METHODS: We queried a private claims database to identify adult patients ( ≤ 65 years) who underwent single-level ACDF in a hospital setting using either structural allograft or a synthetic cage (polyetheretherketone, metal, or hybrid device), from 2010 to 2016. The rate of all-cause reoperations at 2 years were compared between the 2 groups. Index hospitalization costs and 90-day complication rates were also compared. Significance was set at p < 0.05. RESULTS: A total of 26,754 patients were included in the study. 11,514 patients (43%) underwent ACDF with structural allograft and 15,240 (57%) underwent ACDF with a synthetic cage. The patients in the allograft group were younger and more likely to be male. There was no significant difference between the 2 groups with respect to 90-day complications including: wound dehiscence, dysphagia, dysphonia, and hematoma/seroma. In the 2-year postoperative period, the synthetic cage group had a significantly higher rate of allcause reoperation compared to the allograft group (9.1% vs. 8.0%, p = 0.002). Index hospitalization costs were significantly higher in the synthetic cage group compared to those in the allograft group ($23,475 vs. $20,836, p < 0.001). CONCLUSION: Structural allograft is associated with lower all-cause reoperation rates and lower index costs in nonelderly patients undergoing ACDF surgery for degenerative pathology. It is important to understand this data as we transition toward value-based care.

Scoliosis and Cardiopulmonary Outcomes in Osteogenesis Imperfecta Patients.

STUDY DESIGN: Retrospective clinical study of individuals with osteogenesis imperfecta (OI). OBJECTIVE: To assess the relationship between severity of scoliosis and pulmonary function, and to assess the relationship between restrictive lung disease and self-reported quality of life in individuals with OI. SUMMARY OF BACKGROUND DATA: OI is a heritable connective tissue disorder characterized by osteopenia and a predisposition to fracture. Respiratory insufficiency is a leading cause of mortality. Literature on pulmonary function in this population has shown a negative correlation between percent-predicted vital capacity and severity of scoliosis. However, it has been suggested that decreased pulmonary function in OI may be due to intrinsic pulmonary disease, in addition to the impact of vertebral compression fractures and scoliosis. METHODS: Anterior-posterior spine radiographs and pulmonary function tests from 30 individuals with OI were reviewed. Radiographs were evaluated for scoliosis, defined as a curve ≥ 10°. If more than one curve was present, the largest curve was used. Pulmonary function was defined as the forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio. Restrictive pulmonary disease was defined as FEV1/FVC > 80%, while obstructive disease was defined as FEV1/FVC < 70%. Bivariate correlation analysis was performed, using Spearman rho correlation coefficient (P < 0.05). Quality of life was assessed by SF-36. RESULTS: The mean age was 27.6 years (range: 12-42 yrs). 57.6% were female. OI type IV was the most common (46.7%), followed by OI type III (33.3%), OI type I (10%), OI type IX (6.67% each), and OI type VIII (3.33%). Pulmonary comorbidity was present in 40% of individuals, while 6.67% had a cardiac comorbidity. The correlation between scoliosis and pulmonary function was weak and not significant (R = -0.059, P = 0.747). CONCLUSION: Pulmonary function is not significantly correlated with scoliosis, supporting the hypothesis that decreased pulmonary function is intrinsic to OI and/or chest wall deformities, rather than secondary to scoliosis. LEVEL OF EVIDENCE: 4.

Comparison of Anterior Cervical Discectomy and Fusion With a Stand-Alone Interbody Cage Versus a Conventional Cage-Plate Technique: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Compare the clinical and radiographic outcomes of anterior cervical discectomy and fusion (ACDF) with a stand-alone interbody cage versus a conventional cage and anterior cervical plate technique. METHODS: A systematic Medline search was conducted using PubMed, EMBASE, and Cochrane Library Database of Systematic Reviews. Search terms included "anterior cervical discectomy and fusion," "cage," and "bone plates," or variations thereof. Only studies involving a direct comparison of ACDF with a stand-alone cage versus a cage and plate were included. From the selected studies, we extracted data on patient demographics, comorbidities, surgical risk factors, and pre- and postoperative radiographic findings. A meta-analysis was performed on all outcome measures. The quality of each study was assessed using the Downs and Black checklist. RESULTS: Nineteen studies met the inclusion and exclusion criteria. Patients who underwent ACDF with a cage-only technique had significantly lower rates of postoperative dysphagia and adjacent segment disease compared with patients who underwent ACDF with a cage-plate technique. However, patients who underwent ACDF with a cage-plate technique had better radiographic outcomes with significantly less subsidence and better restoration of cervical lordosis. There were no other significant differences in outcomes or postoperative complications. CONCLUSIONS: ACDF with a cage-only technique appears to have better clinical outcomes than the cage-plate technique, despite radiographic findings of increased rates of subsidence and less restoration of cervical lordosis. Future randomized controlled trials with longer term follow-up are needed to confirm the findings of this meta-analysis.

Atypical Presentation of Chiari I Malformation in a 13-Year-Old Adolescent.

In this report, we describe a 13-year-old with opisthotonos as the presenting symptom of Chiari I malformation. This presentation is rare and has previously been reported only in infants. We describe the physical and radiologic findings, literature regarding Chiari malformation, and differential diagnosis of opisthotonos in this patient.

Revised Cardiac Risk Index as a Predictor for Myocardial Infarction and Cardiac Arrest Following Posterior Lumbar Decompression.

STUDY DESIGN: A retrospective analysis of prospectively collected data. OBJECTIVE: The aim of this study was to determine the ability of Revised Cardiac Risk Index (RCRI) to predict adverse cardiac events following posterior lumbar decompression (PLD). SUMMARY OF BACKGROUND DATA: PLD is an increasingly common procedure used to treat a variety of degenerative spinal conditions. The RCRI is used to predict risk for cardiac events following noncardiac surgery. There is a paucity of literature that directly addresses the relationship between RCRI and outcomes following PLD, specifically, the discriminative ability of the RCRI to predict adverse postoperative cardiac events. METHODS: ACS-NSQIP was utilized to identify patients undergoing PLD from 2006 to 2014. Fifty-two thousand sixty-six patients met inclusion criteria. Multivariate and ROC analysis was utilized to identify associations between RCRI and postoperative complications. RESULTS: Membership in the RCRI=1 cohort was a predictor for myocardial infarction (MI) [odds ratio (OR) = 3.3, P = 0.002] and cardiac arrest requiring cardiopulmonary resuscitation (CPR) (OR = 3.4, P = 0.013). Membership in the RCRI = 2 cohort was a predictor for MI (OR = 5.9, P = 0.001) and cardiac arrest requiring CPR (OR = 12.5), Membership in the RCRI = 3 cohort was a predictor for MI (OR = 24.9) and cardiac arrest requiring CPR (OR = 26.9, P = 0.006). RCRI had a good discriminative ability to predict both MI [area under the curve (AUC) = 0.876] and cardiac arrest requiring CPR (AUC = 0.855). The RCRI had a better discriminative ability to predict these outcomes that did ASA status, which had discriminative abilities of "fair" (AUC = 0.799) and "poor" (AUC = 0.674), respectively. P < 0.001 unless otherwise specified. CONCLUSION: RCRI was predictive of cardiac events following PLD, and RCRI had a better discriminative ability to predict MI and cardiac arrest requiring CPR than did ASA status. Consideration of the RCRI as a component of preoperative surgical risk stratification can minimize patient morbidity and mortality. Studies such as this can allow for implementation of guidelines that better estimate the preoperative risk profile of surgical patients. LEVEL OF EVIDENCE: 3.