Spine surgeons facing second opinions: a qualitative study.

BACKGROUND CONTEXT: The social and technological mutation of our contemporary period disrupts the traditional dyad that prevails in the relationship between physicians and patients. PURPOSE: The solicitation of a second opinion by the patient may potentially alter this dyad and degrade the mutual trust between the stakeholders concerned. The doctor-patient relationship has often been studied from the patient's perspective, but data are scarce from the spine surgeon's point of view. STUDY DESIGN/SETTING: This qualitative study used the grounded theory approach, an inductive methodology emphasizing field data and rejecting predetermined assumptions. PATIENT SAMPLE: We interviewed spine surgeons of different ages, experiences, and practice locations. We initially contacted 30 practitioners, but the final number (24 interviews; 11 orthopedists and 13 neurosurgeons) was determined by data saturation (the point at which no new topics appeared). OUTCOME MEASURES: Themes and subthemes were analyzed using semistructured interviews until saturation was reached. METHODS: Data were collected through individual interviews, independently analyzed thematically using specialized software, and triangulated by three researchers (an anthropologist, psychiatrist, and neurosurgeon). RESULTS: Index surgeons were defined when their patients went for a second opinion and recourse surgeons were defined as surgeons who were asked for a second opinion. Data analysis identified five overarching themes based on recurring elements in the interviews: (1) analysis of the patient's motivations for seeking a second opinion; (2) impaired trust and disloyalty; (3) ego, authority, and surgeon image; (4) management of a consultation recourse (measurement and ethics); and (5) the second opinion as an avoidance strategy. Despite the inherent asymmetry in the doctor-patient relationship, surgeons and patients share two symmetrical continua according to their perspective (professional or consumerist), involving power and control on the one hand and loyalty and autonomy on the other. These shared elements can be found in index consultations (seeking high-level care/respecting trust/closing the loyalty gap/managing disengagement) and referral consultations (objective and independent advice/trusting of the index advice/avoiding negative and anxiety-provoking situations). CONCLUSIONS: The second opinion often has a negative connotation with spine surgeons, who see it as a breach of loyalty and trust, without neglecting ego injury in their relationship with the patient. A paradigm shift would allow the second opinion to be perceived as a valuable resource that broadens the physician-patient relationship and optimizes the shared surgical decision-making process.

The Impact of Asymptomatic Human Immunodeficiency Virus-Positive Disease Status on Inpatient Complications Following Spine Surgery: A Propensity Score-Matched Analysis.

In the United States, nearly 1.2 million people > 12 years old have human immunodeficiency virus (HIV), which is associated with postoperative complications following orthopedic procedures. Little is known about how asymptomatic HIV (AHIV) patients fare postoperatively. This study compares complications after common spine surgeries between patients with and without AHIV. The Nationwide Inpatient Sample (NIS) was retrospectively reviewed from 2005-2013, identifying patients aged > 18 years who underwent 2-3-level anterior cervical discectomy and fusion (ACDF), ≥4-level thoracolumbar fusion (TLF), or 2-3-level lumbar fusion (LF). Patients with AHIV and without HIV were 1:1 propensity score-matched. Univariate analysis and multivariable binary logistic regression were performed to assess associations between HIV status and outcomes by cohort. 2-3-level ACDF (n = 594 total patients) and ≥4-level TLF (n = 86 total patients) cohorts demonstrated comparable length of stay (LOS), rates of wound-related, implant-related, medical, surgical, and overall complications between AHIV and controls. 2-3-level LF (n = 570 total patients) cohorts had comparable LOS, implant-related, medical, surgical, and overall complications. AHIV patients experienced higher postoperative respiratory complications (4.3% vs. 0.4%,). AHIV was not associated with higher risks of medical, surgical, or overall inpatient postoperative complications following most spine surgical procedures. The results suggest the postoperative course may be improved in patients with baseline control of HIV infection.

Do Age-Related Variations Of Sagittal Alignment Rely On SpinoPelvic Organization? An Observational Study Of 1540 Subjects.

STUDY DESIGN: Descriptive radiographic analysis of a prospective multi-center database. OBJECTIVE: This study aims to provide normative values of spinopelvic parameters and their correlations according to age and pelvic incidence (PI) of subjects without spinal deformity. METHODS: After Institutional Review Board (IRB) approval, 1540 full spine radiographs were analyzed. Subjects were divided into 3 groups of PI: low PI < 45°, intermediate PI 45-60°, high PI > 60°, and then stratified by age (20-34, 35-49, 50-64, > 65 Y.O). Pelvic and spinal parameters were measured. Statistical analysis between parameters was performed using Bayesian inference and correlation. RESULTS: Mean age was 53.5 years (845 females, 695 males, range 20-93 years).In low PI group, lumbar lordosis (LL) decrease was mainly observed in the 2 younger age groups.In medium and high PI groups, loss of lordosis was linear during aging and occurred mainly on the distal arch of lordosis. Moderate PI group had a stable lordosis apex and thoracolumbar inflection point. High PI group had a stable thoracolumbar inflection point and a more distal lordosis apex in elderly subjects.For all subjects, kyphosis and pelvic tilt (PT) increased with age.There was a constant chain of correlation between PI and age groups. Proximal lumbar lordosis (PLL) was correlated with kyphosis and sagittal vertical axis (SVA C7), while the distal lumbar lordosis (DLL) was correlated with PI and PT. CONCLUSION: This study provides a detailed repository of sagittal spinopelvic parameters normative values with detailed analysis of segmental kyphosis and lordosis distribution according to gender, age, and PI.

The Impact of Osteoporosis on 2-Year Outcomes in Patients Undergoing Long Cervical Fusion.

INTRODUCTION: Osteoporosis affects nearly 200 million individuals worldwide. Given this notable disease burden, there have been increased efforts to investigate complications in patients with osteoporosis undergoing cervical fusion (CF). However, there are limited data regarding long-term outcomes in osteoporotic patients in the setting of ≥4-level cervical fusion. METHODS: The New York State Statewide Planning and Research Cooperative System database was used to identify patients who underwent posterior or combined anterior-posterior ≥4-level CF for cervical radiculopathy or myelopathy from 2009 to 2011, with a minimum follow-up surveillance of 2 years. The following were compared between patients with and without osteoporosis: demographics, hospital-related parameters, medical/surgical complications, readmissions, and revisions. Binary multivariate stepwise logistic regression was used to identify independent predictors of outcomes. RESULTS: A total of 2,604 patients were included (osteoporosis: n = 136 (5.2%); nonosteoporosis: n = 2,468). Patients with osteoporosis were older (66.9 ± 11.2 vs. 60.0 ± 11.4 years, P < 0.001), more often female (75.7% vs. 36.2%, P < 0.001), and White (80.0% vs. 65.3%, P = 0.007). Both cohorts had comparable comorbidity burdens (Charlson/Deyo: 1.1 ± 1.2 vs. 1.0 ± 1.3, P = 0.262), total hospital charges ($100,953 ± 94,933 vs. $91,618 ± 78,327, P = 0.181), and length of stay (9.7 ± 10.4 vs. 8.4 ± 9.6 days, P = 0.109). Patients with osteoporosis incurred higher rates of overall medical complication rates (41.9% vs. 29.4%, P = 0.002) and individual surgical complications, such as nonunion (2.9% vs. 0.7%, P = 0.006). Osteoporosis was associated with medical complications (OR = 1.57, P = 0.021), surgical complications (OR = 1.52, P = 0.030), and readmissions (OR = 1.86, P = 0.003) at 2 years. DISCUSSION: Among patients who underwent multilevel cervical fusion, those with osteoporosis had higher risk of adverse postoperative outcomes at two years. These data indicate that preoperative screening and management of osteoporosis may be important for optimizing long-term outcomes in patients who require multilevel CF. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS: The data used in this study are available for public use at https://www.health.ny.gov/statistics/sparcs/.

Can Lumbopelvic Parameters Be Used to Predict Thoracic Kyphosis at all Ages? A National Cross-Sectional Study.

STUDY DESIGN: National cross-sectional study. BACKGROUND: Thoracic kyphosis (TK) is related to sagittal parameters as pelvic tilt (PT), lumbar lordosis (LL) and pelvic incidence (PI). The equation TK =2 (PT+LL-PI) was validated for adolescents.Objective: to investigate if this equation correctly predicts TK regardless of age. METHODS: Sagittal alignment parameters were assessed on full spine radiographs of 2599 individuals without spine pathology (1488 females, 1111 males). Calculated TK (CTK) = 2 (PT+LL-PI) and measured TK (MTK) were compared by calculating the gap and using a linear regression between both parameters. Subgroup analyses were performed for gender, age, TK groups (≤20°, 21°-40°, 41°-60°, >60°), and PI groups (<45°, 45°-60°, >60°). RESULTS: Average values in the total population were: MTK 45.0°, CTK 36.9°. Average TK gap was 8.1°, 5.2° in females (intercept 11.7, slope .61) and 11.9° in males (intercept 7.1, slope .58). The mean gap was 3.6° for 15-34 years, 5.7° under 15 years and it increased progressively after 35 years with a maximum of 19.9° over 80 years. The gap also increased with the amount of MTK: -3.5° for TK<20° up to 17.3° for TK >60°. Differences in gaps were minor between PI groups. The intercept was smallest and slopes >.6 for PI <45° and TK ≤20°. CONCLUSION: The formula TK=2 (PT+LL-PI) yielded moderate accuracy for adolescents and young adults, but did not fit for over 35 years and under 15. The amount and variance in TK increased in elderly subjects, which made the formula less accurate.

Comparison of Spinopelvic Configuration and Roussouly Alignment Types Between Pediatric and Adult Populations.

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVE: The aim was to describe spinopelvic alignment types by pelvic incidence (PI) and age to compare the Roussouly classification between pediatric and adult populations. SUMMARY OF BACKGROUND DATA: The Roussouly classification was validated for adults. Alignment types may vary during growth. MATERIALS AND METHODS: Radiographs of 1706 non pathologic individuals (5-49 yr) were analyzed. Individuals ≤19 years were stratified by chronological age and skeletal maturity (triradiate cartilage, Risser), and compared with adults. Global and spinopelvic alignment parameters were assessed. Roussouly Types 1, 2, 3, 3A (anteverted pelvis), and 4 were determined. The distribution of parameters was analyzed by Bayesian inference. The relationship between PI and age by Roussouly type was modeled by linear regression. RESULTS: The Sagittal Vertical Axis C7 decreased during growth and was significantly smaller in adults (20-34 yr) (Pr>0.99). Thoracic kyphosis and lumbar lordosis increased during growth and were larger in adults (Pr<0.025). Lordosis increased mainly in the cranial arch (Pr<0.025). PI and pelvic tilt increased during growth and were larger in adults (Pr<0.025). In children and adolescents, PI<45° represented the largest proportion, significantly larger compared with adults (Pr>0.99). Proportions of Roussouly Types 1 and 2 were similar throughout ages. Types 3 and 4 were rarer during the prepubertal period (Pr<0.025). The proportion of Type 3A was significantly higher in children and adolescents (Pr>0.99). Linear regression showed that Type 4 had the largest PI increase with age, with significantly higher curve slope compared with other types (Pr>0.9999). Types 3, 3A and 2 had similar slopes and lowest PI increase with age. CONCLUSION: Global and spinopelvic alignment changed during childhood and adolescence, leading to different kyphosis and lordosis distribution compared with adults. Growth-related PI increase influenced Roussouly types with typical predominance of Type 3A in the pediatric population and larger PI increase in Type 4. LEVEL OF EVIDENCE: Level III.

The Impact of Isolated Baseline Cannabis Use on Outcomes Following Thoracolumbar Spinal Fusion: A Propensity Score-Matched Analysis.

Background: There is limited literature evaluating the impact of isolated cannabis use on outcomes for patients following spinal surgery. This study sought to compare 90-day complication, 90-day readmission, as well as 2-year revision rates between baseline cannabis users and non-users following thoracolumbar spinal fusion (TLF) for adult spinal deformity (ASD). Methods: The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried between January 2009 and September 2013 to identify all patients who underwent TLF for ASD. Inclusion criteria were age ≥18 years and either minimum 90-day (for complications and readmissions) or 2-year (for revisions) follow-up surveillance. Cohorts were created and propensity score-matched based on presence or absence of isolated baseline cannabis use. Baseline demographics, hospital-related parameters, 90-day complications and readmissions, and two-year revisions were retrieved. Multivariate binary stepwise logistic regression identified independent outcome predictors. Results: 704 patients were identified (n=352 each), with comparable age, sex, race, primary insurance, Charlson/Deyo scores, surgical approach, and levels fused between cohorts (all, p>0.05). Cannabis users (versus non-users) incurred lower 90-day overall and medical complication rates (2.4% vs. 4.8%, p=0.013; 2.0% vs. 4.1%, p=0.018). Cohorts had otherwise comparable complication, revision, and readmission rates (p>0.05). Baseline cannabis use was associated with a lower risk of 90-day medical complications (OR=0.47, p=0.005). Isolated baseline cannabis use was not associated with 90-day surgical complications and readmissions, or two-year revisions. Conclusion: Isolated baseline cannabis use, in the absence of any other diagnosed substance abuse disorders, was not associated with increased odds of 90-day surgical complications or readmissions or two-year revisions, though its use was associated with reduced odds of 90-day medical complications when compared to non-users undergoing TLF for ASD. Further investigations are warranted to identify the physiologic mechanisms underlying these findings. Level of Evidence: III.

Variation of Global Sagittal Alignment Parameters According to Gender, Pelvic Incidence, and Age.

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVE: The aim was to describe existing global sagittal alignment parameters across ages and to analyze differences according to gender and pelvic incidence (PI). SUMMARY OF BACKGROUND DATA: Variability with age has been reported. It remains unclear how gender and spinopelvic morphology could additionally influence global alignment parameters. MATERIALS AND METHODS: Radiographs of 2599 individuals (5-93 y) were analyzed. Translation parameters were: Sagittal Vertical Axis (SVA)-C7, SVA-C2, SVA-Center Acoustic Meatus (CAM), C7/Sacrofemoral Distance (SFD) ratio. Inclination parameters were: C7-Vertical Tilt (VT), T1-VT and T9-VT, Odontoid-Hip Axis (OD-HA), OD-CAM. Pelvic compensation parameters were: T1-Pelvic Angle (TPA), Global Tilt (GT), Spino-Sacral Angle (SSA). Global sagittal alignment (GSA) was considered among formulae. The distribution of parameters was analyzed using a Bayesian inference. Correlations with spinopelvic parameters were investigated. RESULTS: SVA-C7, SVA-C2, SVA-CAM were larger in males and high PI, and increased significantly after 50 years (Pr>0.9999). C7/SFD decreased during growth and was larger in low PI (Pr=0.951). There was no correlation with spinopelvic parameters. Age-related variations of inclination parameters were nonsignificant. T1-VT and T9-VT increased with PI and were significantly larger in high PI (Pr>0.95). C7-VT was significantly larger in low PI (Pr>0.9999). OD-HA and OD-CAM were constant and increased after 80 years. TPA and GT increased with PI (Pr>0.9999) and age after 35 years (Pr>0.9999). SSA decreased nonsignificantly after 50 years. TPA correlated with PI (ρ=0.6130) and pelvic tilt (PT) (ρ=0.8375). GT correlated with PI (ρ=0.5961) and PT (ρ=0.8996). SSA correlated with sacral slope (ρ=0.9026). GSA was larger in high PI (Pr>0.9999) and increased after 35 years (Pr>0.9999). GSA correlated with PT (ρ=0.7732). CONCLUSION: Translation parameters increase with age, more prominently in males and high PI. Variations of inclination parameters are smaller. Pelvic compensation parameters and GSA increase with age and are closely related to PT and spinopelvic morphology. LEVEL OF EVIDENCE: Level III.

Variation of cervical sagittal alignment parameters according to gender, pelvic incidence and age.

PURPOSE: The aim was to describe radiographic cervical sagittal alignment variations according to age, gender and pelvic incidence (PI) and to investigate relationships with thoracic alignment. METHODS: A total of 2599 individuals (5-93 years) without spinal deformity were studied. Cranial cervical parameters were: McGregor slope, occipita-C2 angle, McGregor-C2 lordosis and C1-C2 lordosis. Caudal cervical parameters were: C2-C7, cranial arch and caudal arch lordosis and C7- and T1-slope. A Bayesian inference compared parameter distributions. Correlations with spinopelvic and global alignment parameters were investigated. RESULTS: Among cranial cervical parameters, variations of McGregor slope were non-significant. McGregor-C2 lordosis and C1-C2 lordosis were smaller in males and increased significantly during growth, whereas the occipito-C2 angle decreased (Pr > 0.95). The occipito-C2 angle was larger and McGregor-C2 lordosis was smaller in low PI (Pr > 0.95). Among caudal cervical parameters, C2-C7 lordosis and C7- and T1-slope were larger in males and increased after 50 years (Pr > 0.95). Lordosis changes were non-significant in the cranial arch, whereas values increased in the caudal arch after 35 years (Pr > 0.95). Caudal parameter differences were non-significant between PI groups. Strong correlations existed between C2-C7, caudal arch lordosis, C7-slope, T1-slope and thoracic kyphosis. The sagittal vertical axis C2 correlated with caudal arch lordosis and T1-slope (ρ > 0.5; Pr > 0.95). CONCLUSION: Cervical alignment parameters vary according to age, gender and PI. In the cranial cervical spine, changes occur mainly during growth. In the caudal cervical spine, lordosis increases in the caudal arch, which is related to thoracic kyphosis increase with age. The caudal cervical arch acts as a compensatory segment by progressive extension, allowing horizontal gaze.

Comparing Predictors of Complications After Anterior Cervical Diskectomy and Fusion, Total Disk Arthroplasty, and Combined Anterior Cervical Diskectomy and Fusion-Total Disk Arthroplasty With a Minimum 2-Year Follow-Up.

INTRODUCTION: Outcomes after anterior cervical diskectomy and fusion (ACDF) and cervical total disk arthroplasty (TDA) are satisfactory, but related morbidity and revision surgery rates are notable. This study sought to determine complication variations among ACDF, TDA, and combined ACDF-TDA as well as predictors of postoperative complications. METHODS: Patients undergoing 1- to 2-level ACDF and/or TDA with at least a 2-year follow-up from 2009 to 2011 were identified from the Statewide Planning and Research Cooperative System database. Patient demographics, hospital-related parameters, mortality, and postoperative outcomes were compared, and their predictors were identified using multivariate logistic regression. RESULTS: A total of 16,510 and 449 individuals underwent ACDF and cervical TDA, respectively, and 201 underwent ACDF-TDA. ACDF-TDA patients had the highest rates of cardiac complications and pulmonary embolism (PE) (P ≤ 0.006), whereas TDA patients had higher individual surgical and device/implant/internal fixation complications (P ≤ 0.025). ACDF-TDA patients experienced the lowest rate of revisions. Cervical TDA increased the odds of any surgical complications (OR = 2.5, P = 0.002), overall complications (OR = 1.57, P = 0.034), and revisions (OR = 2.29, P < 0.001). Deyo index predicted any medical/surgical complications (OR = 1.43 and 1.19, respectively). Female sex was associated with increased odds of readmission (OR 1.30, P < 0.001) but was protective against medical complications (OR = 0.81, P = 0.013). DISCUSSION: Combined ACDF-TDA procedures were not associated with increases in 2-year individual or overall complications, readmissions, or revisions. LEVEL OF EVIDENCE: Level 3-Therapeutic study.

The Dubousset Functional Test is a Novel Assessment of Physical Function and Balance.

BACKGROUND: Currently, the functional status of patients undergoing spine surgery is assessed with quality-of-life questionnaires, and a more objective and quantifiable assessment method is lacking. Dr. Jean Dubousset conceptually proposed a four-component functional test, but to our knowledge, reference values derived from asymptomatic individuals have not yet been reported, and these are needed to assess the test's clinical utility in patients with spinal deformities. QUESTIONS/PURPOSES: (1) What are the reference values for the Dubousset Functional Test (DFT) in asymptomatic people? (2) Is there a correlation between demographic variables such as age and BMI and performance of the DFT among asymptomatic people? METHODS: This single-institution prospective study was performed from January 1, 2018 to May 31, 2018. Asymptomatic volunteers were recruited from our college of medicine and hospital staff to participate in the DFT. Included participants did not report any musculoskeletal problems or trauma within 5 years. Additionally, they did not report any history of lower limb fracture, THA, TKA, or patellofemoral arthroplasty. Patients were also excluded if they reported any active medical comorbidities. Demographic data collected included age, sex, BMI, and self-reported race. Sixty-five asymptomatic volunteers were included in this study. Their mean age was 42 ± 15 years; 27 of the 65 participants (42%) were women. Their mean BMI was 26 ± 5 kg/m. The racial distribution of the participants was 34% white (22 of 65 participants), 25% black (16 of 65 participants), 15% Asian (10 of 65 participants), 9% subcontinental Indian (six of 65 participants), 6% Latino (four of 65 participants), and 10% other (seven of 65 participants). In a controlled setting, participants completed the DFT after verbal instruction and demonstration of each test, and all participants were video recorded. The four test components included the Up and Walking Test (unassisted sit-to-stand from a chair, walk forward/backward 5 meters [no turn], then unassisted stand-to-sit), Steps Test (ascend three steps, turn, descend three steps), Down and Sitting Test (stand-to-ground, followed by ground-to-stand, with assistance as needed), and Dual-Tasking Test (walk 5 meters forwards and back while counting down from 50 by 2). Tests were timed, and data were collected from video recordings to ensure consistency. Reference values for the DFT were determined via a descriptive analysis, and we calculated the mean, SD, 95% CI, median, and range of time taken to complete each test component, with univariate comparisons between men and women for each component. Linear correlations between age and BMI and test components were studied, and the frequency of verbal and physical pausing and adverse events was noted. RESULTS: The Up and Walking Test was completed in a mean of 15 seconds (95% CI, 14-16), the Steps Test was completed in 6.3 seconds (95% CI, 6.0-6.6), the Down and Sitting Test was completed in 6.0 seconds (95% CI, 5.4-6.6), and the Dual-Tasking Test was performed in 13 seconds (95% CI, 12-14). The length of time it took to complete the Down and Sitting (r = 0.529; p = 0.001), Up and Walking (r = 0.429; p = 0.001), and Steps (r = 0.356; p = 0.014) components increased with as the volunteer's age increased. No correlation was found between age and the time taken to complete the Dual-Tasking Test (r = 0.134; p = 0.289). Similarly, the length of time it took to complete the Down and Sitting (r = 0.372; p = 0.005), Up and Walking (r = 0.289; p = 0.032), and Steps (r = 0.366; p = 0.013) components increased with increasing BMI; no correlation was found between the Dual-Tasking Test's time and BMI (r = 0.078; p = 0.539). CONCLUSIONS: We found that the DFT could be completed by asymptomatic volunteers in approximately 1 minute, although it took longer for older patients and patients with higher BMI. CLINICAL RELEVANCE: We believe, but did not show, that the DFT might be useful in assessing patients with spinal deformities. The normal values we calculated should be compared in future studies with those of patients before and after undergoing spine surgery to determine whether this test has practical clinical utility. The DFT provides objective metrics to assess function and balance that are easy to obtain, and the test requires no special equipment.

Hangman's fracture: Management strategy and healing rate in a prospective multi-centre observational study of 34 patients.

BACKGROUND: Hangman's fractures account for 15% to 20% of all cervical spine fractures. The grading system developed by Effendi and modified by Levine and Edwards is generally used as the basis for management decisions. Nonetheless, the optimal management remains controversial. The objective of this study was to describe the treatments used in France in patients with hangman's fractures. The complications and healing rates were analysed according to the fracture type and treatment used. HYPOTHESIS: Among patients with hangman's fracture, those with disc damage must be treated surgically. MATERIAL AND METHODS: A prospective, multi-centre, observational study was conducted under the aegis of the French Society for Spine Surgery (SociétéFrançaisedeChirurgieRachidienne, SFCR). Patients were included if they had computed tomography (CT) evidence of hangman's fracture. Follow-up data were collected prospectively. Fracture healing was assessed on CT scans obtained 3 and 12 months after the injury. The type of treatment and complications were recorded routinely. RESULTS: We included 34 patients. The fracture type according to Effendi modified by Levine and Edwards was I in 68% of patients, II in 29% of patients, and III in a single patient (3%). The treatment was non-operative in 21 (62%) patients and surgical in 11 (32%). All 28 patients re-evaluated after 1 year had evidence of fracture healing. The remaining 6 patients were lost to follow-up. CONCLUSION: Hangman's fracture is associated with low rates of mortality and neurological complications. Non-operative treatment is appropriate in Type I hangman's fracture, with a 100% healing rate in our study. Types II and III are characterised by damage to the ligaments and discs requiring either anterior C2-C3 fusion or posterior C1-C3 screw fixation. LEVEL OF EVIDENCE: III.

Erratum to Tridimensional Analysis of Rotatory Subluxation and Sagittal Spinopelvic Alignment in the Setting of Adult Spinal Deformity [Spine Deformity 5/4 (2017) 255-264].

The authors regret that one of the co-author's name was misspelt as "Brice Illharreborde, MD, PhD'" in the proof. However, the name should be spelled as "Brice Ilharreborde, MD, PhD'".

Mortality, complication, and fusion rates of patients with odontoid fracture: the impact of age and comorbidities in 204 cases.

PURPOSE: The French Society of Spine Surgery (SFCR) conducted a prospective epidemiologic multicenter study. The purpose was to investigate mortality, complication, and fusion rates in patients with odontoid fracture, depending on age, comorbidities, fracture type, and treatment. METHODS: Out of 204 patients, 60 were ≤ 70 years and 144 were > 70 years. Demographic data, comorbidities, treatment types and complications (general medical, infectious, neurologic, and mechanical), and death were registered within the first year. Fractures were classified according to Anderson-D'Alonzo and Roy-Camille on the initial CT. A 1-year follow-up CT was available in 144 patients to evaluate fracture consolidation. RESULTS: Type II and oblique-posterior fractures were the most frequent patterns. The treatment was conservative in 52.5% and surgical in 47.5%. The mortality rate in patients ≤ 70 was 3.3% and 16.7% in patients > 70 years (p = 0.0002). Fracture pattern and treatment type did not influence mortality. General medical complications were significantly more frequent > 70 years (p = 0.021) and after surgical treatment (p = 0.028). Neurologic complications occurred in 0.5%, postoperative infections in 2.0%, and implant-related mechanical complications in 10.3% (associated with pseudarthrosis). Fracture fusion was observed in 93.5% of patients ≤ 70 years and in 62.5% >70 years (p < 0.0001). Pseudarthrosis was present in 31.5% of oblique-posterior fractures and in 24.3% after conservative treatment. CONCLUSIONS: Age and comorbidities influenced mortality and medical complication rates most regardless of fracture type and treatment choice. Pseudarthrosis represented the main complication, which increased with age. Pseudarthrosis was most frequent in type II and oblique-posterior fractures after conservative treatment.

C1 fracture: Analysis of consolidation and complications rates in a prospective multicenter series.

INTRODUCTION: Three types of C1 fracture have been described, according to location: type 1 (anterior or posterior arc), type 2 (Jefferson: anterior and posterior arc), and type 3 (lateral mass). Stability depends on transverse ligament integrity. The main aim of the present study was to analyze complications and consolidation rates according to fracture type, age and treatment. MATERIAL AND METHODS: The French Society of Spinal Surgery (SFCR) performed a multicenter prospective study on C1-C2 trauma. All patients with recent fracture diagnosed on CT were included. Consolidation on CT was studied at 3 months and 1 year. Medical, neurologic, infectious and mechanical complications were inventoried using the KEOPS data-base. RESULTS: Sixty-three of the 417 patients (15.1%) had C1 fracture: type 1 (33.3%), type 2 (38.1%), or type 3 (28.6%). The transverse ligament was intact in 53.9% of cases. Treatment was non-operative in 63.5% of cases, surgical in 27.0%, and surgical after failure of non-operative treatment in 9.5%. There were 8 medical complications, more frequently in patients aged >70 years, following surgery (p<0.0001). The consolidation rate was 84.2% with non-operative treatment, 100% for primary surgery, and 33.3% for secondary surgery (p=0.002). There were 10 cases of non-union, in 4.8% of type 1, 13.6% of type 2 and 33.3% of type 3 fractures (p=0.001). CONCLUSION: Medical complications showed association with age and with type of treatment. Non-operative treatment was suited to types 1, 2 and 3 with minimal displacement and intact transverse ligament. C1-C2 fusion was suited to displaced unstable type 2 fracture. Displaced type 3 fracture incurred risk of non-union. Early surgery may be recommended. LEVEL OF EVIDENCE: III.

Adult cervical deformity: radiographic and osteotomy classifications.

Cervical spine deformity represents a broad spectrum of pathologies that are both complex in etiology and debilitating towards quality of life for patients. Despite advances in the understanding of drivers and outcomes of cervical spine deformity, only one classification system and one system of nomenclature for osteotomy techniques currently exist. Moreover, there is a lack of standardization regarding the indications for each technique. This article reviews the adult cervical deformity (ACD) and current classification and nomenclature for osteotomy techniques, highlighting the need for further work to develop a unified approach for each case and improve communication amongst the spine community with respect to ACD.

Radiographic Classification for Degenerative Spondylolisthesis of the Lumbar Spine Based on Sagittal Balance: A Reliability Study.

STUDY DESIGN: Inter- and intraobserver reliability study. OBJECT: To assess the reliability of a new radiographic classification of degenerative spondylolisthesis of the lumbar spine (DSLS). SUMMARY OF BACKGROUND DATA: DSLS is a common cause of chronic low back and leg pain in adults. To this date, there is no consensus for a comprehensive analysis of DSLS. The reliability of a new DSLS classification system based on sagittal alignment was assessed. METHODS: Ninety-nine patients admitted to our spinal surgery department for surgical treatment of DSLS between January 2012 and December 2015 were included. Three observers measured sagittal alignment parameters with validated software: segmental lordosis (SL), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sagittal vertical axis (SVA). Full body low-dose lateral view radiographs were analyzed and classified according to three main types: Type 1A: preserved LL and SL; Type 1B: preserved LL and reduced SL (≤5°); Type 2A: PI-LL ≥10° without pelvic compensation (PT <25°); Type 2B: PI-LL ≥10° with pelvic compensation (PT ≥25°); Type 3: global sagittal malalignment (SVA ≥40 mm). The three observers classified radiographs twice with a 3-week interval for intraobserver reproducibility. Interobserver reproducibility was calculated using Fleiss κ and intra-class coefficient. Intraobserver reproducibility was calculated using Cohen κ. RESULTS: Mean age was 68.8 ± 9.8 years. Mean sagittal alignment parameters values were the following: PI: 60.1° ± 12.7°; PI-LL was 12.2° ± 13.9°, PT: 24.7° ± 8.5°; SVA: 44.9 mm ± 44.6 mm; SL: 16.6° ± 8.4°. Intraobserver repeatability showed an almost perfect agreement (ICC > 0.92 and Cohen κ > 0.89 for each observer). Fleiss κ value for interobserver reproducibility was 0.82, with percentage agreement among observers between 88% and 89%. CONCLUSION: This new classification showed an excellent inter- and intraobserver reliability. This simple method could be an additional sagittal balance tool helping surgeons improve their preoperative DSLS analysis.