Return to Play Criteria After Adult Lumbar Spinal Fractures: A Review of Current Literature and Expert Recommendations.

PURPOSE OF REVIEW: Understanding the management of lumbar spinal fractures and return to play (RTP) criteria is an essential component of care for adult athletes. Appropriate management of lumbar spinal fractures must balance minimizing time away from physical activity while also minimizing risk of reinjury. The purpose of this review is to summarize current recommendations on lumbar spinal fracture management and RTP guidelines and to provide expert opinion on areas of discrepancy in the field. RECENT FINDINGS: There is a paucity of high-level evidence on the management and return to play criteria for adult lumbar spine fractures in athletes. Much of the data and recommendations are based on expert opinion and studies in pediatric or osteoporotic patients, which may not be applicable to adult athletes. These data presented here may be used to aid patient-physician conversations and provide guidance on expectations for patients, coaches, and athletic trainers. In general, we recommend that patients be free of lumbar pain, neurologically intact, and have full strength and motion of the lumbar spine and lower extremities before returning to play. Adequate protective equipment is recommended to be worn at all times during practice and play.

Association between opioid utilization and patient reported outcome measures following lumbar spine surgery.

BACKGROUND CONTEXT: The patient-reported outcomes measurement information system (PROMIS), created by the National institute of Health, is a reliable and valid survey for patients with lumbar spine pathology. Preoperative opioid use has been shown to be an important predictor variable of self-reported health status in legacy patient reported outcome measures. PURPOSE: To investigate the impact of chronic preoperative opiate use on PROMIS survey scores. STUDY DESIGN: Retrospective database analysis. PATIENT SAMPLE: Between March 2019 and November 2021, 227 patients underwent lumbar decompression ± ≤ 2 level fusion. Fifty-seven patients (25.11%) had chronic preoperative opioid use. OUTCOME MEASURES: Oswestry disability index (ODI) and PROMIS survey scores. METHODS: A retrospective analysis of a prospectively maintained single center patient-reported outcome database was performed with a minimum of 2 year follow-up. PROMIS Anxiety, Depression, Fatigue, Pain Interference (PI), Physical Function (PF), Sleep disturbance (SD), and Social Roles (SR) surveys were recorded at preoperative intake with subsequent follow-up at 6, 12, and 24 months postoperatively. Patients were grouped into chronic opioid users as defined by >6-month duration of use. Differences in mean survey scores were evaluated using Welch t-tests. RESULTS: Two hundred and twenty-seven patients met our inclusion criteria of completed PROMIS surveys at the designated timepoints. A total of 57 (25.11%) were chronic opioid users (COU) prior to surgery. Analysis of patient-reported health outcomes shows that long term opioid use correlated with worse ODI and PROMIS scores at baseline compared to nonchronic users (NOU). At 1 and 2 year follow-up, the COU cohort continued to have significantly worse ODI, PROMIS Fatigue, PF, PI, SD, and SR scores. There is a statistical difference in the magnitude of change in health status between the 2 cohorts at 1 year follow-up in PROMIS Depression (-5.04±7.88 vs. -2.49±8.73, p=.042), PF (6.25±7.11 vs. 9.03±9.04, p=.019), and PI (-7.40±7.37 vs. -10.58±9.87, p=.011) and 2 year follow-up in PROMIS PF (5.58±6.84 vs. 7.99±9.64, p=.041) and PI (-6.71±8.32 vs. -9.62±10.06, p=.032). Mean improvement in PROMIS scores for the COU cohort at 2 year follow-up exceeded minimal clinically important difference (MCID) in all domains except PROMIS Depression, SR and SD. CONCLUSION: Patients with chronic opioid use status have worse baseline PROMIS scores compared with patients who had nonchronic use. However, patients in the COU cohort displayed clinically significant postoperative improvement in multiple PROMIS domains. These results show that patients with chronic opioid use can benefit greatly from surgical intervention and will allow physicians to better set expectations with their patients.

Obturator inlet and iliac oblique technique for safe, convenient, and reliable iliac screw placement.

Background: There are many described techniques for the placement of posterior iliac screws for extension of lumbar posterior spinal instrumentation to the pelvis. However, each one has its limitations. We describe our technique for fluoroscopic guidance of iliac screw placement utilizing the obturator inlet and iliac oblique views as well as a detailed review of how to obtain and interpret these views for safe iliac screw placement. Methods: Retrospective chart review of patients undergoing iliac screw placement utilizing the obturator inlet and iliac oblique views as part of spine instrumentation between January 2019 and March 2022. Screw length and bony breaches are reported utilizing this technique. Results: Twelve patients underwent posterior lumbopelvic fixation with a total of 23 screws placed via either open or percutaneous technique. The mean screw length was 96.5 mm (Range 80-110, standard dev 7.75). There were no recorded breaches or recannulation attempts. Conclusions: We show how this technique is a much more convenient alternative to the placement of iliac screws under the obturator outlet oblique ("teardrop" view) which necessitates that the C-arm is in line with the instruments being placed. These described views can be used to place screws with either open or percutaneous techniques and with either the posterior superior iliac spine (PSIS) or S2 alar iliac (S2AI) starting points.

Selective thoracolumbar fusion in adult spinal deformity double curves with circumferential minimally invasive surgery: 2-year minimum follow-up.

OBJECTIVE: Selection of the upper instrumented vertebra (UIV) level for adult spinal deformity (ASD) remains controversial. Although selective fusion attempts have been described for fractional curves or adolescent curves, no authors have described selective thoracolumbar fusion performance for ASD with double curves. This study evaluated the clinical impact of selective fusion constructs within the lower thoracic and/or lumbar spine on ASD with double curves. METHODS: A retrospective review was performed on an ASD (Cobb angle > 20°, sagittal vertical axis [SVA] > 50 mm, and pelvic incidence minus lumbar lordosis mismatch [PI-LL] > 10°) database consisting of 438 patients who underwent correction with circumferential minimally invasive surgery (CMIS) between 2007 and 2020. The inclusion criteria were ASD double curves (lumbar Cobb angle > 35° and thoracic Cobb angle > 30°), 4 or more levels fused, and minimum 2-year follow-up. Analyses were performed on spinopelvic data and clinical outcome scores. Complications were recorded, specifically the need for revision surgery and hardware-related complications. RESULTS: Twenty-one ASD double curve patients underwent selective correction with a mean ± SD (range) follow-up of 91 ± 43 (24-174) months. A total of 141 levels were fused with a mean of 6.7 ± 1.3 (4-8) levels. T10 was the most proximal and most common UIV (10/21 [48%]). Pelvic fixation was performed in 12 patients (57%). Significant improvements in lumbar Cobb angle, thoracic Cobb angle, coronal balance, lumbar lordosis, thoracic kyphosis, SVA, and PI-LL were achieved. The uninstrumented thoracic spine demonstrated 14.5° of mean coronal correction and a mean increase of 9.4° in kyphosis. Significant improvements in visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were observed. Four patients required revision for the following reasons: 1) superficial wound infection requiring irrigation and debridement; 2) bilateral L5 pars fractures requiring L5-S1 anterior lumbar interbody fusion and pelvic fixation; 3) adjacent-segment degeneration at L5-S1 requiring anterior lumbar interbody fusion and pelvic fixation; and 4) proximal junctional kyphosis requiring revision fusion to include the entire thoracic curve. There were no instances of hardware failure such as rod breakage or screw loosening. CONCLUSIONS: Selective thoracolumbar fusion with CMIS for ASD double curves can provide significant clinical improvements. Despite limiting fusion constructs to within the lower thoracic and/or lumbar spine, significant correction can be observed in the uninstrumented thoracic curve. The rate of mechanical complications was low, and the 2-year follow-up results suggested that limited fusion constructs are viable options for ASD double curve patients.

Thoracic costotransversectomy characteristics and 90-day complications vary based on underlying diagnosis.

OBJECTIVE: Thoracic costotransversectomies are among the most invasive spinal procedures performed and are associated with unanticipated medical and surgical complications. Few studies have specifically assessed medical and surgical complications after a thoracic corpectomy via a costotransversectomy approach (TCT) or compared complications between different diagnoses. The purpose of this study was to describe the differences in operative characteristics and rates of 90-day surgical and medical complications in patients undergoing TCTs based on underlying diagnosis. METHODS: A retrospective chart review of 123 consecutive patients who underwent TCTs at a single academic referral center over a 10-year period was conducted. Surgical indication, corpectomy levels, intraoperative dural tears, pleural injuries, neurological injuries, 90-day mortality, 90-day reoperations, and hospital-based medical complications were evaluated. RESULTS: One hundred twenty-three patients underwent a TCT, including 35 for infection, 42 for malignancy, 23 for trauma, and 23 for deformity. Fifty-nine patients (48.0%) had at least one medical or 90-day operative complication, with 22 patients (17.9%) having two or more complications. Patients with a diagnosis of infection were more likely to undergo two-level corpectomies (80% vs 26.1%, p < 0.0005). Patients with a diagnosis of malignancy had significantly higher 90-day mortality (19.0% vs 4.9%, p = 0.022) and were more likely to undergo three-level corpectomies (9.5% vs 3.7%, p = 0.002) and upper thoracic (T1-4) corpectomies (37.9% vs 12.4%, p = 0.001), and sustain a pleural injury (14.3% vs 2.5%, p = 0.019). Ninety-day reoperation rates (p = 0.970), postoperative ventilator days (p = 0.224), intensive care unit stays (p = 0.350), hospital lengths of stay (p = 0.094), neurological injuries (p = 0.338), and dural tears (p = 0.794) did not significantly vary between the different groups. CONCLUSIONS: Nearly half of the patients undergoing a TCT will experience an unanticipated short-term complication related to the procedure. Short-term complications may vary with the underlying patient diagnosis.

Degenerative lumbar spondylolisthesis: review of current classifications and proposal of a novel classification system.

PURPOSE: To review existing classification systems for degenerative spondylolisthesis (DS), propose a novel classification designed to better address clinically relevant radiographic and clinical features of disease, and determine the inter- and intraobserver reliability of this new system for classifying DS. METHODS: The proposed classification system includes four components: 1) segmental dynamic instability, 2) location of spinal stenosis, 3) sagittal alignment, and 4) primary clinical presentation. To establish the reliability of this system, 12 observers graded 10 premarked test cases twice each. Kappa values were calculated to assess the inter- and intraobserver reliability for each of the four components separately. RESULTS: Interobserver reliability for dynamic instability, location of stenosis, sagittal alignment, and clinical presentation was 0.94, 0.80, 0.87, and 1.00, respectively. Intraobserver reliability for dynamic instability, location of stenosis, sagittal alignment, and clinical presentation were 0.91, 0.88, 0.87, and 0.97, respectively. CONCLUSION: The UCSF DS classification system provides a novel framework for assessing DS based on radiographic and clinical parameters with established implications for surgical treatment. The almost perfect interobserver and intraobserver reliability observed for all components of this system demonstrates that it is simple and easy to use. In clinical practice, this classification may allow subclassification of similar patients into groups that may benefit from distinct treatment strategies, leading to the development of algorithms to help guide selection of an optimal surgical approach. Future work will focus on the clinical validation of this system, with the goal of providing for more evidence-based, standardized approaches to treatment and improved outcomes for patients with DS.

Do peri-operative parathyroid hormone (PTH) analogues improve bone density and decrease mechanical complications in spinal deformity correction?-a minimum 2-year radiological study measuring Hounsfield units.

OBJECTIVE: To delineate whether use of a PTH analogue in the 1-year peri-operative period improves lumbar bone density. METHODS: A prospectively collected data registry of 254 patients who underwent CMIS correction of ASD (Cobb angle > 20 or SVA > 50 mm or (PI-LL) > 10) from Jan 2011 to Jan 2020 was analysed. Patients who were placed on PTH analogues for one year in conjunction with surgery were included in the study. Ultimately, 41 patients who had pre- and two-year post-operative CT scans for review were included in this study. Hounsfield units were measured off of the L1-L3 levels for all patients before and after surgery on pre-op and post-op CT scans. RESULT: The mean age of patients in this study was 70 (52-84, SD 7). Mean follow-up was 66 (24-132, SD 33) months. Twenty-three patients met criteria for severe deformity (Cobb angle > 50 degrees or SVA > 95 mm or PI/LL mismatch > 20 or PT > 30). Based off 2-year post-op CT scan, there were significant improvements in L1 Hounsfield units when comparing pre-op values (96; SD 55) to post-op values (185 SD 102); p. < 0.05. There was no screw loosening or screw pull out. There were 2 patients with PJF (4.8%). Both these patients had not completed their PTH treatment: one only took PTH for 3 months (PJF at 2-year post-op) and the other one took it only for 1 month (PJF at 1-year post-op). No increase in bone density was noted (based off of Hounsfield units) in five patients (12%) despite completion of their PTH therapy. Only one patient experienced nausea from PTH therapy. There were no other PTH related adverse events. CONCLUSION: The incidence of PTH analogues failing to increase bone density in our series was low at 12%. This study shows that PTH analogues may be a powerful adjunct for increasing bone density and may help to mitigate the risk of mechanical complications in patients undergoing deformity correction with minimally invasive techniques. Future comparative studies are warranted to confirm these latter findings and to potentially protocolize the ideal peri-operative bone health optimization strategy.

Impact of social determinants of health on perioperative opioid utilization in patients with lumbar degeneration.

Background: Social determinants of health (SDOH), have been demonstrated to significantly impact health outcomes in spine patients. There may be interaction between opioid use and these factors in spine surgical patients. We aimed to evaluate the social determinants of health (SDOH) which are associated with perioperative opioid use among lumbar spine patients. Methods: This retrospective cohort study included patients undergoing spine surgery for lumbar degeneration in 2019. Opioid use was determined based on prescription records from the electronic medical records. Preoperative opioid users (OU) were compared with opioid-naïve patients regarding SDOH including demographics like age and race, and clinical data such as activity and tobacco use. Demographics and surgical data, including age, comorbidities, surgical invasiveness, and other variables were also collected from the records. Multivariate logistic regression was used for analysis of these factors. Results: Ninety-eight patients were opioid-naïve and 90 used opioids preoperatively. All OU had ≥3 months of use, had more prior spine surgeries (1.07 vs. 0.44, p<.001) and more comorbidities including diabetes, hypertension, and depression (p=.021, 0.043, 0.017). Patients from lower community median income areas, unemployed, or with lower physical capacity (METS<5) were more likely to use opioids preoperatively. Postoperative opioid use was strongly associated with preoperative opioid use, as well as alcohol use, and lower community median income. At one year postoperatively, OU had higher rates of opioid use [72.2% vs. 15.3%, p<.001]. Conclusions: Unemployment, low physical activity level, and lower community median income were associated with preoperative opioid use and longer-term opioid use postoperatively.

Does the Global Alignment and Proportion score predict mechanical complications in circumferential minimally invasive surgery for adult spinal deformity?

OBJECTIVE: The Global Alignment and Proportion (GAP) score was developed to serve as a tool to predict mechanical complication probability in patients undergoing surgery for adult spinal deformity (ASD), serving as an aid for setting surgical goals to decrease the prevalence of mechanical complications in ASD surgery. However, it was developed using ASD patients for whom open surgical techniques were used for correction. Therefore, the purpose of this study was to assess the applicability of the score for patients undergoing circumferential minimally invasive surgery (cMIS) for correction of ASD. METHODS: Study participants were patients undergoing cMIS ASD surgery without the use of osteotomies with a minimum of four levels fused and 2 years of follow-up. Postoperative GAP scores were calculated for all patients, and the association with mechanical failure was analyzed. RESULTS: The authors identified 182 patients who underwent cMIS correction of ASD. Mechanical complications were found in 11.1% of patients with proportioned spinopelvic states, 20.5% of patients with moderately disproportioned spinopelvic states, and 18.8% of patients with severely disproportioned spinopelvic states. Analysis with a chi-square test showed a significant difference between the cMIS and original GAP study cohorts in the moderately disproportioned and severely disproportioned spinopelvic states, but not in the proportioned spinopelvic states. CONCLUSIONS: For patients stratified into proportioned, moderately disproportioned, and severely disproportioned spinopelvic states, the GAP score predicted 6%, 47%, and 95% mechanical complication rates, respectively. The mechanical complication rate in patients undergoing cMIS ASD correction did not correlate with the calculated GAP spinopelvic state.

Prevalence and Modes of Posterior Hardware Failure With a Staged Protocol for Circumferential Minimally Invasive Surgical Correction of Adult Spinal Deformity: A 13-Year Experience.

BACKGROUND: One of the common complications of adult spinal deformity (ASD) correction is the failure to relieve pain. This may result from the failure of implanted hardware to provide adequate stabilization. While numerous studies exist, characterizing complications that can occur with minimally invasive correction of ASD and data regarding hardware failure in this setting are limited. OBJECTIVE: This article characterizes the rate and mode of posterior hardware failure in the setting of circumferential minimally invasive surgery (CMIS) for ASD correction. METHODS: Patients undergoing staged CMIS correction of ASD from January 2007 to September 2018 were identified. Patients with a minimum 2-year follow-up were included in the study. RESULT: A total of 263 patients (168 women and 95 men) were included in the study. The mean age of patients was 64 years (21-85, SD 13.7), and the mean length of follow-up was 90 months (24-164, SD 40.2). An average of 6 levels (3-16, SD 3.15) was fused per patient.Eight patients had a mechanical hardware failure and required revision surgery (3.04%). No catastrophic failures were noted in our series. Hardware failures were characterized as follows: 2 patients with broken screws, 5 patients with loose screws, and 1 patient who had symptomatic T12-L1 and L5-S1 nonunion with bilateral distal rod fractures, iliac set screw loosening, and proximal T12 screw loosening. Following revision surgery, all of these patients had confirmed solid fusion on computed tomography (CT) scan at their latest follow-up visit.Interestingly, 3 other patients had loosening of the set screw on their iliac bolts. Five patients had rod fractures between L5 and S1 or below S1. All 8 of these patients were asymptomatic with confirmed fusion at L5-S1 on CT scans. CONCLUSION: The prevalence of clinically significant hardware failure needing revision in our series was low at 3.04%. Symptomatic hardware prominence requiring revision was 2.3%. Specifically, rod fractures were not common (2.2%). Our study suggests that in the appropriately selected patient, CMIS to correct ASD without osteotomies may result in acceptable rates of hardware failure. Future studies should compare the results of CMIS deformity correction to a matched population of patients undergoing open deformity correction. CLINICAL RELEVANCE: This study suggests that in the appropriately selected patient, CMIS to correct ASD without osteotomies may result in acceptable rates of hardware failure.

Management of severe adult spinal deformity with circumferential minimally invasive surgical strategies without posterior column osteotomies: a 13-year experience.

OBJECTIVE: To evaluate the mid- to long-term clinical outcomes of circumferential minimally invasive surgery (CMIS) without posterior column osteotomies for severe adult spine deformity (ASD) correction. METHODS: All patients with a minimum of 2-year follow-up undergoing staged CMIS correction of ASD from January 2007 to July 2018 were identified. All included patients had fusion of 3 or more interbody levels that spanned the L5-S1 junction. Only patients with severe deformity, Coronal Cobb > 50° or at least one SRS-Schwab ++ sagittal modifier (SVA > 95 mm, or PI-LL > 20, or PT > 30) were included. All complications were noted. RESULT: 136 patients met inclusion criteria; mean age of patients was 63.6 years (21-85, SD 13.7). The mean follow-up was 82.8 months (24-159, SD 36.6). The mean number of levels fused was 7 (3-16, SD 3). A total of 40 (29.4%) major complications were noted at final follow-ups: 2 (1.4%) intra-operative, 12 (8.9%) peri-operative (≤ 6 weeks from index), 26 (19.1%) post-operative (> 6 weeks from index). There was a total of 53 (40.0%) minor complications. Seven (5.1%) patients who developed radiographic proximal junctional kyphosis. Three patients (2.2%) developed proximal junctional failure. There were 8 (5.9%) cases of pseudarthrosis. Five of these occurred in patients undergoing AxiaLIF. All patients experienced improvements in patient-perceived outcomes (VAS, TIS, ODI, and SRS-22) and radiographic parameters at last follow-up when compared to pre-op (p < 0.05). CONCLUSION: Rates of complications with CMIS correction of severe ASD are lower than published rates of complications seen with open ASD correction. Specifically, the incidence of catastrophic complications is lower. Furthermore, CMIS is associated with significant improvements in clinical and functional outcomes, low rates of pseudarthrosis and proximal junctional kyphosis. Therefore, in the appropriately selected patient, CMIS may be an excellent alternative approach to addressing severe ASD.

Guidelines on How to Perform a Systematic Review in Spine Surgery.

Primary literature can be contradictory due to a multitude of factors, including poorly designed studies, error types, and confounding factors, and thus literature reviews can be difficult and time-consuming. Systematic reviews are designed to provide unbiased and comprehensive comparisons of relevant primary studies. This method is considered superior to traditional literature reviews due to the unbiased consideration of a broad number of sources rather than a limited literature review. This article will provide guidance for performing a systematic review, including framing a question, selecting studies with inclusion and exclusion criteria, evaluating primary literature, and explaining analysis types.

Guidelines on How to Perform a Meta-Analysis in Spine Surgery: Strengths and Weaknesses of Design.

There are many questions in the literature that remain unanswered due to the paucity of available subjects or the large sample size needed to detect a difference. A meta-analysis consists of integrating together data from multiple studies into one larger data set in order to increase the subject size and power of a paper. In essence, it is a systematic review in which one uses statistical methods to summarize the results of these studies. It is important that a meta-analysis be performed in a systematic and orderly manner with the assistance of a statistician. When carried out correctly, these studies serve as powerful tools to help us better address our knowledge. Because of their complexity, they are prone to bias at multiple levels. This article will discuss the steps involved in performing a meta-analysis, select good studies, as well as explain the statistics conducted in these studies. Furthermore, we will discuss examples from the literature that demonstrate a good meta-analysis.

Utility of a long arm extension cast in management of pediatric fractures: A technique revisited.

A long arm cast with the elbow extended is a useful but often forgotten technique to manage some pediatric fractures. Specifically, proximal forearm fractures of both the radius and ulna, olecranon fractures, flexion-type supracondylar fractures and type II Monteggia fractures are well managed in this manner. Although some of these fractures are seen infrequently, timely diagnosis and treatment are essential to prevent complications. In this article, we present a review of the evaluation and management of these fractures in children, and a description of the technique used to apply a long arm cast in extension.

Lyme Arthritis of the Pediatric Elbow: A Case Series.

Most patients with untreated Lyme disease will experience joint symptoms. Owing to their resemblance in clinical presentation, Lyme arthritis and septic arthritis are often difficult to differentiate. However, their treatment is different. The elbow is rarely the first joint to present with symptoms. Therefore, Lyme disease is not commonly included in the differential diagnosis for children presenting with isolated elbow pain. The authors report 4 cases of monoarticular Lyme arthritis presenting in the elbow. There was an average delay of diagnosis of 4.75 days. Three cases were treated with oral antibiotics alone; 1 case was treated with unnecessary surgery due to uncertainty of the diagnosis and the delay in the laboratory performing the Lyme serology tests. The authors strongly recommend that Lyme serology be performed on an emergent basis to prevent unneeded surgery. [Orthopedics. 2018; 41(4):e511-e515.].