Intraoperative and Postoperative Management of Incidental Durotomies During Open Degenerative Lumbar Spine Surgery: A Systematic Review.

SUMMARY OF BACKGROUND DATA: Incidental durotomy is a common intraoperative complication of lumbar spine surgery. Intra and postoperative protocols in the management of this common complication vary considerably, with no consensus in the literature. OBJECTIVE: To systematically review (1) lumbar dural repair techniques for open degenerative procedures; (2) review described postoperative protocols after lumbar dural repairs. STUDY DESIGN: Systematic review. MATERIALS AND METHODS: A systematic review of the literature was performed for all articles published from inception until September 2022 using Pubmed, EMBASE, Medline, and Cochrane databases to identify articles assessing the management of durotomy in open surgery for degenerative diseases of the lumbar spine. Two independent reviewers assessed the articles for inclusion criteria, and disagreements were resolved by consensus. Outcomes included persistent leaks, return to the operating room, recurrent symptoms, medical complications, or patient satisfaction. RESULTS: A total of 10,227 articles were initially screened. After inclusion criteria were applied, 9 studies were included (n=1270 patients) for final review. Repair techniques included; no primary repair, suture repair in running or interrupted manner with or without adjunctive sealants, sealants alone, or patch repair with muscle, fat, epidural blood patch, or synthetic graft. Postoperative protocols included the placement of a subfascial drain with varying durations of bed rest. Notable findings included no benefit of prolonged bedrest compared with early ambulation ( P =0.4), reduced cerebrospinal fluid leakage with fat graft compared with muscle grafts ( P <0.001), and decreased rates of revision surgery in studies that used subfascial drains (1.7%-2.2% vs 4.34%-6.66%). CONCLUSIONS: Significant variability in intraoperative durotomy repair techniques and postoperative protocols exists. Primary repair with fat graft augmentation seems to have the highest success rate. Postoperatively, the use of a subfascial drain with early ambulation reduces the risk of pseudomenignocele formation, medical complications, and return to the operating room. Further research should focus on prospective studies with the goal to standardize repair techniques and postoperative protocols.

Cervical disc arthroplasty versus anterior cervical discectomy and fusion: an analysis of the Michigan Spine Surgery Improvement Collaborative Database.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are established surgical options for the treatment of cervical radiculopathy, myelopathy, and cervical degenerative disc disease. However, current literature does not demonstrate a clear superiority between ACDF and CDA. PURPOSE: To investigate procedural and patient-reported outcomes of ACDF and CDA among patients included in the Michigan Spine Surgery Improvement Collaborative (MSSIC) database. DESIGN: Retrospective study of prospectively collected outcomes registry data. PATIENT SAMPLE: Individuals within the MSSIC database presenting with radiculopathy, myelopathy, or cervical spondylosis refractory to typical conservative care undergoing primary ACDF or CDA from January 4, 2016, to November 5, 2021. OUTCOME MEASURES: Perioperative measures (including surgery length, length of stay, return to OR, any complications), patient-reported functional outcomes at 2-year follow-up (including return to work, patient satisfaction, PROMIS, EQ-5D, mJOA). METHODS: Patients undergoing ACDF were matched 4:1 with those undergoing CDA; propensity analysis performed on operative levels (1- and 2- level procedures), presenting condition, demographics, and comorbidities. Initial comparisons performed with univariate testing and multivariate analysis performed with Poisson generalized estimating equation models clustering on hospital. RESULTS: A total of 2,208 patients with ACDF and 552 patients with CDA were included. Baseline demographics were similar, with younger patients undergoing CDA (45.6 vs 48.6 years; p<.001). Myelopathy was more frequent in ACDF patients (30% vs 25%; p=.015). CDA was more frequently planned as an outpatient procedure. Length of stay was increased in ACDF (1.3 vs 1.0 days; p<.001). Functional outcomes were similar, with comparable proportions of patients meeting minimal clinically important difference thresholds in neck pain, arm pain, PROMIS, EQ-5D, and mJOA score. After multivariate regression, no significant differences were seen in surgical or functional outcomes. CONCLUSIONS: This study demonstrates similar outcomes for those undergoing ACDF and CDA at 2 years. Previous meta-analyses of CDA clinical trial data adhere to strict inclusion and exclusion criteria required by clinical studies; this registry data provides "real world" clinical outcomes reflecting current practices for ACDF and CDA patient selection.

Characterization of Glutathione Dithiophosphates as Long-Acting H2S Donors.

Considering the important cytoprotective and signaling roles but relatively narrow therapeutic index of hydrogen sulfide (H2S), advanced H2S donors are required to achieve a therapeutic effect. In this study, we proposed glutathione dithiophosphates as new combination donors of H2S and glutathione. The kinetics of H2S formation in dithiophosphate solutions suggested a continuous H2S release by the donors, which was higher for the dithiophosphate of reduced glutathione than oxidized glutathione. The compounds, unlike NaHS, inhibited the proliferation of C2C12 myoblasts at submillimolar concentrations due to an efficient increase in intracellular H2S. The H2S donors more profoundly affected reactive oxygen species and reduced glutathione levels in C2C12 myocytes, in which these parameters were elevated compared to myoblasts. Oxidized glutathione dithiophosphate as well as control donors exerted antioxidant action toward myocytes, whereas the effect of reduced glutathione dithiophosphate at (sub-)micromolar concentrations was rather modulating. This dithiophosphate showed an enhanced negative inotropic effect mediated by H2S upon contraction of the atrial myocardium, furthermore, its activity was prolonged and reluctant for washing. These findings identify glutathione dithiophosphates as redox-modulating H2S donors with long-acting profile, which are of interest for further pharmacological investigation.

Robot-assisted versus conventional percutaneous sacroiliac screw fixation for posterior pelvic ring injuries: a systematic review and meta-analysis.

PURPOSE: Robot-assisted pelvic screw fixation is a new technology with promising benefits on intraoperative outcomes for patients with posterior pelvic ring injuries. We aim to compare robot-assisted pelvic screw fixation to the traditional fluoroscopy-assisted technique with regards to intraoperative and postoperative outcomes. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used along with a search of electronic information to identify all studies comparing the outcomes of robot-assisted versus conventional screw fixation in patients with posterior pelvic ring injuries. Primary outcomes included operative duration (minutes), intraoperative bleeding (mL), fluoroscopy exposure and intraoperative drilling frequency. Secondary outcome measures included Majeed score, healing time (minutes) and rate (%), postoperative complications, screw positioning, incision length (cm) and guide wire insertion times (minutes). The random effects model was used for analysis. RESULTS: Four observational studies including a total of 294 patients were identified. There was a significant difference between robot-assisted and conventional groups in terms of operative duration (MD = - 24.66, p < 0.05), intraoperative bleeding (MD = - 10.37, P < 0.05), fluoroscopy exposure (MD = - 2.15, P < 0.05) and intraoperative drilling frequency (MD = - 2.42, P = < 0.05). For secondary outcomes, no significant difference was seen in Majeed score, healing time and rate and postoperative complications. The robot-assisted group had better screw positioning, smaller incision length, and shorter anaesthesia and guide wire insertion times. CONCLUSIONS: Robot-assisted fixation has superior intraoperative outcomes compared to conventional fixation. Further studies are needed to look at postoperative outcomes as there is no significant difference in postoperative prognosis between the techniques.

Frequency division multiplexing readout of a transition edge sensor bolometer array with microstrip-type electrical bias lines.

We demonstrate multiplexed readout of 43 transition edge sensor (TES) bolometers operating at 90 mK using a frequency division multiplexing (FDM) readout chain with bias frequencies ranging from 1 to 3.5 MHz and a typical frequency spacing of 32 kHz. We improve the previously reported performance of our FDM system by two important steps. First, we replace the coplanar wires with microstrip wires, which minimize the cross talk from mutual inductance. From the measured electrical cross talk (ECT) map, the ECT of all pixels is carrier leakage dominated. Only five pixels show an ECT level higher than 1%. Second, we reduce the thermal response speed of the TES detectors by a factor of 20 by increasing the heat capacity of the TES, which allows us to bias all TES detectors below 50% in transition without oscillations. We compare the current-voltage curves and noise spectra of the TESs measured in single-pixel mode and multiplexing mode. We also compare the noise equivalent power (NEP) and the saturation power of the bolometers in both modes, where 38 pixels show less than 10% difference in NEP and 5% difference in saturation power when measured in the two different modes. The measured noise spectrum is in good agreement with the simulated noise based on measured parameters from an impedance measurement, confirming that our TES is dominated by phonon noise.

Are resident research projects correlated to future subspecialty choice in orthopaedic surgery? A ten-year retrospective review of a single centre's experience.

AIM: To determine (1) frequency of resident research projects being in the same orthopaedic subspecialty that they ultimately choose for fellowship and practice; (2) percentage of research projects that were published. METHODS: Resident Thesis Day programs were independently assessed by two reviewers from 2010 to 2020. Reviewers classified projects based on orthopaedic subspecialty: Spine, Joints, Trauma, Hand, Foot and Ankle, Sports, Pediatrics, Oncology, and Shoulder Elbow. Presenting residents' fellowship subspecialty, current practice specialty, and geographic state of current practice were collected using internet searches. Correlation of residents who completed a thesis day project in the same subspecialty as their fellowship and current practice was calculated. RESULTS: A total of 81 resident physicians, 11 (13.6%) female, were included. In the entire cohort, 50.6% did a thesis day project in a different field than their current or projected subspecialty. Of those who completed, or are currently completing fellowship, 33 (52.4%) did their thesis day project in the same subspecialty as their fellowship. Of the current residents who have matched into fellowship, 46.7% did a thesis day project in the same subspecialty. A total of 51 (63.0%) projects were published. CONCLUSION: The majority of resident research projects were published, and about 50% of orthopaedic residents went on to complete a fellowship and practice in the same subspecialty as their research project. As residents often spend a considerable amount of time and effort on their projects, these findings may help tailor resident education and research curriculums to focus more on research principles than specific orthopedic content.

Evaluating a novel, low-cost technique for cervical-spine immobilization for application in resource-limited LMICs: a non-inferiority trial.

STUDY DESIGN: Non-inferiority trial. OBJECTIVE: Limited cervical spinal (c-spine) immobilization in resource-limited settings of LMICs suggests alternatives are necessary for patients with traumatic injuries. We propose a novel method of c-spine immobilization using folded towels. SETTING: Washington University in St. Louis. METHODS: Using non-inferiority trial design, thirty healthy patients (median age = 22) were enrolled to test the efficacy of folded towels in comparison with rigid cervical collars, foam neck braces, and no immobilization. We measured cervical range of motion (CROM) in six cardinal directions in seated and supine positions. A weighted composite score (CS) was generated to compare immobilization methods. A preserved fraction of 75% was determined for non-inferiority, corresponding to the difference between the median values for CROM between control (no immobilization) and c-collar states. RESULTS: C-collars reduce median CROM in six cardinal directions in seated and supine positions by an average of -36.83° seated (-17.75° supine) vs. no immobilization. Folded towels and foam neck braces reduced CROM by -27° seated (-16.75° supine) and -14.25° seated (-9.5° supine), respectively. Compared to a 25% non-inferiority margin (permitting an average 9.21° of cervical movement across six cardinal directions), the CS determined folded towels are non-inferior (CSseated = 0.89, CSsupine = 0.47). Foam neck braces are inferior (CSseated = 2.35, CSsupine = 2.10). CS > 1 surpassed the non-inferiority margin and were deemed inferior. CONCLUSIONS: Folded towels are a non-inferior means of immobilizing c-spine in extension and rotation, but not flexion, vs. c-collars. We propose folded towels could be trialed in combination with backboards to deliver affordable and effective prehospital TSCI management in resource-limited settings.

Lateral mass screw placement in the atlas: description of a novel surgical technique, radiographic parameters, and review of the literature.

BACKGROUND: Numerous techniques of C1 lateral mass screw placement have been described. We sought to delineate the radiographic angle of safety medially and laterally and describe a novel surgical technique of C1 lateral mass screw placement. We sought to (I) determine the angle of safety medially and laterally of the C1 lateral mass; (II) assess the size available of the lateral mass in the AP and coronal planes; (III) describe novel technique of insertion of a C1 lateral mass screw utilizing navigation and a novel start point. METHODS: We retrospectively reviewed cervical computed tomography (CT) images of normal adults. Radiographic measurements were then obtained using these images including the angle (degrees) of safety medially and lateral of the C1 lateral mass bilaterally, as well as the length and width (mm) of the C1 lateral masses. A novel surgical technique was used by identifying the confluence of the medial aspect of the posterior arch and the lateral mass. This confluence is then marked out as the C1 screw start point. Under navigation guidance, lateral mass screws were placed with 0 degrees of medial-lateral angulation from posterior to anterior. RESULTS: Forty-five patients with a mean age of 52.6±25.6 years (33% female) were included. The mean medial and lateral angle of safety of the C1 lateral mass bilaterally was 23±3.8 degrees and 32±5 degrees, respectively. Average length and width of the lateral mass was 17.7 and 13.3 mm respectively. CONCLUSIONS: This study describes the radiographic window of safety medially and laterally for safe and reproducible placement of C1 lateral mass screws. Further, a novel technique using a medial start point and navigation guidance with 0 degrees of angulation in the coronal plane is described. Further research is required to assess outcomes of patients utilizing this method as well as biomechanical studies to assess this construct strength compared to others that are frequently used.

A Multicenter Evaluation of the Feasibility, Patient/Provider Satisfaction, and Value of Virtual Spine Consultation During the COVID-19 Pandemic.

OBJECTIVE: To assess the feasibility, patient/provider satisfaction, and perceived value of telehealth spine consultation after rapid conversion from traditional in-office visits during the COVID-19 pandemic. METHODS: Data were obtained for patients undergoing telehealth visits with spine surgeons in the first 3 weeks after government restriction of elective surgical care at 4 sites (March 23, 2020, to April 17, 2020). Demographic factors, technique-specific elements of the telehealth experience, provider confidence in diagnostic and therapeutic assessment, patient/surgeon satisfaction, and perceived value were collected. RESULTS: A total of 128 unique visits were analyzed. New (74 [58%]), preoperative (26 [20%]), and postoperative (28 [22%]) patients were assessed. A total of 116 (91%) visits had successful connection on the first attempt. Surgeons felt very confident 101 times (79%) when assessing diagnosis and 107 times (84%) when assessing treatment plan. The mean and median patient satisfaction was 89% and 94%, respectively. Patient satisfaction was significantly higher for video over audio-only visits (P < 0.05). Patient satisfaction was not significantly different with patient age, location of chief complaint (cervical or thoracolumbar), or visit type (new, preoperative, or postoperative). Providers reported that 76% of the time they would choose to perform the visit again in telehealth format. Sixty percent of patients valued the visit cost as the same or slightly less than an in-office consultation. CONCLUSIONS: This is the first study to demonstrate the feasibility and high patient/provider satisfaction of virtual spine surgical consultation, and appropriate reimbursement and balanced regulation for spine telehealth care is essential to continue this existing work.

Robotic navigation system utilization for percutaneous sacroiliac screw placement: surgical setup and technique.

Sacroiliac joint (SIJ) pathology is a common cause of significant pain and disability, and operative treatment consisting of SIJ fusion can be performed in cases where non-operative measures fail to provide sustained relief. Through the years, SIJ fusion has evolved from an open invasive procedure, to more recently, being performed through minimally invasive techniques. Intraoperative navigation systems and robotic guidance are becoming popularized for SIJ fusion, as well as other routine and complex spinal cases. The utility of navigation and robotics is the enhanced ability of the surgeon to place instrumentation more accurately, with less dissection, blood less, and overall operative time. We present a technique guide for robotic instrumented SIJ fusion with intraoperative navigation that we have put into practice at our institution and found to be very beneficial to patients for the above reasons. We describe the setup and utilization of these technologies intraoperatively, and provide specific case examples to highlight our technique. The described methods have been found to be effective and reproducible, allowing for minimally invasive SIJ screw placement with high accuracy and safety. We emphasize that utilizing intraoperative navigation and robotics is not meant to substitute for surgeon knowledge of case steps or anatomy, but rather to enhance safety and efficacy. To our knowledge, robotic SIJ fusion has not been previously described in the literature.

Dithiophosphate-Induced Redox Conversions of Reduced and Oxidized Glutathione.

Phosphorus species are potent modulators of physicochemical and bioactive properties of peptide compounds. O,O-diorganyl dithiophoshoric acids (DTP) form bioactive salts with nitrogen-containing biomolecules; however, their potential as a peptide modifier is poorly known. We synthesized amphiphilic ammonium salts of O,O-dimenthyl DTP with glutathione, a vital tripeptide with antioxidant, protective and regulatory functions. DTP moiety imparted radical scavenging activity to oxidized glutathione (GSSG), modulated the activity of reduced glutathione (GSH) and profoundly improved adsorption and electrooxidation of both glutathione salts on graphene oxide modified electrode. According to NMR spectroscopy and GC-MS, the dithiophosphates persisted against immediate dissociation in an aqueous solution accompanied by hydrolysis of DTP moiety into phosphoric acid, menthol and hydrogen sulfide as well as in situ thiol-disulfide conversions in peptide moieties due to the oxidation of GSH and reduction of GSSG. The thiol content available in dissolved GSH dithiophosphate was more stable during air oxidation compared with free GSH. GSH and the dithiophosphates, unlike DTP, caused a thiol-dependent reduction of MTS tetrazolium salt. The results for the first time suggest O,O-dimenthyl DTP as a redox modifier for glutathione, which releases hydrogen sulfide and induces biorelevant redox conversions of thiol/disulfide groups.

Prehospital care for traumatic spinal cord injury by first responders in 8 sub-Saharan African countries and 6 other low- and middle-income countries: A scoping review.

INTRODUCTION: Traumatic spinal cord injury (TSCI) constitutes a considerable portion of the global injury burden, disproportionately affecting low- and middle-income countries (LMICs). Prehospital care can address TSCI morbidity and mortality, but emergency medical services are lacking in LMICs. The current standard of prehospital care for TSCI in sub-Saharan Africa and other LMICs is unknown. METHODS: This review sought to describe the state of training and resources for prehospital TSCI management in sub-Saharan Africa and other LMICs. Articles published between 1 January 1995 and 1 March 2020 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for TSCI. Two reviewers assessed full texts meeting inclusion criteria for quality using the Newcastle-Ottawa Scale and extracted relevant characteristics to assess trends in the state of prehospital TSCI care in sub-Saharan Africa and other LMICs. RESULTS: Of an initial 482 articles identified, 23 met inclusion criteria, of which ten were set in Africa, representing eight countries. C-spine immobilization precautions for suspected TSCI patients is the most prevalent prehospital TSCI intervention for and is in every LMIC first responder program reviewed, except one. Numerous first responder programs providing TSCI care operate without C-collar access (n = 13) and few teach full spinal immobilization (n = 5). Rapid transport is most frequently reported as the key mortality-reducing factor (n = 11). Despite more studies conducted in the Southeast Asia/Middle East (n = 13), prehospital TSCI studies in Africa are more geographically diverse, but responder courses are shorter, produce fewer professional responders, and have limited C-collar availability. DISCUSSION: Deficits in training and resources to manage TSCI highlights the need for large prospective trials evaluating alternative C-spine immobilization methods for TCSI that are more readily available across diverse LMIC environments and the importance of understanding resource variability to sustainably improve prehospital TSCI care.

Disparities in outcomes after spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: Most studies on racial disparities in spine surgery lack data granularity to control for both comorbidities and self-assessment metrics. Analyses from large, multicenter surgical registries can provide an enhanced platform for understanding different factors that influence outcome. In this study, the authors aimed to determine the effects of race on outcomes after lumbar surgery, using patient-reported outcomes (PROs) in 3 areas: the North American Spine Society patient satisfaction index, the minimal clinically important difference (MCID) on the Oswestry Disability Index (ODI) for low-back pain, and return to work. METHODS: The Michigan Spine Surgery Improvement Collaborative was queried for all elective lumbar operations. Patient race/ethnicity was categorized as Caucasian, African American, and "other." Measures of association between race and PROs were calculated with generalized estimating equations (GEEs) to report adjusted risk ratios. RESULTS: The African American cohort consisted of a greater proportion of women with the highest comorbidity burden. Among the 7980 and 4222 patients followed up at 1 and 2 years postoperatively, respectively, African American patients experienced the lowest rates of satisfaction, MCID on ODI, and return to work. Following a GEE, African American race decreased the probability of satisfaction at both 1 and 2 years postoperatively. Race did not affect return to work or achieving MCID on the ODI. The variable of greatest association with all 3 PROs at both follow-up times was postoperative depression. CONCLUSIONS: While a complex myriad of socioeconomic factors interplay between race and surgical success, the authors identified modifiable risk factors, specifically depression, that may improve PROs among African American patients after elective lumbar spine surgery.

Perioperative Corticosteroids Reduce Dysphagia Severity Following Anterior Cervical Spinal Fusion: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: The anterior approach to the cervical spine is commonly used to treat cervical pathology. It is, however, associated with high rates of dysphagia, which may be associated with substantial patient morbidity. Perioperative corticosteroid administration has been advocated to decrease dysphagia rates; its efficacy, however, remains uncertain. We conducted a meta-analysis of randomized trials to determine the efficacy of perioperative corticosteroid administration in reducing postoperative dysphagia as well as any adverse effects, such as pseudarthrosis and infection. METHODS: We conducted a systematic search of electronic databases (MEDLINE, Embase, CENTRAL [Cochrane Central Register of Controlled Trials], ClinicalTrials.gov) to identify randomized controlled trials (RCTs) that evaluated corticosteroids versus any comparator for prevention of postoperative dysphagia after anterior cervical spine procedures. Two independent reviewers used the GRADE (Grades of Recommendation Assessment, Development and Evaluation) criteria to assess eligibility and risk of bias, perform data extraction, and rate the quality of evidence. The primary outcome was severity of postoperative dysphagia. We conducted meta-analyses of dysphagia (both overall and by delivery method), pseudarthrosis, and postoperative infection. RESULTS: After screening of 927 articles, a total of 7 studies were eligible for final inclusion. These included 431 patients, of whom 247 received corticosteroids and 184 received placebo or a control treatment. Moderate-quality evidence demonstrated a significant improvement in postoperative dysphagia rates (odds ratio, 0.35; 95% confidence interval, 0.20 to 0.63; p < 0.001), and this finding was robust to both permutation analyses and sensitivity analyses removing the studies with a high risk of bias. There was no significant difference between intravenous and local steroid administration (p = 0.16). There were no documented infections. There was no significantly increased risk of pseudarthrosis in those receiving steroids compared with placebo or a control treatment (p = 0.13). CONCLUSIONS: This meta-analysis found moderate-quality evidence supporting the use of perioperative corticosteroid administration as an adjunct to anterior cervical spinal procedures. Patients treated with corticosteroids intravenously or locally had significantly decreased severity of dysphagia. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Electrical cross talk of a frequency division multiplexing readout for a transition edge sensor bolometer array.

We have characterized and mapped the electrical cross talk (ECT) of a frequency division multiplexing (FDM) system with a transition edge sensor (TES) bolometer array, which is intended for space applications. By adding a small modulation at 120 Hz to the AC bias voltage of one bolometer and measuring the cross talk response in the current noise spectra of the others simultaneously, we have for the first time mapped the ECT level of 61 pixels with a nominal frequency spacing of 32 kHz in a 61 × 61 matrix and a carrier frequency ranging from 1 MHz to 4 MHz. We find that about 94% of the pixels show an ECT level of less than 0.4%. Only the adjacent pixels reach this level, and the ECT for the rest of the pixels is less than 0.1%. We also observe higher ECT levels, up to 10%, between some of the pixels, which have bundled long, parallel coplanar wires connecting TES bolometers to inductor-capacitor filters. In this case, the high mutual inductances dominate. To mitigate this source of ECT, the coplanar wires should be replaced by microstrip wires in the array. Our study suggests that an FDM system can have a relatively low ECT level, e.g., around 0.4% if the frequency spacing is 30 kHz. Our results successfully demonstrate a low electrical cross talk for a space FDM technology.

Intravenous lidocaine in spine surgery: A meta-analysis of randomized controlled trials.

BACKGROUND: This study aimed to evaluate the role of intravenous lidocaine as a supplemental pain control modality in patients undergoing spine surgery. METHODS: We conducted a meta-analysis of randomized controlled trials (RCTs) involving the use of supplemental intravenous lidocaine in spine surgery. We developed a comprehensive search strategy to adequately screen for randomized controlled trials involving intravenous lidocaine in spine surgery. Continuous outcomes included postoperative opiate consumption and postoperative pain scores. Dichotomous outcomes included nausea, vomiting, pneumonia, delirium, and wound infection. RESULTS: A total of 3 RCTs comprising 235 patients were selected for inclusion in the meta-analysis. Cumulative morphine consumption at 48 h was not statistically significant between lidocaine and control groups. Postoperative pain was not statistically significant at any measured time points in the first and second day postoperatively. There was no statistical difference in postoperative complications including nausea, vomiting, pneumonia, delirium, or surgical site infection. CONCLUSION: Our results indicated that current literature does not support the use of intravenous lidocaine as an adjunctive measure of pain management after spine surgery. Given the relatively few numbers of studies in this field, further randomized controlled trials are needed to make a definitive conclusion on the effectiveness of lidocaine in spine surgery patients.

Impact of Michigan's new opioid prescribing laws on spine surgery patients: analysis of the Michigan Spine Surgery Improvement Collaborative.

OBJECTIVE: In 2017, Michigan passed new legislation designed to reduce opioid abuse. This study evaluated the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery. METHODS: Patient data from 1 year before and 1 year after initiation of the new opioid laws (beginning July 1, 2018) were queried from the Michigan Spine Surgery Improvement Collaborative database. Before and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated. RESULTS: Patients before and after passage of the opioid laws had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3783 (48.7%) to 2698 (39.7%; p < 0.0001). Three months postoperatively, there were no differences in minimum clinically important difference (56.0% vs 58.0%, p = 0.1068), numeric rating scale (NRS) score of back pain (3.5 vs 3.4, p = 0.1156), NRS score of leg pain (2.7 vs 2.7, p = 0.3595), satisfaction (84.4% vs 84.7%, p = 0.6852), or 90-day readmission rate (5.8% vs 6.2%, p = 0.3202) between groups. Although there was no difference in readmission rates, pain as a reason for readmission was marginally more common (0.86% vs 1.22%, p = 0.0323). CONCLUSIONS: There was a meaningful decrease in preoperative narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed.

Surgical correction of rigid cervicothoracic deformity in a transgender patient: case report.

A number of spinal pathologies result in fusion of the spine, including ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis (DISH), as well as severe degenerative arthropathies. This fusion of spinal elements may result in spinal deformity affecting any region of the spine. Cervicothoracic deformity resulting in chin on chest deformity is poorly tolerated due to inability to maintain a horizontal gaze. Surgical treatment options for this condition are complex and require extensive discussion between the patient and surgical team. Here we present a case report of a 26-year-old transgender female (male to female) patient with severe chin on chest deformity and a unique pattern of spinal fusion involving only the posterior elements. She underwent C2-T8 posterior spinal fusion with thoracic pedicle subtraction osteotomy and multiple cervical facet osteotomies with good functional result. She did have severe dysphagia and required feeding tube for several weeks but did very well by 1 year postoperatively. While posterior elements of the spine are normally affected first in spondyloarthropathies such as ankylosing spondylitis, the lack of anterior spinal involvement is unique and could be attributed to hormonal therapy in this patient. This case describes a unique pattern of spondyloarthropathy and highlights the importance of a having a multi-disciplinary team for the treatment of patients with complex spinal pathologies.

3D-printed Patient-specific Spine Implants: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To review the current clinical use of 3-dimensional printed (3DP) patient-specific implants in the spine. SUMMARY OF BACKGROUND DATA: Additive manufacturing is a transformative manufacturing method now being applied to spinal implants. Recent innovations in technology have allowed the production of medical-grade implants with unprecedented structure and customization, and the complex anatomy of the spine is ideally suited for patient-specific devices. Improvement in implant design through the process of 3DP may lead to improved osseointegration, lower subsidence rates, and faster operative times. METHODS: A comprehensive search of the literature was conducted using Ovid MEDLINE, EMBASE, Scopus, and other sources that resulted in 1842 unique articles. All manuscripts describing the use of 3DP spinal implants in humans were included. Two independent reviewers (N.W. and N.E.S.) assessed eligibility for inclusion. The following outcomes were collected: pain score, Japanese Orthopedic Association (JOA) score, subsidence, fusion, Cobb angle, vertebral height, and complications. No conflicts of interest existed. No funding was received for this work. RESULTS: A total of 17 studies met inclusion criteria with a total of 35 patients. Only case series and case reports were identified. Follow-up times ranged from 3 to 36 months. Implant types included vertebral body replacement cages, interbody cages, sacral reconstruction prostheses, iliolumbar rods, and a posterior cervical plate. All studies reported improvement in both clinical and radiographic outcomes. 11 of 35 cases showed subsidence >3 mm, but only 1 case required a revision procedure. No migration, loosening, or pseudarthrosis occurred in any patient on the basis of computed tomography or flexion-extension radiographs. CONCLUSIONS: Results of the systematic review indicate that 3DP technology is a viable means to fabricate patient-matched spinal implants. The effects on clinical and radiographic outcome measures are still in question, but these devices may produce favorable subsidence and pseudoarthrosis rates. Currently, the technology is ideally suited for complex tumor pathology and atypical bone defects. Future randomized controlled trials and cost analyses are still needed. LEVEL OF EVIDENCE: IV-systematic review.