Impact of a Remote Patient Monitoring Platform on Outcomes Following a Total Hip or Knee Arthroplasty.

Background: The coronavirus pandemic highlighted the need for remote patient monitoring to deliver and provide access to patient care and education. A mobile-based app providing interactive tools for patient education and monitoring was piloted at Thunder Bay Regional Health Sciences Centre (TBRHSC) in November 2020. We aimed to examine the platform's impact on postoperative length of stay, hospital readmissions, and emergency department (ED) visits 60 days postsurgery in total hip and knee arthroplasty patients in Northwestern Ontario. Methods: Data were assessed from patients undergoing primary total hip or knee arthroplasties at TBRHSC from March 1, 2020, to February 28, 2022. Patients were divided into 2 cohorts based on enrollment with the mobile-based app (SeamlessMD). Statistical differences in outcomes were determined using Mann-Whitney or χ2 tests. An odds ratio was calculated for ED visits. Results: Patients enrolled in the mobile-based app had statistically lower length of stay (U = 7779.0, P < .001) and fewer ED visits (χ2 (1,212) = 5.570, P = .018) than patients not enrolled in the program. Patients not enrolled had 2.31 times greater odds of visiting the ED postsurgery (odds ratio = 0.432, 95% confidence interval = 0.213-0.877, P = .022). There were no statistical differences found in readmission rates. Conclusions: The implementation of the mobile-based app at TBRHSC showed its potential value as a tool to reduce costs in the healthcare system and improve patient outcomes. Consequentially, more formal studies are required to elucidate the magnitude of this effect.

Natural history of degenerative cervical myelopathy: a meta-analysis and neurologic deterioration survival curve synthesis.

BACKGROUND CONTEXT: Cervical spine surgery is rapidly increasing, and our knowledge of the natural history of degenerative cervical myelopathy (DCM) is limited. PURPOSE: To synthesize accurate time-based estimates of meaningful neurologic decline in patients with DCM managed conservatively and to provide formulae to help communicate survivorship estimates to patients. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review and meta-analysis was conducted using Cochrane and PRISMA guidelines. A librarian-assisted search strategy using multiple databases with broad search terms and validated filter functions was used. All articles were reviewed in duplicate. RESULTS: A total of 9570 studies were captured in the initial search, which after deletion of duplicates and manual review of abstracts and full texts revealed 6 studies for analyses. All studies were prospective cohorts or randomized controlled trials. The pooled survival estimates for neurologic stability (95% CrI) for mild DCM patients are: 91% (83%-97%) at one year; 85% (72%-94%) at 2 years; 84% (70%-94%) at 3 years; 75% (54%-90%) at 5 years; 66% (40%-86%) at 15 years; and 65% (39%-86%) at 20 years. The pooled survival estimates for neurologic stability (95% CrI) for moderate/severe DCM patients are: 83% (76%-89%) at 1 year; 72% (62%-81%) at 2 years; 71% (60%-80%) at 3 years; 55% (41%-68%) at 5 years; 44% (27%-59%) at 15 years; and 43% (25%-58%) at 20 years. CONCLUSIONS: This is the first quantitative synthesis of the totality of published data on DCM natural history. Our review confirms a slow decline in neurologic function. We developed formulae which can be easily used by surgeons to communicate to patients their risk of neurologic deterioration. These formulae can be used to facilitate the shared decision-making process.

Comparison of a validated decision-support tool to a standard of care triage system for knee osteoarthritis assessment: a proof-of-concept study.

BACKGROUND: Patients with knee osteoarthritis (OA) in northwestern Ontario are referred by their primary care provider (PCP) to a centralized assessment clinic for evaluation by an advanced practice physiotherapist (APP) to determine if they will require surgical management. However, many patients are found to not require surgical management, resulting in delays for patients who do. A decision-support tool was developed to address this issue and to guide treatment options by determining the need for surgical or nonsurgical approaches. METHODS: We used a proof-of-concept method to assess the use of the decision-support tool in northwestern Ontario. Data from 100 consecutive patients assessed for knee OA management were collected from the Thunder Bay centralized assessment clinic. Two levels of agreement analyses (calculated using Cohen κ statistic) were performed, between the APP assessment decision (surgical or non-surgical) and the decision-support tool recommendation, and between the surgeon's decision (surgical or non-surgical) and the decision-support tool recommendation. RESULTS: We found a near-perfect agreement (κ = 0.870, n = 65) between the APP decision and the decision-support tool recommendation, when controlled for patient preference. There was a substantial level of agreement (κ = 0.618, n = 72) between the decision-support tool recommendation and the surgeon's decision. CONCLUSION: The decision-support tool recommendation showed considerable agreement with the decisions of the APP and surgeon indicating that it could be a valuable tool to guide PCPs caring for patients with knee OA. The applicability of a decision-support tool in northwestern Ontario displayed promising results, but further research is needed to examine the feasibility in a primary care setting.

Patient, clinical, surgical, and institutional factors associated with length of stay in scheduled degenerative thoracolumbar spine surgery: National Multicenter Cohort Analysis from the Canadian Spine Outcomes and Research Network.

OBJECTIVE: Length of stay (LOS) is a contributor to costs and resource utilization. The primary goal of this study was to identify patient, clinical, surgical, and institutional variables that influence LOS after elective surgery for thoracolumbar degenerative pathology. The secondary objective was to examine variability in LOS and institutional strategies used to decrease LOS. METHODS: This is a retrospective study of prospectively collected data from a multicentric cohort enrolled in the Canadian Spine Outcomes and Research Network (CSORN) between January 2015 and October 2020 who underwent elective thoracolumbar surgery (discectomy [1 or 2 levels], laminectomy [1 or 2 levels], and posterior instrumented fusion [up to 5 levels]). Prolonged LOS was defined as LOS greater than the median. Logistic regression models were used to determine factors associated with prolonged LOS for each procedure. A survey was sent to the principal investigators of the participating healthcare institutions to understand institutional practices that are used to decrease LOS. RESULTS: A total of 3700 patients were included (967 discectomies, 1094 laminectomies, and 1639 fusions). The median LOSs for discectomy, laminectomy, and fusion were 0.0 (IQR 1.0), 1.0 (IQR 2.0), and 4.0 (IQR 2.0) days, respectively. On multivariable analysis, predictors of prolonged LOS for discectomy were having more leg pain, higher Oswestry Disability Index (ODI) scores, symptom duration more than 2 years, having undergone an open procedure, occurrence of an adverse event (AE), and treatment at an institution without protocols to reduce LOS (p < 0.05). Predictors of prolonged LOS for laminectomy were increased age, living alone, higher ODI scores, higher BMI, open procedures, longer operative time, AEs, and treatment at an institution without protocols to reduce LOS (p < 0.05). For posterior instrumented fusion, predictors of prolonged LOS were older age, living alone, more comorbidities, higher ODI scores, longer operative time, AEs, and treatment at an institution without protocols to reduce LOS (p < 0.05). The laminectomy group had the largest variability in LOS (SD 4.4 days, range 0-133 days). Three hundred fifty-four patients (22%) had an LOS above the 75th percentile. Ten institutions (53%) had either Enhanced Recovery After Surgery or standardized protocols in place. CONCLUSIONS: Among the factors identified in this study, worse baseline ODI scores, experiencing AEs, and treatment at an institution without protocols aimed at reducing LOS were predictive of prolonged LOS in all surgical groups. The laminectomy group had the largest variability in LOS.

Long-Term Survivorship of Cervical Spine Procedures; A Survivorship Meta-Analysis and Meta-Regression.

STUDY DESIGN: Systematic Review. OBJECTIVES: To conduct a meta-analysis on the survivorship of commonly performed cervical spine procedures to develop survival function curves for (i) second surgery at any cervical level, and (ii) adjacent level surgery. METHODS: A systematic review of was conducted following PRISMA guidelines. Articles with cohorts of greater than 20 patients followed for a minimum of 36 months and with available survival data were included. Procedures included were anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (ADR), laminoplasty (LAMP), and posterior laminectomy and fusion (PDIF). Reconstructed individual patient data were pooled across studies using parametric Bayesian survival meta-regression. RESULTS: Of 1829 initial titles, 16 citations were included for analysis. 73 811 patients were included in the second surgery analysis and 2858 patients in the adjacent level surgery analysis. We fit a Log normal accelerated failure time model to the second surgery data and a Gompertz proportional hazards model to the adjacent level surgery data. Relative to ACDF, the risk of second surgery was higher with ADR and PDIF with acceleration factors 1.73 (95% CrI: 1.04, 2.80) and 1.35 (95% CrI: 1.25, 1.46) respectively. Relative to ACDF, the risk of second surgery was lower with LAMP with deceleration factor .06 (95% CrI: .05, .07). ADR decreased the risk of adjacent level surgery with hazard ratio .43 (95% CrI: .33, .55). CONCLUSIONS: In cases of clinical equipoise between fusion procedures, our analysis suggests superior survivorship with anterior procedures. For all procedures, laminoplasty demonstrated superior survivorship.

Rate and Predictors of Failure in the Conservative Management of Stable Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review. OBJECTIVES: Management of stable traumatic thoracolumbar burst fractures in neurologically-intact patients remains controversial. Conservative management fails in a subset of patients who require subsequent surgical fixation. The aim of this review is to (1) determine the rate of conservative management failure, and (2) analyze predictive factors at admission influencing conservative management failure. METHODS: A systematic review adhering to PRISMA guidelines was performed. Studies with data pertaining to traumatic thoracolumbar burst fractures without posterior osteoligamentous injury (e.g. AO Type A3/A4) and/or the rate and predictive factors of conservative management failure were included. Risk of bias appraisal was performed. Pooled analysis of rates of failure was performed with qualitative analysis of predictors of conservative management failure. RESULTS: 16 articles were included in this review (11 pertaining to rate of conservative management failure, 5 pertaining to predictive risk factors). Rate of failure of conservative management from a pooled analysis of 601 patients is 9.2% (95% CI: 4.5%-13.9%). Admission factors predictive of conservative management failure include age, greater initial kyphotic angle, greater initial interpedicular distance, smaller initial residual canal size, greater Load Sharing Classification (LSC) score and greater admission Visual Analog Scale (VAS) pain scores. CONCLUSION: A proportion (9.2%) of conservatively managed, neurologically-intact thoracolumbar burst fractures fail conservative management. Among other factors, age, kyphotic angle, residual canal area and interpedicular distance should be investigated in prospective studies to identify the subset of patients prone to failure of conservative management. Surgical management should be carefully considered in patients with the above risk factors.

The Role of Spinal Orthoses in Osteoporotic Vertebral Fractures of the Elderly Population (Age 60 Years or Older): Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: Spinal orthoses have been generally used in the management of osteoporotic vertebral fractures in the elderly population with purported positive biomechanical and functional effects. To our knowledge, this is the first systematic review of the literature examining the role of spinal orthoses in osteoporotic elderly patients who sustain low energy trauma vertebral fractures. METHODS: A systematic literature review adherent to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted. Methodical searches utilizing MEDLINE, EMBASE, Google Scholar, and Cochrane Databases was performed. RESULTS: Of the 2019 articles initially retrieved, 7 published articles (4 randomized controlled trials and 3 prospective cohort studies) satisfied the inclusion criteria. Five studies reported improvement in quantitative measurements of spinal column stability when either a rigid or semirigid orthosis was used, while 1 study was equivocal. The studies also showed the translation of biomechanical benefit into significant functional improvement as manifested by improved postural stability and reduced body sway. Subjective improvement in pain scores and quality of life was also noted with bracing. CONCLUSION: The use of spinal orthoses in neurologically intact elderly patients aged 60 years and older with osteoporotic compression vertebral fractures results in improved biomechanical vertebral stability, reduced kyphotic deformity, enhanced postural stability, greater muscular strength and superior functional outcomes.

The Effect of Compression Applied Through Constrained Lateral Eccentricity on the Failure Mechanics and Flexibility of the Human Cervical Spine.

In contrast to sagittal plane spine biomechanics, little is known about the response of the cervical spine to axial compression with lateral eccentricity of the applied force. This study evaluated the effect of lateral eccentricity on the kinetics, kinematics, canal occlusion, injuries, and flexibility of the cervical spine in translationally constrained axial impacts. Eighteen functional spinal units were subjected to flexibility tests before and after an impact. Impact axial compression was applied at one of three lateral eccentricity levels based on percentage of vertebral body width (low = 5%, medium = 50%, high = 150%). Injuries were graded by dissection. Correlations between intrinsic specimen properties and injury scores were examined for each eccentricity group. Low lateral force eccentricity produced predominantly bone injuries, clinically recognized as compression injuries, while medium and high eccentricity produced mostly contralateral ligament and/or disc injuries, an asymmetric pattern typical of lateral loading. Mean compression force at injury decreased with increasing lateral eccentricity (low = 3098 N, medium = 2337 N, and high = 683 N). Mean ipsilateral bending moments at injury were higher at medium (28.3 N·m) and high (22.9 N·m) eccentricity compared to low eccentricity specimens (0.1 N·m), p < 0.05. Ipsilateral bony injury was related to vertebral body area (VBA) (r = -0.974, p = 0.001) and disc degeneration (r = 0.851, p = 0.032) at medium eccentricity. Facet degeneration was correlated with central bony injury at high eccentricity (r = 0.834, p = 0.036). These results deepen cervical spine biomechanics knowledge in circumstances with coronal plane loads.

The Safety Profile of Intentional or Iatrogenic Sacrifice of the Artery of Adamkiewciz and Its Vicinity's Spinal Segmental Arteries: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVES: There is paucity of consensus on whether (1) the artery of Adamkiewicz (AoA) and (2) the number of contiguous segmental spinal arteries (SSAs) that can be safely ligated without causing spinal cord ischemia. The objective of this review is to determine the risk of motor neurological deficits from iatrogenic sacrifice of the (1) AoA and (2) its vicinity's SSAs. METHODS: Systematic review of the spine and vascular surgery was carried out in accordance to PRISMA guidelines. Outcomes in terms of risk of postoperative motor neurological deficit with occlusion of the AoA, bilateral contiguous SSAs, or unilateral contiguous SSAs were analyzed. RESULTS: Ten articles, all retrospective case series, were included. Three studies (total N = 50) demonstrated a postoperative neurological deficit risk of 4.0% when the AoA is occluded. When 1 to 6 pairs of SSAs (without knowledge of AoA location) were ligated, the postoperative neurological deficit risk was 0.6%, as compared with 5.4% when more than 6 bilateral pairs of SSAs were ligated (relative risk [RR] = 0.105, 95% CI 0.013-0.841, P = .0337). For unilateral ligation of SSAs of two to nine levels, the risk of postoperative neurological deficit does not exceed 1.3%. CONCLUSION: The current best evidence indicates that (1) occlusion of the AoA and (2) occlusion of up to 6 pairs of SSAs is associated with a low risk of postoperative neurological deficit. This limited number of low quality studies restrict the ability to draw definitive conclusions. Ligation of AoA and SSAs should only be undertaken when absolutely required to mitigate the small but devastating risk of paralysis.

Cyanoacrylate Dermal Closure in Spine Surgery: Systematic Review and Pooled Analysis.

STUDY DESIGN: Systematic review. OBJECTIVES: Cyanoacrylate glue closure has been utilized for dermal closure in surgical incisions. Its safety and efficacy in spine surgery are not established. The authors perform a systematic review to determine the rate of surgical site infection (SSI), wound dehiscence, and wound erythema with cyanoacrylate dermal closure in spine surgery. METHODS: A systematic review adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed utilizing the PubMed/MEDLINE, EMBASE, and Cochrane databases on patients undergoing spine surgery with cyanoacrylate dermal closure. Pooled analysis was performed with stratification of patients according to spinal level and the presence/absence of instrumentation. Risk-of-bias and methodological quality was appraised using 17 prespecified criteria. RESULTS: Five articles (1 retrospective cohort study, 4 cases series) with a total of 1282 patients were included. A total of 967 patients, all diagnosed with degenerative spine disease, were suitable for pooled analysis. In 290 patients who underwent anterior cervical discectomy and fusion, and in 23 patients with posterior cervical decompression (without instrumentation), there was 0% rate of SSI, wound dehiscence, and erythema. In 489 patients who underwent lumbar microdiscectomy, there was 0.41% rate of SSI, 0.20% rate of wound dehiscence, and 0.20% rate of wound erythema. In 165 lumbar laminectomy patients, there was a 1.82% rate of SSI, 0.61% rate of wound dehiscence, and 0% rate of wound erythema. CONCLUSION: Cyanoacrylate dermal closure for the aforementioned procedures is associated with low rates of wound complications (SSI, dehiscence, and erythema). Further studies should be performed, especially in nondegenerative surgery, instrumented thoracic and lumbar spine surgery.

Does Combined Anterior-Posterior Approach Improve Outcomes Compared with Posterioronly Approach in Traumatic Thoracolumbar Burst Fractures?: A Systematic Review.

The aim of this systematic review was to evaluate the surgical, radiological, and functional outcomes of posterior-only versus combined anterior-posterior approaches in patients with traumatic thoracolumbar burst fractures. The ideal approach (anterior-only, posterior-only, or combined anterior-posterior) for the surgical management of thoracolumbar burst fracture remains controversial, with each approach having its advantages and disadvantages. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed (registration no., CRD42018115120). The authors reviewed comparative studies evaluating posterior-only approach compared with combined anterior-posterior approaches with respect to clinical, surgical, radiographic, and functional outcome measures. Five retrospective cohort studies were included. Postoperative neurological deterioration was not reported in either group. Operative time, estimated blood loss, and postoperative length of stay were increased among patients in the combined anterior-posterior group in one study and equivalent between groups in another study. No significant difference was observed between the two approaches with regards to long-term postoperative Cobb angle (mean difference, -0.2; 95% confidence interval, -5.2 to 4.8; p =0.936). Moreover, no significant difference in functional patient outcomes was observed in the 36item Short-Form Health Survey, Visual Analog Scale, and return-to-work rates between the two groups. The available evidence does not indicate improved clinical, radiologic (including kyphotic deformity), and functional outcomes in the combined anterior-posterior and posterior-only approaches in the management of traumatic thoracolumbar burst fractures. Further studies are required to ascertain if a subset of patients will benefit from a combined anterior-posterior approach.

Prophylactic postoperative measures to minimize surgical site infections in spine surgery: systematic review and evidence summary.

BACKGROUND CONTEXT: There are three phases in prophylaxis of surgical site infections (SSI): preoperative, intraoperative and postoperative. There is lack of consensus and paucity of evidence with SSI prophylaxis in the postoperative period. PURPOSE: To systematically evaluate the literature, and provide evidence-based summaries on postoperative measures for SSI prophylaxis in spine surgery. STUDY DESIGN: Systematic review, meta-analysis, evidence synthesis. METHODS: A systematic review conforming to PRIMSA guidelines was performed utilizing PubMed (MEDLINE), EMBASE, and the Cochrane Database from inception to January 2019. The GRADE approach was used for quality appraisal and synthesis of evidence. Six postoperative care domains with associated key questions were identified. Included studies were extracted into evidence tables, data synthesized quantitatively and qualitatively, and evidence appraised per GRADE approach. RESULTS: Forty-one studies (nine RCT, 32 cohort studies) were included. In the setting of preincisional antimicrobial prophylaxis (AMP) administration, use of postoperative AMP for SSI reduction has not been found to reduce rate of SSI in lumbosacral spine surgery. Prolonged administration of AMP for more than 48 hours postoperatively does not seem to reduce the rate of SSI in decompression-only or lumbar spine fusion surgery. Utilization of wound drainage systems in lumbosacral spine and adolescent idiopathic scoliosis corrective surgery does not seem to alter the overall rate of SSI in spine surgery. Concomitant administration of AMP in the presence of a wound drain does not seem to reduce the overall rate of SSI, deep SSI, or superficial SSI in thoracolumbar fusion performed for degenerative and deformity spine pathologies, and in adolescent idiopathic scoliosis corrective surgery. Enhanced-recovery after surgery clinical pathways and infection-specific protocols do not seem to reduce rate of SSI in spine surgery. Insufficient evidence exists for other types of spine surgery not mentioned above, and also for non-AMP pharmacological measures, dressing type and duration, suture and staple management, and postoperative nutrition for SSI prophylaxis in spine surgery. CONCLUSIONS: Despite the postoperative period being key in SSI prophylaxis, the literature is sparse and without consensus on optimum postoperative care for SSI prevention in spine surgery. The current best evidence is presented with its limitations. High quality studies addressing high risk cohorts such as the elderly, obese, and diabetic populations, and for traumatic and oncological indications are urgently required.

VIS-IT: Visualizing the Injured Tibia-A Cadaveric Study of Limb Positioning for Posterolateral Tibial Plateau Fracture Visualization.

Posterolateral tibial plateau (PLTP) fractures are often associated with anterior cruciate ligament (ACL) incompetence, such as tibial eminence fractures. Both occur from a pivot shift like mechanism. Malreductions of the tibial plateau most frequently occur in the posterolateral quadrant. Acquiring adequate intraoperative visualization of the PLTP poses a challenge. We hypothesized that visualization of PLTP could be improved by positioning the knee at 110 degrees of flexion with the addition of a varus anterolateral rotatory vector. This position and maneuver take advantage of both the nonisometric nature of the lateral soft tissues and, when present, ACL incompetence. In this cadaveric study, we digitally quantified the percentage of the lateral tibial plateau visualized under different conditions after performing an anterolateral surgical approach with submeniscal arthrotomy. Four conditions were assessed for articular visualization: (1) 30 degrees of knee flexion, (2) 110 degrees of knee flexion, (3) 110-degrees of knee flexion plus varus anterolateral rotatory vector, (4) 110-degrees of knee flexion plus varus anterolateral rotatory vector with ACL sacrifice (ACL incompetence model). In the ACL competent models, maximal lateral tibial plateau exposure was obtained with the knee positioned at 110 degrees of flexion with a varus anterolateral rotatory vector (58.2%, range: 52.9-63.4%). Articular visualization was further improved with the ACL incompetent model (82.4%, range: 77.1-87.7%), modeling a tibial eminence fracture.

Effect of Frailty on Outcome after Traumatic Spinal Cord Injury.

Frailty negatively affects outcome in elective spine surgery populations. This study sought to determine the effect of frailty on patient outcome after traumatic spinal cord injury (tSCI). Patients with tSCI were identified from our prospectively collected database from 2004 to 2016. We examined effect of patient age, admission Total Motor Score (TMS), and Modified Frailty Index (mFI) on adverse events (AEs), acute length of stay (LOS), in-hospital mortality, and discharge destination (home vs. other). Subgroup analysis (for three age groups: <60, 61-75, and 76+ years), and multi-variable analysis was performed to investigate the impact of age, TMS, and mFI on outcome. For the 634 patients, the mean age was 50.3 years, 77% were male, and falls were the main cause of injury (46.5%). On bivariate analysis, mFI, age at injury, and TMS were predictors of AEs, acute LOS, and in-hospital mortality. After statistical adjustment, mFI was a predictor of LOS (p = 0.0375), but not of AEs (p = 0.1428) or in-hospital mortality (p = 0.1245). In patients <60 years of age, mFI predicted number of AEs, acute LOS, and in-hospital mortality. In those aged 61-75, TMS predicted AEs, LOS, and mortality. In those 76+ years of age, mFI no longer predicted outcome. Age, mFI, and TMS on admission are important determinants of outcome in patients with tSCI. mFI predicts outcomes in those <75 years of age only. The inter-relationship of advanced age and decreased physiological reserve is complex in acute tSCI, warranting further study. Identifying frailty in younger patients with tSCI may be useful for peri-operative optimization, risk stratification, and patient counseling.

Anterior versus posterior approach in traumatic thoracolumbar burst fractures deemed for surgical management: Systematic review and meta-analysis.

Uncertainties remain regarding the optimal surgical approach in the treatment of traumatic thoracolumbar burst fractures. We aim to compare the surgical, radiological and functional outcomes in anterior versus posterior approaches in patients with traumatic thoracolumbar burst fractures deemed for surgical management. A systematic review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Qualitative analysis and where suitable, meta-analysis were performed to compute pooled estimates of the differences between anterior and posterior approaches. A total of six studies (three observational, one prospective non-randomized trial, two randomized controlled trials) were included. There were no cases of postoperative neurological decline. Meta-analysis demonstrates a longer duration (Mean Difference (MD) + 81.68, 95% CI 39.20 to 123.16, p < 0.001) and increased estimated blood loss (MD + 426.27, 95% CI 119.84 to 732.70, p = 0.006) for the anterior approach. No difference between approaches was found regarding length of hospital stay, late postoperative kyphotic angle, construct failure rate, instrumentation revision rate, rate of return to work, and total hospital charges. Limitations include the small number of, and heterogeneity across studies. Given the similarities in neurological, radiological and functional outcomes between the two approaches, the longer duration and estimated blood loss in the anterior approach should be a point of consideration when selecting the surgical approach. There is an urgent need for contemporary, high quality research in this area.

A simplified clinical prediction rule for prognosticating independent walking after spinal cord injury: a prospective study from a Canadian multicenter spinal cord injury registry.

BACKGROUND CONTEXT: Traumatic spinal cord injury (SCI) is a debilitating condition with limited treatment options for neurologic or functional recovery. The ability to predict the prognosis of walking post injury with emerging prediction models could aid in rehabilitation strategies and reintegration into the community. PURPOSE: To revalidate an existing clinical prediction model for independent ambulation (van Middendorp et al., 2011) using acute and long-term post-injury follow-up data, and to investigatethe accuracy of a simplified model using prospectively collected data from a Canadian multicenter SCI database, the Rick Hansen Spinal Cord Injury Registry (RHSCIR). STUDY DESIGN: Prospective cohort study. PARTICIPANT SAMPLE: The analysis cohort consisted of 278 adult individuals with traumatic SCI enrolled in the RHSCIR for whom complete neurologic examination data and Functional Independence Measure (FIM) outcome data were available. OUTCOME MEASURES: The FIM locomotor score was used to assess independent walking ability (defined as modified or complete independence in walk or combined walk and wheelchair modality) at 1-year follow-up for each participant. METHODS: A logistic regression (LR) model based on age and four neurologic variables was applied to our cohort of 278 RHSCIR participants. Additionally, a simplified LR model was created. The Hosmer-Lemeshow goodness of fit test was used to check if the predictive model is applicable to our data set. The performance of the model was verified by calculating the area under the receiver operating characteristic curve (AUC). The accuracy of the model was tested using a cross-validation technique. This study was supported by a grant from The Ottawa Hospital Academic Medical Organization ($50,000 over 2 years). The RHSCIR is sponsored by the Rick Hansen Institute and is supported by funding from Health Canada, Western Economic Diversification Canada, and the provincial governments of Alberta, British Columbia, Manitoba, and Ontario. ET and JP report receiving grants from the Rick Hansen Institute (approximately $60,000 and $30,000 per year, respectively). DMR reports receiving remuneration for consulting services provided to Palladian Health, LLC and Pacira Pharmaceuticals, Inc ($20,000-$30,000 annually), although neither relationship presents a potential conflict of interest with the submitted work. KEH received a grant for involvement in the present study from the Government of Canada as part of the Canada Summer Jobs Program ($3,000). JP reports receiving an educational grant from Medtronic Canada outside of the submitted work ($75,000 annually). TM reports receiving educational fellowship support from AO Spine, AO Trauma, and Medtronic; however, none of these relationships are financial in nature. All remaining authors have no conflicts of interest to disclose. RESULTS: The fitted prediction model generated 85% overall classification accuracy, 79% sensitivity, and 90% specificity. The prediction model was able to accurately classify independent walking ability (AUC 0.889, 95% confidence interval [CI] 0.846-0.933, p<.001) compared with the existing prediction model, despite the use of a different outcome measure (FIM vs. Spinal Cord Independence Measure) to qualify walking ability. A simplified, three-variable LR model based on age and two neurologic variables had an overall classification accuracy of 84%, with 76% sensitivity and 90% specificity, demonstrating comparable accuracy with its five-variable prediction model counterpart. The AUC was 0.866 (95% CI 0.816-0.916, p<.01), only marginally less than that of the existing prediction model. CONCLUSIONS: A simplified predictive model with similar accuracy to a more complex model for predicting independent walking was created, which improves utility in a clinical setting. Such models will allow clinicians to better predict the prognosis of ambulation in individuals who have sustained a traumatic SCI.

Previously Identified Common Post-Injury Adverse Events in Traumatic Spinal Cord Injury-Validation of Existing Literature and Relation to Selected Potentially Modifiable Comorbidities: A Prospective Canadian Cohort Study.

Adverse events (AEs) are common during care in patients with traumatic spinal cord injury (tSCI). Increased risk of AEs is linked to patient factors including pre-existing comorbidities. Our aim was to examine the relationships between patient factors and common post-injury AEs, and identify potentially modifiable comorbidities. Adults with tSCI admitted to a Level I acute specialized spine center between 2006 and 2014 who were enrolled in the Rick Hansen SCI Registry (RHSCIR) and had AE data collected using the Spine Adverse Events Severity system were included. Patient demographic, neurological injury, and comorbidities data were obtained from RHSCIR. Potentially modifiable comorbidities were grouped into health-related conditions, substance use/withdrawal, and psychiatric conditions. Negative binomial regression and multiple logistic regression were used to model the impact of patient factors on the number of AEs experienced and the occurrence of the five previously identified common AEs, respectively. Of the 444 patients included in the study, 24.8% reported a health-related condition, 15.3% had a substance use/withdrawal condition, 8% reported having a psychiatric condition; and 79.3% experienced one or more AEs. Older age (p = 0.004) and more severe injuries (p < 0.001) were nonmodifiable independent variables significantly associated with increased AEs. The AEs experienced by patients were urinary tract infections (42.8%), pneumonia (39.2%), neuropathic pain (31.5%), delirium (18.2%), and pressure ulcers (11.0%). Risk of delirium increased in those with substance use/withdrawal; and pneumonia risk increased with psychiatric comorbidities. Opportunity exists to develop clinical algorithms that include these types of risk factors to reduce the incidence and impact of AEs.

Factors predictive of topographical accuracy in spine level localization.

BACKGROUND: Pre-operative spine level localization by palpation of anatomical landmarks (ribs, spinous processes) in posterior approaches for surgeries from T4 to L2 is often inaccurate. This can lead to ineffective utilization of procedural time, increased radiation dose, potentially longer skin incision and wrong level surgery. Factors affecting topographical accuracy includes body mass index (BMI) of the patient, congenital or acquired deformity and knowledge of topographical anatomy. METHODS: All patients had the presumed location of their pathology marked on the skin using anatomical landmarks prior to application of the Target Tape® (Vancouver, BC, Canada) and verification using an anterior-posterior radiograph. Potential factors predictive of accurate pre-operative spine level localization such as age, gender, BMI, palpable deformity, pathology related interspinous distance (ISPD) and pathology related skin to spinous process distance were evaluated. RESULTS: A prospective study was performed with 30 consecutive patients undergoing posterior spine surgery (T4 to L2). Accuracy of pathology related spine level localization using anatomical landmarks was only 40%. Pathology related ISPDs of more than 10 mm and palpable deformity was significantly correlated with successful determination of spine levels using anatomical landmarks. CONCLUSIONS: This study showed that poor spine level localization using anatomical landmarks was associated with pathology related ISPDs of less than 10 mm. Conversely, patients with palpable spinal deformity have their levels easily localized.

Technical note: removal of metal ion inhibition encountered during DNA extraction and amplification of copper-preserved archaeological bone using size exclusion chromatography.

A novel technique for the removal of metal ions inhibiting DNA extraction and PCR of archaeological bone extracts is presented using size exclusion chromatography. Two case studies, involving copper inhibition, demonstrate the effective removal of metal ion inhibition. Light microscopy, SEM, elemental analysis, and genetic analysis were used to demonstrate the effective removal of metal ions from samples that previously exhibited molecular inhibition. This research identifies that copper can cause inhibition of DNA polymerase during DNA amplification. The use of size exclusion chromatography as an additional purification step before DNA amplification from degraded bone samples successfully removes metal ions and other inhibitors, for the analysis of archaeological bone. The biochemistry of inhibition is explored through chemical and enzymatic extraction methodology on archaeological material. We demonstrate a simple purification technique that provides a high yield of purified DNA (>95%) that can be used to address most types of inhibition commonly associated with the analysis of degraded archaeological and forensic samples. We present a new opportunity for the molecular analysis of archaeological samples preserved in the presence of metal ions, such as copper, which have previously yielded no DNA results.