Freehand Pre-drilling Technique for Lateral Mass Screw Fixation Is More Efficient and Reliable Versus Sequential Drilling Technique: A Sawbone Analysis.

Background Since posterior cervical fixation with lateral mass screws was introduced in 1979, multiple techniques have been described in the literature. However, no study to date has determined whether pre-drilling all lateral masses prior to screw insertion has a benefit over the traditional sequential drilling and screw insertion on the alignment of the screw-rod construct. This study sought to determine the efficacy and efficiency in achieving alignment with a novel pre-drilling technique compared to the traditional sequential drilling technique. The authors hypothesized that the novel pre-drilling technique could be applied more quickly and precisely than the traditional sequential drilling technique. Methods Eight cervical spine sawbones models were utilized to place 64 lateral mass screws by two surgeons. The pre-drilling technique was utilized to place 32 screws in four models, and the sequential drilling technique was utilized to place the 32 screws in the remaining four models. In the traditional sequential drilling technique, each lateral mass underwent screw tract preparation and insertion before proceeding to the subsequent vertebra. In the pre-drilling technique, all lateral masses were marked and drilled sequentially before screw placement. CT imaging with 3D reconstructions was generated for all models. Variability in screw placement and time taken to fully instrument the models were compared.  Results The mean time to completion of the pre-drilling technique was 337 ± 22 seconds compared to 490 ± 22 seconds with the traditional technique (p<0.01). There was a significantly higher variability in the coronal plane within the traditional group between C5 and C6 compared to other adjacent vertebrae (p<0.05). There was no significant difference in the start point variability and the overall tightness of line fit between the techniques. Conclusions Our study suggests that a novel pre-drilling technique for lateral mass screw insertion may be more efficient and reliable than the traditional sequential drilling technique. In addition, this technique may reduce the need for rod contouring or additional implants to optimize the alignment of cervical instrumentation. However, further clinical studies are necessary to validate the potential clinical and radiologic benefits of this described technique.

An Analysis of Patient and Fracture Characteristics and Clinical Outcomes in Patients With Hyperostotic Spine Fractures.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate outcomes and complications following operative and nonoperative management of hyperostotic spine fractures. METHODS: Patients presenting between 2008 and 2017 to a single level 1 trauma center with hyperostotic spine fractures had their information and fracture characteristics reviewed. Bivariate analyses were conducted to compare patients across a number of characteristics and outcomes. Multivariate logistic regression models for complication and mortality were done in a stepwise fashion. RESULTS: Sixty-five ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH) patients with a spine fracture met our inclusion criteria. DISH was slightly more prevalent (55% vs 45%). Overall delayed diagnosis, reoperation, mortality (at 1 year), and complication rates were high at 32%, 13%, 23%, and 57%, respectively. In multivariate logistic regression models, patients undergoing operative management had significantly increased odds of having a complication (odds ratio [OR] = 23.03, 95% confidence interval [CI] = 2.24-236.45, P = .008), while increasing age was associated with increased odds of death (OR = 1.18, 95% CI = 1.06-1.31, P = .003). CONCLUSIONS: Patients with AS or DISH who fracture their spine are at high risk of complication and death. However, neither operative nor nonoperative treatment increases the odds of mortality. This study helps add to a growing, but still limited, body of literature on the characteristics of patients with spine fractures in the setting of AS or DISH.

Geriatric Cyclists: Assessing Risks, Safety, and Benefits.

Nearly 1 in every 3 Americans ride bicycles each year, but only 20% of the reported 100 million cyclists ride on a weekly basis. Bicycling is a common form of transportation and recreation and has gained popularity among the elderly patients. In recent years, the number of elderly cyclists has increased steadily and studies have cited ease of use, need for exercise, and enjoyment as important contributing factors. The benefits of physical activity on health is well-documented, and elderly individuals are encouraged to remain active to reduce the progression of age-related weakness and loss of muscle mass. Safety concerns, however, have been a prevalent public health issue. According to the Center for Disease Control and Prevention, elderly and teenage cyclists account for the highest number of head injuries and fatalities among all cyclists. Safety measures that include wearing protective gear such as helmets and choosing the appropriate bicycle have been recommended to minimize the risk of sustaining injuries while riding. Despite these concerns, bicycling has remained a popular and exciting activity for the elderly patients.

Louis A. Goldstein, MD: A Pioneer in Spinal Deformity Surgery.

MINI: During the first half of the 20th century interest in spinal deformity grew due to common conditions of that era including polio and tuberculosis. This article will discuss Louis Arnold Goldstein, a visionary leader in spinal deformity surgery from Rochester, New York and one of the founders of the Scoliosis Research Society.During the first half of the 20th century interest in spinal deformity grew due to common conditions of that era including polio and tuberculosis. This article will discuss Louis Arnold Goldstein, a visionary leader in spinal deformity surgery from Rochester, New York and one of the founders of the Scoliosis Research Society. Louis A. Goldstein was a talented surgeon, administrator, and clinician scientist. He also started a spine surgery fellowship program that still bears his name and that continues to train complex spine surgeons.

Myositis ossificans of the longus coli muscle following cervical spine fracture-dislocation.

BACKGROUND: Upper cervical spine fractures are traumatic injuries typically associated with high-energy trauma and have a high morbidity and mortality rate. We describe a case of upper cervical spine fracture occurring due to high-energy trauma that resulted in significant myositis ossificans (MO) of the longus coli muscle. STUDY DESIGN: Case Report and literature review. METHODS: Retrospective review of medical records. RESULTS: The patient was treated non-operatively for the neck rotation and MO of his longus coli muscle and had gradual improvement of symptoms. CONCLUSIONS: To our knowledge, this is the first report of symptomatic MO of the longus coli following traumatic cervical spine fracture in an adult. Treatment with supportive measures appears to achieve satisfactory outcome.

An Independent Evaluation of the Validity of a DNA-Based Prognostic Test for Adolescent Idiopathic Scoliosis.

BACKGROUND: ScoliScore is a DNA-based prognostic test, designed and used to help to predict the risk of curve progression in patients with adolescent idiopathic scoliosis. The role of this test in clinical practice remains unclear as the published results of the ScoliScore have not been validated independently. The purpose of this study was to determine if the ScoliScore effectively predicted the risk of curve progression in patients with mild and moderate adolescent idiopathic scoliosis in two urban academic medical centers. METHODS: One hundred and twenty-six patients with adolescent idiopathic scoliosis who met inclusion criteria at two centers were administered the ScoliScore test. Two groups were created: a progression group (those who had a Cobb angle of >40° or those who had undergone surgical fusion) and a non-progression group (those who had skeletal maturity without curve progression to 40°). ScoliScore values and risk levels were compared between the two groups. The negative predictive value was calculated for low-risk scores and the positive predictive value was calculated for high-risk scores. RESULTS: There was no significant difference (p = 0.706) in the mean ScoliScore (and standard deviation) between patients with curve progression (107 ± 55 points) and those without curve progression (102 ± 62 points). There was also no significant difference (p = 0.399) in curve progression between patients with high-risk scores (26.7%) and those with low-risk scores (12.9%). The positive predictive value of the test was 0.27 (95% confidence interval, 0.09 to 0.55), and the negative predictive value was 0.87 (95% confidence interval, 0.69 to 0.96). ScoliScores and rates of progression were not affected by brace-wear. CONCLUSIONS: ScoliScores did not differ between patients with and without curve progression, and the negative and positive predictive values were lower in our study than in the previously published validation study by the developers of the test. This may be due to differences in our test population, genetic variability, or failure of patients in the non-progression group to follow up.

Development and initial validation of the Classification of Early-Onset Scoliosis (C-EOS).

BACKGROUND: Early-onset scoliosis is a heterogeneous condition, with highly variable manifestations and natural history. No standardized classification system exists to describe and group patients, to guide optimal care, or to prognosticate outcomes within this population. A classification system for early-onset scoliosis is thus a necessary prerequisite to the timely evolution of care of these patients. METHODS: Fifteen experienced surgeons participated in a nominal group technique designed to achieve a consensus-based classification system for early-onset scoliosis. A comprehensive list of factors important in managing early-onset scoliosis was generated using a standardized literature review, semi-structured interviews, and open forum discussion. Three group meetings and two rounds of surveying guided the selection of classification components, subgroupings, and cut-points. Initial validation of the system was conducted using an interobserver reliability assessment based on the classification of a series of thirty cases. RESULTS: Nominal group technique was used to identify three core variables (major curve angle, etiology, and kyphosis) with high group content validity scores. Age and curve progression ranked slightly lower. Participants evaluated the cases of thirty patients with early-onset scoliosis for reliability testing. The mean kappa value for etiology (0.64) was substantial, while the mean kappa values for major curve angle (0.95) and kyphosis (0.93) indicated almost perfect agreement. The final classification consisted of a continuous age prefix, etiology (congenital or structural, neuromuscular, syndromic, and idiopathic), major curve angle (1, 2, 3, or 4), and kyphosis (-, N, or +) variables, and an optional progression modifier (P0, P1, or P2). CONCLUSIONS: Utilizing formal consensus-building methods in a large group of surgeons experienced in treating early-onset scoliosis, a novel classification system for early-onset scoliosis was developed with all core components demonstrating substantial to excellent interobserver reliability. This classification system will serve as a foundation to guide ongoing research efforts and standardize communication in the clinical setting.

Deletion of the receptor for advanced glycation end products reduces glomerulosclerosis and preserves renal function in the diabetic OVE26 mouse.

OBJECTIVE: Previous studies showed that genetic deletion or pharmacological blockade of the receptor for advanced glycation end products (RAGE) prevents the early structural changes in the glomerulus associated with diabetic nephropathy. To overcome limitations of mouse models that lack the progressive glomerulosclerosis observed in humans, we studied the contribution of RAGE to diabetic nephropathy in the OVE26 type 1 mouse, a model of progressive glomerulosclerosis and decline of renal function. RESEARCH DESIGN AND METHODS: We bred OVE26 mice with homozygous RAGE knockout (RKO) mice and examined structural changes associated with diabetic nephropathy and used inulin clearance studies and albumin:creatinine measurements to assess renal function. Transcriptional changes in the Tgf-beta1 and plasminogen activator inhibitor 1 gene products were measured to investigate mechanisms underlying accumulation of mesangial matrix in OVE26 mice. RESULTS: Deletion of RAGE in OVE26 mice reduced nephromegaly, mesangial sclerosis, cast formation, glomerular basement membrane thickening, podocyte effacement, and albuminuria. The significant 29% reduction in glomerular filtration rate observed in OVE26 mice was completely prevented by deletion of RAGE. Increased transcription of the genes for plasminogen activator inhibitor 1, Tgf-beta1, Tgf-beta-induced, and alpha1-(IV) collagen observed in OVE26 renal cortex was significantly reduced in OVE26 RKO kidney cortex. ROCK1 activity was significantly lower in OVE26 RKO compared with OVE26 kidney cortex. CONCLUSIONS: These data provide compelling evidence for critical roles for RAGE in the pathogenesis of diabetic nephropathy and suggest that strategies targeting RAGE in long-term diabetes may prevent loss of renal function.