Development of a Novel Risk Stratification Score to Predict 30-Day Mortality in Cervical Trauma Patients: CLAAD Score.

STUDY DESIGN: Case control. OBJECTIVE: Traumatic cervical spine injuries are associated with a substantial risk of mortality. The aim of this study is to develop a novel mortality prediction model for patients with cervical trauma who require operative treatment. SUMMARY OF BACKGROUND DATA: Patients with cervical spine trauma have a high risk of postoperative complications and mortality. There are few reliable systems that can accurately predict mortality after surgery for cervical spine trauma, and those that do exist are typically not specific to cervical trauma. MATERIALS AND METHODS: The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients undergoing surgery for cervical spine trauma. Univariate analyses were performed to identify variables associated with mortality. Variables that were found to be significant in the univariate models were compiled into a multivariable model. The final model was compared with the American Society of Anesthesiologists (ASA), a modified Charlson comorbidity index (mCCI), and the 5-factor modified frailty index (mFI-5) in respect to predicting 30-day mortality after cervical trauma. The score was then externally validated using the Nationwide Inpatient Sample (NIS) database. RESULTS: Fifty-five (6.7%) of 822 patients did not survive 30 days after surgery. The final multivariable logistic regression model consisted of the following variables: circumferential fusion "C." long "L" fusion (more than 4 levels), anemia "A," age over 60 "A," and dialysis "D." The risk of mortality increased with increasing CLAAD score, with mortality rates of 0.9%, 3.1%, 7.4%, 22.7%, and 14.3% for scores of 0, 1, 2, 3, and 4, respectively. The CLAAD model had an AUC of 0.73 for predicting mortality after cervical trauma. CONCLUSIONS: The CLAAD score is a simple and effective system that can help identify patients at risk of increased mortality within 30 days of cervical trauma. LEVEL OF EVIDENCE: Level III.

Increased Time to Fixation After Traumatic Spinal Cord Injury Influenced by Race and Insurance Status.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Although the optimal timing of surgical intervention for traumatic spinal cord injury (TSCI) is controversial, early intervention has been recognized as being beneficial in several studies. The objective of this study was to evaluate the socioeconomic factors that may delay time to surgical fixation in the management of TSCI. METHODS: The present study utilized the Trauma Quality Improvement Program (TQIP) dataset to identify patients aged greater than 18 undergoing spinal fusion for TSCI from 2007-2016. Patients were divided into subgroups based on race and insurance types. Multivariable linear regression was used to compare time to procedure based on race and payer type while adjusting for demographic and injury-specific factors. Significance was set at P < .05. RESULTS: Using multivariable analysis, Hispanic and Black patients were associated with significantly increased time to fixation of 12.1 h (95% CI 5.5-18.7, P < .001), and 20.1 h (95% CI 12.1-28.1, P < .001), respectively compared to White patients. Other cohorts based on racial status did not have significantly different times to fixation (P > .05). Medicaid was associated with an increased time to fixation compared to private insurance (11.6 h, 95% CI 3.9-19.2, P = .003). CONCLUSIONS: Black and Hispanic race and Medicaid were associated with statistically significant increases in time to fixation following TSCI, potentially compromising quality of patient care and resulting in poorer outcomes. More research is needed to elucidate this relationship and ensure equitable care is being delivered.

Gender diversity at spine surgery academic conferences: a 15-year investigation.

BACKGROUND CONTEXT: Enhancing gender diversity at academic conferences is critical for advancing women's representation and career trajectories in spine surgery. PURPOSE: To discover trends in women's representation at major spine conferences over a 15-year period. STUDY DESIGN/SETTING: Conference records from the 2007-2021 annual meetings of the Congress of Neurological Surgeons, North American Spine Society, and Scoliosis Research Society (SRS). PATIENT SAMPLE: Authors of spine-related presentations. OUTCOME MEASURES: Authorship by gender. METHODS: Retrospective bibliometric analysis with univariate and multivariate modeling to identify trends and predictors of gender diversity. RESULTS: Among 8,948 presentations, 750 (8.4%) had female first authors and 618 (6.9%) had female senior authors. There was no change in rates of female first authorship (p=.41) or senior authorship (p=.88) over time. The strongest predictors of female first authorship were having a female senior author (OR 7.32, p<.001), and delivering presentations at SRS (OR 1.95, p=.001). Factors negatively associated with female first authorship included poster format (OR 0.82, p=.039) and conference location in the United States/Canada (OR 0.76, p=.045). Similar trends were encountered for senior authorship. Productivity per senior author was similar between genders (p=.160); whereas a gender gap in productivity per first author during 2007 to 2011 (p=.020) equalized by 2017 to 2021 (p=.300). Among the 10 most productive authors of each gender, male authors delivered more presentations, but all authors shared similar format, content, and location. CONCLUSIONS: Women's representation in spine-related presentations did not increase at three major conferences over a 15-year period. Our findings regarding the positive effects of female mentorship, and international or virtual venues merit further investigation to address the gender gap. The upstream pipeline of recruiting women into academic spine surgery also needs to be addressed.

Predicting Mortality Following Odontoid Fracture Fixation in Elderly Patients: CAADS-16 Score.

STUDY DESIGN: Retrospective Review of a National Database. INTRODUCTION: By utilizing a national database, this study aims to quantify the predictors of 30-day mortality after odontoid fixation and guide appropriate management for patients in whom the choice between operative and non-operative management is unclear. METHODS: The American College of Surgeons National Surgical Quality Improvement Database was queried using Current Procedural Terminology (CPT) codes and International Classification of Disease (ICD) codes to identify patients 60 or older who underwent surgical fixation of an odontoid fracture from 2005 to 2020. Risk factors for mortality significant in univariate and subsequent multivariate analysis were used to develop a scoring system to predict post-operative mortality. RESULTS: 608 patients were identified. Patients were split into a non-mortality 30 days post-op group, and into a mortality 30 days post-op group. The following risk factors were included in the scoring system: functional dependency, disseminated cancer, albumin less than 3.5, WBC count greater than 16 k, anterior surgical approach, and pre-op SIRS. Using a cutoff value of 2, the CAAD-16 score had a sensitivity and specificity of 82% and 81%, respectively. The ASA score, cutoff at 4, showed a sensitivity and specificity of 64% and 75% respectively. CONCLUSIONS: This sample of 294 patients represents one of the largest samples of odontoid fracture fixation patients available in the literature and comes from a nationally representative database. We structure relevant risk factors into the CAADS-16 score, which has the potential to be a clinically relevant tool to prevent short-term postoperative mortality.

Prevention of Proximal Junctional Kyphosis Using Proximal Fixation Techniques.

BACKGROUND: Adult spinal deformity (ASD) is a disorder characterized by abnormal curvature of the spine resulting from progressive degeneration of spinal elements. Although operative intervention for ASD is commonplace, it is associated with several complications, including proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). The objective of this review is to outline the role of proximal fixation in preventing PJK and PJF. METHODS: We conducted a literature search using the Embase, Scopus, Web of Science, CINHAL, Cochrane Library, and PubMed MEDLINE databases. We considered only studies focusing on adult patients and selected clinical studies investigating proximal fixation techniques. RESULTS: There was mixed evidence of the efficacy of hooks and other instrumentation methods in preventing PJK, although most studies supported the use of hooks. Selection of lower thoracic vertebrae was associated with higher rates of PJK and PJF in several studies, although the relationship was inconsistent, and many studies reported no significant difference in rates of PJK or PJF between different upper instrumented vertebra (UIV) levels. Other techniques that are not related to specific instrumentation or vertebral selection, such as adjusting UIV screw trajectory, were also referenced. However, the evidence supporting these techniques was limited. DISCUSSION: Despite the presence of numerous studies in the literature discussing proximal fixation strategies to reduce the incidence of PJK/PJF, the lack of prospective studies and high variability in study methods make direct comparison challenging. We could not draw strong conclusions regarding the superiority of any one technique, despite promising clinical results with a strong biomechanical basis in several studies. CLINICAL RELEVANCE: This systematic literature review showed that a variety of proximal fixation techniques have been used to prevent PJK/PJF without clear evidence in favor of any particular technique.

Improvement of postural stability and gait velocity after cervical decompression surgery in patients with cervical spondylotic myelopathy.

OBJECTIVE: Cervical spondylotic myelopathy (CSM) is a progressive degenerative condition that can lead to significant neurological deficits, including gait instability. Biomechanical alterations of gait and its various components are poorly understood. The goal of the current study was to determine how spatiotemporal gait parameters, as well as postural and dynamic stability, change after surgery in CSM patients. METHODS: A total of 47 subjects were included, with 23 test subjects and 24 controls. Baseline measurements were made for both cohorts. In the CSM cohort, repeat measurements were made at 3 and 6 months postoperatively. To record spatiotemporal and dynamic stability parameters, subjects performed walking trials over force plates on a 15-m runway. To assess postural stability, standing balance trials were conducted on a floor-mounted force plate. Three-dimensional motion analysis cameras and gait modeling software were used to quantify and visually represent results. Statistical analysis was completed using repeated-measures ANOVA and paired t-tests. Significance was set at p < 0.05. RESULTS: CSM patients had significantly increased gait velocity at the 6-month follow-up (mean 0.948 ± 0.248 m/sec/leg length) versus baseline (mean 0.852 ± 0.257 m/sec/leg length) (p = 0.039). The tilted ellipse area was significantly decreased at the 6-month follow-up compared with baseline (mean 979.8 ± 856.7 mm2 vs 598.0 ± 391.1 mm2, p = 0.018). Angular momentum excursion was not significantly different between baseline and the 3- and 6-month follow-ups. CONCLUSIONS: CSM patients displayed significant improvement in gait velocity and postural stability parameters after decompressive surgery. Dynamic stability parameters did not change significantly during the study period.

Does a Reduced Secondary Operation Rate Offset Higher Implant Charges when Utilizing Suture Button Fixation for Syndesmotic Injuries?

OBJECTIVE: To determine whether a reduced secondary operation rate offsets higher implant charges when using suture button fixation for syndesmotic injuries. DESIGN: Retrospective cohort study. SETTING: Single, urban, Level 1 trauma center. PARTICIPANTS: Three-hundred twenty-seven (N = 327) skeletally mature patients with rotational ankle fractures (OTA/AO type 44) necessitating concurrent syndesmotic fixation. INTERVENTION: Suture button or solid 3.5-mm screw syndesmotic fixation. MAIN OUTCOME MEASUREMENTS: To compare implant charges with secondary operation charges based on differential implant removal rates between screws and suture buttons. RESULTS: Patients undergoing screw fixation were older (48.8 vs. 39.6 years, P < 0.01), had more ground-level fall mechanisms (59.3% vs. 51.1%, P = 0.026), and sustained fewer 44C type injuries (34.7% vs. 56.8%, P = 0.01). Implant removal occurred at a higher rate in the screw fixation group (17.6% vs. 5.7%, P = 0.005). Binomial logistic regression identified nonsmoker status (B = 1.03, P = 0.04) and implant type (B = 1.41, P = 0.008) as factors associated with implant removal. Adjusting for age, the NNT with a suture button construct to prevent one implant removal operation was 9, with mean resulting additional implant charges of $9747 ($1083/case). Backward calculations using data from previous large studies estimated secondary operation charges at approximately $14220, suggesting a potential 31.5% cost savings for suture buttons when considering reduced secondary operation rates. CONCLUSIONS: A reduced secondary operation rate may offset increased implant charges for suture button syndesmotic fixation when considering institutional implant removal rates for operations occurring in tertiary care settings. Given these offsetting charges, surgeons should use the syndesmotic fixation strategy they deem most appropriate in their practice setting. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

No Difference in Two-Year Revisions Between Hybrid Fusion and Two-Level Anterior Discectomy and Fusion: A National Database Study.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: This study utilized a large national database to compare two-year revision rates, in addition to complications and costs, of hybrid surgery (HS) compared to two-level anterior cervical discectomy and fusion (ACDF). METHODS: This study used the PearlDiver Mariner dataset selecting for patients aged 18 and older who had at least 90-day active longitudinal follow-up who underwent two-level ACDF or two-level Hybrid surgery (single level ACDF and single level CDA). Patients with prior spinal trauma, infection, cancer, or posterior fusion were excluded. Primary outcomes measures were 90-day major and minor medical complications, ED visits, readmissions, as well as two-year revisions. Patients were also assessed for postoperative dysphagia, incidental durotomy, vascular injury, 90-day surgical site, and implant complications. Additionally, hospitalization and postoperative costs were evaluated. RESULTS: There were 4570 two-level ACDF surgeries and 888 hybrid surgeries. After matching the cohorts, no statistical differences in demographics were found. There were no differences in reoperation rates at all measured time points nor 2-year complications. HS had a lower incidence of major (1.6% vs 3.1%, P = .003) and minor complications (3.0% vs 4.6%, P = .009) than ACDF. 90-day readmission was lower in the HS cohort (2.8% vs 4.2%), P = .024. HS was associated with reduced hospitalization costs -$2614 (-$3916 to -$904, P < .001). 3516 patients had ACDF, and 699 had HS with at least 2 years of follow-up. CONCLUSION: Hybrid surgery is a safe and effective surgical treatment for cervical disease in appropriately selected patients.

Outcomes of Various Antibiotic Cement-Coated Intramedullary Implants on the Treatment of Long Bone Septic Nonunion.

OBJECTIVE: To determine the effectiveness of various types of antibiotic-coated intramedullary implants in the treatment of septic long bone nonunion. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PARTICIPANTS: Forty-one patients with septic long bone nonunion treated with an antibiotic cement-coated intramedullary implant. INTERVENTION: Surgical debridement and placement of a type of antibiotic-coated intramedullary implant. MAIN OUTCOME MEASUREMENTS: Union and need for reoperation. RESULTS: At an average 27-month follow-up (6-104), 27 patients (66%) had a modified radiographic union score of the tibia of 11.5 or greater, 12 patients (29%) a score lower than 11.5, and 2 patients (5%) underwent subsequent amputation. Six patients underwent no further surgical procedures after the index operation. Patients treated with a rigid, locked antibiotic nail achieved earlier weight-bearing (P = 0.001), less frequently required autograft (P = 0.005), and underwent fewer subsequent procedures (average 0.38 vs. 3.60, P = 0.004) than those treated with flexible core antibiotic rods. CONCLUSIONS: Antibiotic-coated intramedullary implants are successful in the treatment of septic nonunions in long bones. In our cohort, rigid, statically locked nails allowed faster rehabilitation, decreased the need for autograft, and decreased the number of additional surgical procedures. Further study is needed to confirm these findings. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pervasive distribution of polyester fibres in the Arctic Ocean is driven by Atlantic inputs.

Microplastics are increasingly recognized as ubiquitous global contaminants, but questions linger regarding their source, transport and fate. We document the widespread distribution of microplastics in near-surface seawater from 71 stations across the European and North American Arctic - including the North Pole. We also characterize samples to a depth of 1,015 m in the Beaufort Sea. Particle abundance correlated with longitude, with almost three times more particles in the eastern Arctic compared to the west. Polyester comprised 73% of total synthetic fibres, with an east-to-west shift in infra-red signatures pointing to a potential weathering of fibres away from source. Here we suggest that relatively fresh polyester fibres are delivered to the eastern Arctic Ocean, via Atlantic Ocean inputs and/or atmospheric transport from the South. This raises further questions about the global reach of textile fibres in domestic wastewater, with our findings pointing to their widespread distribution in this remote region of the world.

Clinical Outcome of Non-Surgical Root Canal Treatment Using a Single-cone Technique with Endosequence Bioceramic Sealer: A Retrospective Analysis.

INTRODUCTION: One of the important steps in root canal treatment is to create a well-sealed root canal system. EndoSequence BC Sealer (BC; Brasseler USA, Savannah, GA) has several beneficial properties and thus has been incorporated into the practitioner's armamentarium. No studies to date have evaluated the clinical success of using BC. The purpose of this study was to evaluate the outcome of nonsurgical root canal treatment using a single-cone and BC technique and to identify factors associated with success or failure. METHODS: This retrospective cohort study included patients treated in a private practice environment between 2009 and 2015. All cases, including initial and retreatment, were obturated with BC using a single-cone technique with a minimum of a 1-year recall. Patient and treatment factors were analyzed to determine their significance as prognostic factors. Outcome was evaluated based on clinical and radiographic findings at recall. Teeth were classified as healed, healing (success), or not healed (failure). Statistical analysis of potential prognostic factors was performed using the chi-square test (α = 0.05). RESULTS: Three hundred seven teeth were included in the analysis, and the average follow-up time was 30.1 months. The overall success rate was 90.9%. Lesions <5 mm in diameter had a significantly higher success rate than lesions >5 mm in diameter. Sealer extrusion was observed in 47.4% of the cases. The presence of sealer extrusion did not have any significant effect on the treatment outcome. CONCLUSIONS: BC used with a single-cone technique is a viable option for obturation.

Relationship Between Dental Hygiene Students' Performance in an Oral Radiology Course and the National Board Dental Hygiene Examination: A Retrospective Study.

Dental hygiene students' performance in oral radiology courses may give an early indication of their readiness prior to taking the National Board Dental Hygiene Examination (NBDHE). The aim of this study was to determine the relationship between dental hygiene students' performance in an oral radiology lecture course and their performance on the NBDHE. Data were collected for all 117 dental hygiene students at Texas A&M University College of Dentistry from 2006 to 2009 who took the NBDHE during their second year of the program. Their final grades and scores on three written section examinations in an oral radiology course taken in their first year were compared with their overall NBDHE scores and raw scores on the oral radiology and case study sections. Moderate correlations (0.3

Dentist shortage: an analysis of dentists, practices, and populations in the underserved areas.

OBJECTIVES: The objectives of this study are to identify and describe the characteristics of dental underserved geographic areas. Understanding these characteristics is an important step in addressing access to dental care barriers. METHODS: Dental underserved areas were identified from the Health Resources and Services Administration (HRSA) database and converted to census tracts for analysis. Characteristics of dental underserved geographic areas were compared with areas not designated as underserved. Dental practices included in the Dun & Bradstreet Business information database were geocoded and analyzed according to the underserved designation of their location and census demographic data. Thus, the relationships between dental underserved status, practice, and population characteristics were evaluated. RESULTS: Dental underserved areas are more likely to comprise individuals with lower socio-economic status (income and education levels), higher levels of underrepresented population groups, and have lower population densities than non-underserved areas. The populations living in dental underserved areas are more likely to experience geographic, financial, and educational barriers to dental care. CONCLUSIONS: The study identifies the geographic and financial barriers to dental care access. These findings suggest that the likelihood of a market-driven solution to dental underserved geographic areas is low and support public sector interventions to improve the status quo.

Practice Location Characteristics of Non-Traditional Dental Practices.

Current and future dental school graduates are increasingly likely to choose a non-traditional dental practice-a group practice managed by a dental service organization or a corporate practice with employed dentists-for their initial practice experience. In addition, the growth of non-traditional practices, which are located primarily in major urban areas, could accelerate the movement of dentists to those areas and contribute to geographic disparities in the distribution of dental services. To help the profession understand the implications of these developments, the aim of this study was to compare the location characteristics of non-traditional practices and traditional dental practices. After identifying non-traditional practices across the United States, the authors located those practices and traditional dental practices geographically by zip code. Non-traditional dental practices were found to represent about 3.1% of all dental practices, but they had a greater impact on the marketplace with almost twice the average number of staff and annual revenue. Virtually all non-traditional dental practices were located in zip codes that also had a traditional dental practice. Zip codes with non-traditional practices had significant differences from zip codes with only a traditional dental practice: the populations in areas with non-traditional practices had higher income levels and higher education and were slightly younger and proportionally more Hispanic; those practices also had a much higher likelihood of being located in a major metropolitan area. Dental educators and leaders need to understand the impact of these trends in the practice environment in order to both prepare graduates for practice and make decisions about planning for the workforce of the future.

Texas First Dental Home: A Snapshot after Five Years.

BACKGROUND: Early caries is still the most prevalent disease of childhood. Its incidence continues to be high, despite recent progress in the amount of untreated caries. The disease is more prevalent in low socio-economic and minority groups. To address this issue, in 2008 Texas implemented the First Dental Home Program for Medicaid children from 6 to 35 months old. The program consists in providing up to 10 preventive and oral health education visits to children very early in life. A specific dental visit code and a bundled payment of $94 were offered to insure adequate dental provider participation. Little is known about the program results to date. This paper evaluates program development at 5 years. METHODS: Two data sets on first dental home patients and providers were obtained from the Texas Department of Health Services. The data cover a 5-year period (3rd quarter of 2008 to end of 2nd quarter 2013). Program participants were geocoded and their distribution was compared to dental underserved areas. Program uptake over time and the relationship between provider and patient locations were also evaluated. RESULTS: The program covered 440,191 children between September 1st, 2011 and February 28th, 2013. All but two counties in Texas had at least one patient enrolled in the program. As expected, program uptake was higher in highly populated and economically disadvantaged counties. Forty-five percent of Texas licensed dentists participated in the program. The number of dental providers certified to provide first dental home services was highly correlated with the number of patients enrolled in the program (r = 0.893). The number of children participating in the program was between 20.4% and 23%. 29.7% of the first dental home patients had only one visit while only 17.1% had five or more visits. The number of patients and the number of visits per patient peaked at the end of 2011 and flatten thereafter. CONCLUSION: Many children benefited from the program since its rollout. However, despite considerable financial resources and dental provider participation, the uptake of the first dental home program by Medicaid beneficiaries could be improved. Moreover, those who participate do not always take full advantage of the program. Without adequate participation, the desired outcomes of the program may not materialize. Additional efforts to catalyze program development and on-going evaluation may be needed.

The past and future evolution of the dental workforce team.

This article looks at changes in the number and mix of providers in the dental workforce over the past sixty years. First, enrollment trends in dental education programs are investigated. These educational programs feed directly into the dental workforce. Then, the changes in the dental workforce are examined. The focus of this investigation is the composition of the dental workforce and how the components of the workforce have changed over time. The forces that are responsible for these changes in the workforce are explored next. Finally, the possibility for workforce changes in the future is considered.