Sagittal Alignment in the Degenerative Lumbar Spine: Surgical Planning.

➤ Sagittal alignment of the spine has gained attention in the field of spinal deformity surgery for decades. However, emerging data support the importance of restoring segmental lumbar lordosis and lumbar spinal shape according to the pelvic morphology when surgically addressing degenerative lumbar pathologies such as degenerative disc disease and spondylolisthesis.➤ The distribution of caudal lordosis (L4-S1) and cranial lordosis (L1-L4) as a percentage of global lordosis varies by pelvic incidence (PI), with cephalad lordosis increasing its contribution to total lordosis as PI increases.➤ Spinal fusion may lead to iatrogenic deformity if performed without attention to lordosis magnitude and location in the lumbar spine.➤ A solid foundation of knowledge with regard to optimal spinal sagittal alignment is beneficial when performing lumbar spinal surgery, and thoughtful planning and execution of lumbar fusions with a focus on alignment may improve patient outcomes.

An Artificial Intelligence Approach to Predicting Unplanned Intubation Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Level III retrospective database study. OBJECTIVES: The purpose of this study is to determine if machine learning algorithms are effective in predicting unplanned intubation following anterior cervical discectomy and fusion (ACDF). METHODS: The National Surgical Quality Initiative Program (NSQIP) was queried to select patients who had undergone ACDF. Machine learning analysis was conducted in Python and multivariate regression analysis was conducted in R. C-Statistics area under the curve (AUC) and prediction accuracy were used to measure the classifier's effectiveness in distinguishing cases. RESULTS: In total, 54 502 patients met the study criteria. Of these patients, .51% underwent an unplanned re-intubation. Machine learning algorithms accurately classified between 72%-100% of the test cases with AUC values of between .52-.77. Multivariable regression indicated that the number of levels fused, male sex, COPD, American Society of Anesthesiologists (ASA) > 2, increased operating time, Age > 65, pre-operative weight loss, dialysis, and disseminated cancer were associated with increased risk of unplanned intubation. CONCLUSIONS: The models presented here achieved high accuracy in predicting risk factors for re-intubation following ACDF surgery. Machine learning analysis may be useful in identifying patients who are at a higher risk of unplanned post-operative re-intubation and their treatment plans can be modified to prophylactically prevent respiratory compromise and consequently unplanned re-intubation.

Risk of Dislocation and Revision Following Primary Total Hip Arthroplasty in Patients With Prior Lumbar Fusion With Spinopelvic Fixation.

BACKGROUND: The effect of spinopelvic fixation in addition to lumbar spinal fusion (LSF) on dislocation/instability and revision in patients undergoing primary total hip arthroplasty (THA) has not been reported previously. METHODS: The PearlDiver Research Program was used to identify patients aged 30 and above undergoing primary THA who received (1) THA only, (2) THA with prior single-level LSF, (3) THA with prior 2-5 level LSF, or (4) THA with prior LSF with spinopelvic fixation. The incidence of THA revision and dislocation/instability was compared through logistic regression and Chi-squared analysis. All regressions were controlled for age, gender, and Elixhauser Comorbidity Index (ECI). RESULTS: Between 2010 and 2018, 465,558 patients without history of LSF undergoing THA were examined and compared to 180 THA patients with prior spinopelvic fixation, 5,299 with prior single-level LSF, and 1,465 with prior 2-5 level LSF. At 2 years, 7.8% of THA patients with prior spinopelvic fixation, 4.7% of THA patients with prior 2-5 level LSF, 4.2% of THA patients with prior single-level LSF, and 2.2% of THA patients undergoing only THA had a dislocation event or instability (P < .0001). After controlling for length of fusion, pelvic fixation itself was associated with higher independent risk of revision (at 2 years: 2-5 level LSF + spinopelvic fixation: aHR = 3.15, 95% CI 1.77-5.61, P < .0001 vs 2-5 level LSF with no spinopelvic fixation: aOR = 1.39, 95% CI 1.10-1.76, P < .0001). CONCLUSION: At 2 years, spinopelvic fixation in THA patients were associated with a greater than 3.5-fold increase in hip dislocation risk compared to those without LSF, and an over 2-fold increase in THA revision risk compared to those with LSF without spinopelvic fixation. LEVEL OF EVIDENCE: III.

Diffuse Spinal Hyperostosis Causing Severe Spinal Stenosis and Thoracic Myelopathy.

Introduction: Spinal stenosis has a wide range of causes including disc herniation, facet hypertrophy, degenerative spondylosis, facet cyst, ossification of the ligamentum flavum (OLF) and ossification of the posterior longitudinal ligament (OPLL). We present three cases of diffuse spinal hyperostosis causing severe spinal stenosis and myelopathy, which demonstrate a unique association between obesity and a novel syndrome of hyperostosis. Case Presentation: This report describes 3 morbidly obese patients with diffuse spinal hyperostosis causing critical thoracic stenosis. Their presenting complaints focus on lower extremity weakness and the CT/MRI imaging is striking for diffuse hyper-ossification at thoracic levels. Two patients were subsequently managed with spinal decompression, and one patient was managed non-operatively. Discussion: Metabolic changes associated with obesity may result in diffuse hyperostosis with ligament ossification and spinal stenosis. Pre-operative imaging is essential to identify the degree of ossification and potential dural involvement as this may complicate management.

Cervical Laminoplasty Versus Posterior Laminectomy and Fusion: Trends in Utilization and Evaluation of Complication and Revision Surgery Rates.

INTRODUCTION: Cervical laminoplasty (LP) and laminectomy with fusion (LF) are common operations used to treat cervical spondylotic myelopathy. Conflicting data exist regarding which operation provides superior patient outcomes while minimizing the risk of complications. This study evaluates the trends of LP compared with LF over the past decade in patients with cervical myelopathy and examines long-term revision rates and complications between the two procedures. METHODS: Patients aged 18 years or older who underwent LP or LF for cervical myelopathy from 2010 to 2019 were identified in the PearlDiver Mariner Database. Patients were grouped independently (LP versus fusion) and assessed for association with common medical and surgical complications. The primary outcome was the incidence of LP versus LF for cervical myelopathy over time. Secondary outcomes were revision rates up to 5 years postoperatively and the development of complications attributable to either surgery. RESULTS: In total, 1,420 patients underwent LP and 10,440 patients underwent LF. Rates of LP (10.5% to 13.7%) and LF (86.3% to 89.5%) remained stable, although the number of procedures nearly doubled from 865 in 2010 to 1,525 in 2019. On matched analysis, LP exhibited lower rates of wound complications, surgical site infections, spinal cord injury, dysphagia, cervical kyphosis, limb paralysis, incision and drainage/exploration, implant removal, respiratory failure, renal failure, and sepsis. Revision rates for both procedures at were not different at any time point. CONCLUSION: From 2010 to 2019, rates of LP have not increased and represent less than 15% of posterior-based myelopathy operations. Up to 5 years of follow-up, there were no differences in revision rates for LP compared with LF; however, LP was associated with fewer postoperative complications than LF. LEVEL OF EVIDENCE: Level III retrospective cohort study.

Preoperative Resilience and Early Postoperative Outcomes following Lumbar Spinal Fusion.

BACKGROUND: Previous studies identified a correlation between preoperative resilience scores and patient reported outcome measures in several surgical subspecialities. No previous studies, to our knowledge, have analyzed preoperative resilience and patient reported outcomes in lumbar spinal fusion. METHODS: Patients undergoing lumbar spinal fusion completed the Brief Resilience Scale (BRS) preoperatively, in addition to measures of disability (Oswestry Disability index [ODI]), quality of life (PROMIS global physical and mental health scales and EuroQol5), and leg and back pain (VAS) at pre- and 3-months postoperatively. The 3-month follow-up was selected due to the association with return to work. Multiple linear regression evaluated relationships between resilience and postoperative changes in outcomes measures, controlling for baseline values and body mass index, age, number of levels fused, and severity of comorbidities. RESULTS: Ninety-five participants (mean age 58 years, 56% male) completed the BRS preoperatively and outcome measures before and 3 months after lumbar fusion. On average, participants reported significant postoperative improvements on all outcome measures (P < 0.001). Higher preoperative resilience scores related to greater postoperative improvements in back and leg pain, global mental and physical health and EuroQol scores (P < 0.05), after controlling for baseline values and other covariates. Resilience scores did not significantly correlate with postoperative changes in ODI (P > 0.05). CONCLUSIONS: Preoperative resilience is associated with improvement in pain and physical and mental health quality of life during the early postoperative period following lumbar spinal fusion. Additional research is needed to determine if improvements are maintained beyond this interval and whether resilience can be modified to optimize outcomes.

Low-Density Pedicle Screw Constructs Are Associated with Lower Incidence of Proximal Junctional Failure in Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Determine whether screws per level and rod material/diameter are associated with incidence of proximal junctional kyphosis (PJF). SUMMARY OF BACKGROUND DATA: PJF is a common and particularly adverse complication of adult spinal deformity (ASD) surgery. There is evidence that the rigidity of posterior spinal constructs may impact risk of PJF. METHODS: Patients with ASD and 2-year minimum follow-up were included. Only patients undergoing primary fusion of more than or equal to five levels with lower instrumented vertebrae (LIV) at the sacro-pelvis were included. Screws per level fused was analyzed with a cutoff of 1.8 (determined by receiver operating characteristic curve (ROC) analysis). Multivariable logistic regression was utilized, controlling for age, body mass index (BMI), 6-week postoperative change from baseline in lumbar lordosis, number of posterior levels fused, sex, Charlson comorbidity index, approach, osteotomy, upper instrumented vertebra (UIV), osteoporosis, preoperative TPA, and pedicle screw at the UIV (as opposed to hook, wire, etc.). RESULTS: In total, 504 patients were included. PJF occurred in 12.7%. The mean screws per level was 1.7, and 56.8% of patients had less than 1.8 screws per level. No differences were observed between low versus high screw density groups for T1-pelvic angle or magnitude of lordosis correction (both P > 0.15). PJF occurred in 17.0% versus 9.4% of patients with more than or equal to 1.8 versus less than 1.8 screws per level, respectively (P < 0.05). In multivariable analysis, patients with less than 1.8 screws per level exhibited lower odds of PJF (odds ratio (OR) 0.48, P < 0.05), and a continuous variable for screw density was significantly associated with PJF (OR 3.87 per 0.5 screws per level, P < 0.05). Rod material and diameter were not significantly associated with PJF (both P > 0.1). CONCLUSION: Among ASD patients undergoing long-segment primary fusion to the pelvis, the risk of PJF was lower among patients with less than 1.8 screws per level. This finding may be related to construct rigidity. Residual confounding by other patient and surgeon-specific characteristics may exist. Further biomechanical and clinical studies exploring this relationship are warranted.Level of Evidence: 3.

Supervised Machine Learning for Predicting Length of Stay After Lumbar Arthrodesis: A Comprehensive Artificial Intelligence Approach.

INTRODUCTION: Few studies have evaluated the utility of machine learning techniques to predict and classify outcomes, such as length of stay (LOS), for lumbar fusion patients. Six supervised machine learning algorithms may be able to predict and classify whether a patient will experience a short or long hospital LOS after lumbar fusion surgery with a high degree of accuracy. METHODS: Data were obtained from the National Surgical Quality Improvement Program between 2009 and 2018. Demographic and comorbidity information was collected for patients who underwent anterior, anterolateral, or lateral transverse process technique arthrodesis procedure; anterior lumbar interbody fusion (ALIF); posterior, posterolateral, or lateral transverse process technique arthrodesis procedure; posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF); and posterior fusion procedure posterior spine fusion (PSF). Machine learning algorithmic analyses were done with the scikit-learn package in Python on a high-performance computing cluster. In the total sample, 85% of patients were used for training the models, whereas the remaining patients were used for testing the models. C-statistic area under the curve and prediction accuracy (PA) were calculated for each of the models to determine their accuracy in correctly classifying the test cases. RESULTS: In total, 12,915 ALIF patients, 27,212 PLIF/TLIF patients, and 23,406 PSF patients were included in the algorithmic analyses. The patient factors most strongly associated with LOS were sex, ethnicity, dialysis, and disseminated cancer. The machine learning algorithms yielded area under the curve values of between 0.673 and 0.752 (PA: 69.6% to 80.1%) for ALIF, 0.673 and 0.729 (PA: 66.0% to 81.3%) for PLIF/TLIF, and 0.698 and 0.749 (PA: 69.9% to 80.4%) for PSF. CONCLUSION: Machine learning classification algorithms were able to accurately predict long LOS for ALIF, PLIF/TLIF, and PSF patients. Supervised machine learning algorithms may be useful in clinical and administrative settings. These data may additionally help inform predictive analytic models and assist in setting patient expectations. LEVEL III: Diagnostic study, retrospective cohort study.

Predicting Readmission After Anterior, Posterior, and Posterior Interbody Lumbar Spinal Fusion: A Neural Network Machine Learning Approach.

BACKGROUND: Readmission after spine surgery is costly and a relatively common occurrence. Previous research identified several risk factors for readmission; however, the conclusions remain equivocal. Machine learning algorithms offer a unique perspective in analysis of risk factors for readmission and can help predict the likelihood of this occurrence. This study evaluated a neural network (NN), a supervised machine learning technique, to determine whether it could predict readmission after 3 lumbar fusion procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried between 2009 and 2018. Patients who had undergone anterior, lateral, and/or posterior lumbar fusion were included in the study. The Python scikit Learn package was used to run the NN algorithm. A multivariate regression was performed to determine risk factors for readmission. RESULTS: There were 63,533 patients analyzed (12,915 anterior lumbar interbody fusion, 27,212 posterior lumbar interbody fusion, and 23,406 posterior spinal fusion cases). The NN algorithm was able to successfully predict 30-day readmission for 94.6% of anterior lumbar interbody fusion, 94.0% of posterior lumbar interbody fusion, and 92.6% of posterior spinal fusion cases with area under the curve values of 0.64-0.65. Multivariate regression indicated that age >65 years and American Society of Anesthesiologists class >II were linked to increased risk for readmission for all 3 procedures. CONCLUSIONS: The accurate metrics presented indicate the capability for NN algorithms to predict readmission after lumbar arthrodesis. Moreover, the results of this study serve as a catalyst for further research into the utility of machine learning in spine surgery.

Dual expandable interbody cage utilization for enhanced stability in vertebral column reconstruction following thoracolumbar corpectomy: A report of two cases.

BACKGROUND: Thoracolumbar corpectomies require adequate anterior column spinal reconstruction, often achieved through a single static or expandable cage. Patients with larger vertebrae, or those who require a larger footprint of reconstruction placed via a posterior approach are technically challenging. The aim of this report was to describe a novel approach for reconstruction using two smaller expandable cages following corpectomy, in the setting of tumor and trauma. METHODS: These technical reports illustrate a novel intraoperative technique with reconstruction via dual expandable cages implanted posteriorly from a bilateral costotransversectomy and transpedicular approaches. Due to the smaller size of each cage, implantation in the vertebral column was achieved with minimal retraction of the spinal cord. RESULTS: Two patients underwent urgent corpectomy in the thoracolumbar spine using this technique. Clinical improvement was evident post-surgery and adequate spine stabilization was confirmed radiographically without cage migration or subsidence, at up to one year of clinical follow up. No iatrogenic neurological deficits were reported in each case as well. CONCLUSION: To the authors' knowledge, this is the first report of a corpectomy where this surgical technique was implemented in the thoracolumbar spine. This technique created a large footprint of reconstruction with less retraction on the spinal cord during surgery, reducing the potential for neurological complications. An alternative strategy is to place a larger footprint reconstruction through an anterior or lateral approach; however, these techniques also have potential morbidity which require consideration.

Predicting Postoperative Mortality After Metastatic Intraspinal Neoplasm Excision: Development of a Machine-Learning Approach.

OBJECTIVE: Mortality following surgical resection of spinal tumors is a devastating outcome. Naïve Bayes machine learning algorithms may be leveraged in surgical planning to predict mortality. In this investigation, we use a Naïve Bayes classification algorithm to predict mortality following spinal tumor excision within 30 days of surgery. METHODS: Patients who underwent laminectomies between 2006 and 2018 for excisions of intraspinal neoplasms were selected from the National Surgical Quality Initiative Program. Naïve Bayes classifier analysis was conducted in Python. The area under the receiver operating curve (AUC) was calculated to evaluate the classifier's ability to predict mortality within 30 days of surgery. Multivariable logistic regression analysis was performed in R to identify risk factors for 30-day postoperative mortality. RESULTS: In total, 2094 spine tumor surgery patients were included in the study. The 30-day mortality rate was 5.16%. The classifier yielded an AUC of 0.898, which exceeds the predictive capacity of the National Surgical Quality Initiative Program mortality probability calculator's AUC of 0.722 (P < 0.0001). The multivariable regression indicated that smoking history, chronic obstructive pulmonary disease, disseminated cancer, bleeding disorder history, dyspnea, and low albumin levels were strongly associated with 30-day mortality. CONCLUSIONS: The Naïve Bayes classifier may be used to predict 30-day mortality for patients undergoing spine tumor excisions, with an increasing degree of accuracy as the model better performs by learning continuously from the input patient data. Patient outcomes can be improved by identifying high-risk populations early using the algorithm and applying that data to inform preoperative decision making, as well as patient selection and education.

Patients Who Undergo Primary Lumbar Spine Fusion After Recent but Not Remote Total Hip Arthroplasty Are at Increased Risk for Complications, Revision Surgery, and Prolonged Opioid Use.

OBJECTIVE: To evaluate the effect of a recent history of total hip arthroplasty (THA) on primary lumbar spine fusion (LSF) for concurrent hip and spine disease. METHODS: A total of 98,242 patient records from the PearlDiver Database were evaluated and divided into 3 cohorts: 1) patients with a history of LSF alone, 2) patients with a history of LSF for newly diagnosed lumbar disease after having a remote THA> 2 years previously, and 3) patients with a history of LSF after having recent THA <2 years before LSF who initially presented with concurrent hip and lumbar spine disease and underwent THA before LSF. Postoperative outcomes were assessed with multivariable logistic regression to determine the effect of THA on outcomes after LSF with respect to postoperative complications, LSF revision rates, and opioid use. RESULTS: Patients who had LSF after a recent THA had increased risk of deep venous thrombosis (adjusted odds ratio [aOR], 1.39; P = 0.0191), neurologic complications (aOR, 1.81; P = 0.0459), prolonged opioid use (aOR, 1.22; P = 0.0032), and revision LSF (12.8%; P = 0.0004 vs. 9.9%; OR, 1.41; P < 0.0001; hazard ratio, 1.69; P < 0.0001). Patients who underwent LSF after a remote history of THA had no significant difference in DVT (4.2% vs. 2.6%, aOR, 1.31; P = 0.2190), neurologic complications (1.0% vs. 0.5%, aOR, 2.02; P = 0.1220), revision surgery (9.6% vs. 9.9%, aOR, 1.06; P = 0.7197), or prolonged opioid use (36.5% vs. 24.4%, aOR, 1.17; P = 0.1120). CONCLUSIONS: Patients who undergo LSF with a history of THA may be at increased risk of postoperative complications, revision LSF, and prolonged opioid use if their THA was performed for concurrent hip-spine disease in the recent past (<2 years).

Complications of Thoracolumbar Adult Spinal Deformity Surgery.

Adult spinal deformity (ASD) is a challenging problem for spine surgeons given the high risk of complications, both medical and surgical. Surgeons should have a high index of suspicion for medical complications, including cardiac, pulmonary, thromboembolic, genitourinary and gastrointestinal, renal, cognitive and psychiatric, and skin conditions, in the perioperative period and have a low threshold for involving specialists. Surgical complications, including neurologic injuries, vascular injuries, proximal junctional kyphosis, durotomy, and pseudarthrosis and rod fracture, can be devastating for the patient and costly to the health-care system. Mortality rates have been reported to be between 1.0% and 3.5% following ASD surgery. With the increasing rate of ASD surgery, surgeons should properly counsel patients about these risks and have a high index of suspicion for complications in the perioperative period.

Postoperative complication rates and hazards-model survival analysis of revision surgery following occipitocervical and atlanto-axial fusion.

BACKGROUND: Complication rates following occipitocervical and atlanto-axial fusion are high. While methods to fuse the upper cervical spine levels have evolved, complication rates and surgical survivorship of occipitocervical fusion versus atlanto-axial fusion are incompletely understood. METHODS: The PearlDiver Research Program (www.pearldiverinc.com) was used to identify patients undergoing primary occipitocervical or atlanto-axial fusion between 2007 and 2017. Incidence of each fusion procedure was studied across time. Multivariable logistic regression was used to compare 30-day readmission, 30-day medical complications, and post-operative opioid utilization at 1, 3, 6, and 12 months between cohorts, controlling for age, gender, Charlson Comorbidity Index (CCI), and indication for surgery. Risk of revision was compared through Cox-proportional hazards modeling, Kaplan-Meier survival, and log-rank test. RESULTS: Cohorts of 483 occipitocervical fusions and 737 atlanto-axial fusions were examined. From 2008 to 2016, incidence of occipitocervical fusion rose 55.9%, whereas atlanto-axial fusion rose 21.6%. A greater percentage of atlanto-axial fusions were due to trauma (69.9% vs. 50.5%), whereas a greater percentage of occipitocervical fusions were due to degenerative disease (41.6% vs. 29.4%) (p = 0.0161). Total 30-day complications were seen in 40.9% of occipitocervical fusion patients compared to 26.3% of atlanto-axial fusion patients (aOR=2.06, p < 0.0001). Risk of surgical site infection was increased (aOR=2.59, p = 0.0075). Kaplan Meier survival analysis and Cox-proportional hazards demonstrated greater risk of revision following surgery for occipitocervical fusion (log rank: p < 0.0001, aHR=2.66, 95%CI 1.73-4.10, p < 0.0001). CONCLUSIONS: Rates of occipitocervical and atlanto-axial fusion are rising, while complication and revision surgery rates remain high, with occipiticervical fusion leading to higher rates even after controlling for patient characteristics and surgical indication. Spine surgeons should be cautious when considering fusion of the occipitocervical levels if atlanto-axial fusion could be performed safely and provide adequate stabilization to treat the same pathology.

Outcomes of Anterior Cruciate Ligament Reconstruction in Obese and Overweight Patients: A Systematic Review.

OBJECTIVE: To evaluate the mechanism of injury, outcomes, and complications of anterior cruciate ligament (ACL) reconstruction in overweight and obese patients. DATA SOURCES: MEDLINE, EMBASE, and OVID electronic libraries were systematically searched from inception to December, 2017 for any eligible articles using a combination of the phrases "anterior cruciate ligament," "ACL," "overweight," "obese," and "BMI." RESULTS: Studies that evaluated patients with primary ACL reconstruction, classified patients as overweight or obese, and reported a minimum of 1-year follow-up data were included. Eight cohorts from 9 studies fulfilled the inclusion criteria. There were no significant differences for mechanism of injury, Lysholm scores, Knee injury and Osteoarthritis Outcome Scores values, or return to sports with a body mass index (BMI) above or below 25 kg/m. A significant difference was described in International Knee Documentation Committee (IKDC) scores when comparing obese patients (BMI >30 kg/m) to patients with BMI <25 kg/m (P <0.01). In patients with BMI >25 kg/m, the risk for arthritis was significantly higher but the risk for revision surgery or contralateral ACL tear was lower (P <0.05). There was no significant difference in complication rates (P = 0.77). CONCLUSION: Patient-reported outcome measures were similar for patients with BMI above and below 25 kg/m, but there is evidence that obese patients have lower IKDC scores. There is a consistent association between overweight status and developing arthritis among patients having an ACL reconstruction. Overweight and obese patients have a lower risk of revision ACL reconstruction and contralateral ACL tear. There is insufficient data to make any conclusions regarding mechanism of injury or complications. More research is needed to better understand what is the appropriate counsel and treatment for overweight or obese patients with ACL tears. PROSPERO REGISTRATION NUMBER: CRD42017055594.

When Can I Drive After Orthopaedic Surgery? A Systematic Review.

BACKGROUND: Patients often ask their doctors when they can safely return to driving after orthopaedic injuries and procedures, but the data regarding this topic are diverse and sometimes conflicting. Some studies provide observer-reported outcome measures, such as brake response time or simulators, to estimate when patients can safely resume driving after surgery, and patient survey data describing when patients report a return to driving, but they do not all agree. We performed a systematic review and quality appraisal for available data regarding when patients are safe to resume driving after common orthopaedic surgeries and injuries affecting the ability to drive. QUESTIONS/PURPOSES: Based on the available evidence, we sought to determine when patients can safely return to driving after (1) lower extremity orthopaedic surgery and injuries; (2) upper extremity orthopaedic surgery and injuries; and (3) spine surgery. METHODS: A search was performed using PubMed and EMBASE®, with a list of 20 common orthopaedic procedures and the words "driving" and "brake". Selection criteria included any article that evaluated driver safety or time to driving after major orthopaedic surgery or immobilization using observer-reported outcome measures or survey data. A total of 446 articles were identified from the initial search, 48 of which met inclusion criteria; abstract-only publications and non-English-language articles were not included. The evidence base includes data for driving safety on foot, ankle, spine, and leg injuries, knee and shoulder arthroscopy, hip and knee arthroplasty, carpal tunnel surgery, and extremity immobilization. Thirty-four of the articles used observer-reported outcome measures such as total brake time, brake response time, driving simulator, and standardized driving track results, whereas the remaining 14 used survey data. RESULTS: Observer-reported outcome measures of total brake time, brake response time, and brake force postoperatively suggested patients reached presurgical norms 4 weeks after right-sided procedures such as TKA, THA, and ACL reconstruction and approximately 1 week after left-sided TKA and THA. The collected survey data suggest patients resumed driving 1 month after right-sided and left-sided TKAs. Patients who had THA reported returning to driving between 6 days and 3 months postoperatively. Observer-reported outcome measures showed that patients' driving abilities often are impaired when wearing an immobilizing cast above or below the elbow or a shoulder sling on their dominant arm. Patients reported a return to driving on average 2 months after rotator cuff repair procedures and approximately 1-3 months postoperatively for total shoulder arthroplasties. Most patients with spine surgery had normal brake response times at the time of hospital discharge. Patients reported driving 6 weeks after total disc arthroplasty and anterior cervical discectomy and fusion procedures. CONCLUSIONS: The available evidence provides a best-case scenario for when patients can return to driving. It is important for observer-reported outcome measures to have normalized before a patient can consider driving, but other factors such as strength, ROM, and use of opioid analgesics need to be considered. This review can provide a guideline for when physicians can begin to consider evaluating these other factors and discussing a return to driving with patients. Survey data suggest that patients are returning to driving before observer-reported outcome measures have normalized, indicating that physicians should tell patients to wait longer before driving. Further research is needed to correlate observer-reported outcome measures with adverse events, such as motor vehicle accidents, and clinical tests that can be performed in the office. LEVEL OF EVIDENCE: Level III, therapeutic study.

Systematic Reviews in Sports Medicine.

BACKGROUND: The number of systematic reviews published in the orthopaedic literature has increased, and these reviews can help guide clinical decision making. However, the quality of these reviews can affect the reader's ability to use the data to arrive at accurate conclusions and make clinical decisions. PURPOSE: To evaluate the methodological and reporting quality of systematic reviews and meta-analyses in the sports medicine literature to determine whether such reviews should be used to guide treatment decisions. The hypothesis was that many systematic reviews in the orthopaedic sports medicine literature may not follow the appropriate reporting guidelines or methodological criteria recommended for systematic reviews. STUDY DESIGN: Systematic review. METHODS: All clinical sports medicine systematic reviews and meta-analyses from 2009 to 2013 published in The American Journal of Sports Medicine (AJSM), The Journal of Bone and Joint Surgery (JBJS), Arthroscopy, Sports Health, and Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA) were reviewed and evaluated for level of evidence according to the guidelines from the Oxford Centre for Evidence-Based Medicine, for reporting quality according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, and for methodological quality according to the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Analysis was performed by year and journal of publication, and the levels of evidence included in the systematic reviews were also analyzed. RESULTS: A total of 200 systematic reviews and meta-analyses were identified over the study period. Of these, 53% included evidence levels 4 and 5 in their analyses, with just 32% including evidence levels 1 and 2 only. There were significant differences in the proportion of articles with high levels of evidence (P < .001) and low levels of evidence (P = .005) by journal. The average PRISMA score was 87% and the average AMSTAR score was 73% among all journals. The average AMSTAR and PRISMA scores were significantly different by journal (P = .002 and .001, respectively) and by year (P = .046 and .019, respectively). Arthroscopy, AJSM, and JBJS all scored higher than Sports Health and KSSTA on the PRISMA and AMSTAR. The average PRISMA score by year varied from 85% to 89%, and the average AMSTAR score varied from 70% to 76%. CONCLUSION: Systematic reviews and meta-analyses in orthopaedics sports medicine literature relied on evidence levels 4 and 5 in 53% of studies over the 5-year study period. Overall, PRISMA and AMSTAR scores are high and may be better than those in other disciplines. Readers need to be conscious of potential shortcomings when reading systematic reviews and using them in practice.