Long-term assessment of the functional independence measure in sports-related spinal cord injury.

CONTEXT: Patients with spinal cord injury (SCI) secondary to traumatic sports-related etiology potentially face loss of independence. The Functional Independence Measure (FIM) assesses the amount of assistance patients require and has shown sensitivity to changes in patient functional status post injury. OBJECTIVES: We aimed to (1) examine long-term outcomes following sports-related SCI (SRSCI) using FIM scoring at the time of injury, one year, and five years post-injury, and (2) determine predictors of independence at one and five-year follow-up considering surgical and non-surgical management. Few studies have investigated the cohort analyzed in this study. METHODS: The 1973-2016 National Spinal Cord Injury Model Systems (SCIMS) Database was used to develop a SRSCI cohort. The primary outcome of interest captured functional independence using a multivariate logistic regression, defined by FIM individual scores greater than or equal to six, evaluated at one and five years. RESULTS: A total of 491 patients were analyzed, 60 (12%) were female, 452 (92%) underwent surgery. The cohort demographics were stratified by patients with and without spine surgery and evaluated for functional independence in FIM subcategories. Increased time spent in inpatient rehabilitation and FIM score at post-operative discharge were associated with greater likelihood of functional ability at both one and five-year follow-up. CONCLUSION: Our study demonstrated that SRSCI patients are a unique subset of SCI patients for whom factors repeatedly associated with independence at one year follow-up were dissimilar to those associated with independence at five-year follow-up. Larger prospective studies should be conducted to establish guidelines for this unique subcategory of SCI patients.

Trends in Technology for Pedicle Screw Placement: A Temporal Meta-Analysis.

STUDY DESIGN: Systematic Review. OBJECTIVE: We sought to determine which method of the pedicle screw (PS) placement is most accurate and understand how the development of subsequent generations of robotic systems has changed placement accuracy over time. SUMMARY OF BACKGROUND DATA: Previous studies have demonstrated the success of robotic PS placement, but how this accuracy compares to other methods is unclear. METHODS: A systematic review following PRISMA Guidelines was performed on articles published between January 2000 and August 2021, comparing PS insertion methods with at least 10 screws per study arm. Single and multiple-arm trials were included. Data were extracted for patient outcomes, including optimal PS placement, misplacement, and accuracy. The logit-event rate of misplacement was calculated for each study. P values were adjusted for multiple comparisons using the Tukey post hoc correction. RESULTS: Our search revealed 127 studies, and 156 comparative arms, with 77,360 pedicle screws placed using five different modalities. Meta-regression of pooled accuracy revealed no significant changes in PS accuracy over time for freehand, 2D fluoroscopic navigation, 3D fluoroscopic navigation, and computed tomography navigation. Robotic navigation had a significant increase in accuracy over time ( P =0.036). Pooled misplacement rates were also compared across all modalities. Robotics was found to have the lowest rates of misplacement for PS compared to freehand ( P =0.0015) and 2D fluoroscopic navigation ( P =0.026). CONCLUSION: Our analysis is the largest study to date on pedicle screw placement. Pedicle screw placement through robotics was found to be superior due to its low misplacement rates compared with other modalities. Intraoperative 3D fluoroscopic navigation was found to have comparable misplacement rates. In addition, pedicle screw placement accuracy with robotics has continued to improve over time. This speaks to both the stability of the technology and the potential for continued improvement with new and more accurate robotic systems.

Perioperative prophylaxis for surgical site infections in pediatric spinal surgery: a systematic review and network meta-analysis.

OBJECTIVE: Postoperative infections in pediatric spinal surgery commonly occur and necessitate reoperation(s). However, pediatric-specific infection prophylaxis guidelines are not available. This network meta-analysis compares perioperative prophylaxis methods including Betadine irrigation, saline irrigation, intrawound vancomycin powder, combination therapy (Betadine, vancomycin, gentamicin, and cefuroxime), Betadine irrigation plus vancomycin powder, and no intervention to determine the most efficacious prevention method. METHODS: A systematic review was performed by searching the PubMed, EBSCO, Scopus, and Web of Science databases for peer-reviewed articles published prior to February 2022 comparing two or more infection prophylaxis methods in patients younger than 22 years of age. Data were extracted for treatment modalities, patient demographics, and patient outcomes such as total number of infections, surgical site infections, deep infections, intraoperative blood loss, operative time, follow-up time, and postoperative complications. Quality and risk of bias was assessed using National Institutes of Health tools. A network meta-analysis was performed with reduction of infections as the primary outcome. RESULTS: Overall, 10 studies consisting of 5164 procedures were included. There was no significant difference between prophylactic treatment options in reduction of infection. However, three treatment options showed significant reduction in total infection compared with no prophylactic treatment: Betadine plus vancomycin (OR 0.22, 95% CI 0.09-0.54), vancomycin (OR 3.26, 95% CI 1.96-5.44), and a combination therapy (Betadine, vancomycin, gentamicin, and cefuroxime) (OR 0.24, 95% CI 0.07-0.75). P-Score hierarchical ranking estimated Betadine plus vancomycin to be the superior treatment to prevent total infections, deep infections, and surgical site infections (P-score 0.7876, 0.7175, and 0.7291, respectively). No prophylaxis treatment-related complications were reported. CONCLUSIONS: The results of this network meta-analysis show the strongest support for Betadine plus vancomycin as a method to reduce infections following pediatric spinal surgery. There was heterogeneity among studies and inconsistent outcome reporting; however, three effective treatment options are identified.

Early Predictors and Outcomes of American Spinal Injury Association Conversion at Discharge in Surgical and Nonsurgical Management of Sports-Related Spinal Cord Injury.

OBJECTIVE: This study aims to evaluate the rate of improvement in neurologic recovery of patients with sports-related spinal cord injury (SRSCI) who had surgical intervention (SS) and those who did not (NSS). We aimed to 1) evaluate the rate of American Spinal Injury Association (ASIA) conversion in patients with and without surgery, and 2) assess predictors of conversion in ASIA grade. METHODS: The National Spinal Cord Injury Model Systems Database (SCIMS) was used from 1973 to 2016. Patients with SRSCI were included. The primary outcome was rate of conversion in ASIA grade. Multivariate logistic regression was performed with separate subgroup analysis on patients with cervical injury (represented by odds ratio [OR]; 95% confidence interval [CI]). RESULTS: A total of 1647 patients had SRSCI with 1502 (91%) SSs. Most patients (88%) were male, white (87%), and between the ages of 15 and 29 years (63%). Patients undergoing SS had significantly longer inpatient rehabilitation length of stay (LOS) (P < 0.001) and a more patients undergoing SS had complete motor or sensory loss compared with the NSS group. Multivariate logistic regression showed that injury at the thoracic level (OR, 0.41; 95% CI, 0.21-0.78), age 15-29 years (OR, 0.44; 95% CI, 0.20-0.97]), water-based injury (OR, 0.45; 95% CI, 0.21-0.95), and ASIA impairment grades of B, C, and D at admission were significantly associated with ASIA SCORE conversion. CONCLUSIONS: We found that patients undergoing SS had longer LOS and a higher prevalence of complete injuries. Surgical intervention was not associated with conversion in ASIA grade to an improved status at time of discharge in a large cohort of patients with SRSCI and in a subcohort of patients with cervical SRSCI.

Gender Representation in Orthopaedic Surgery: A Geospatial Analysis From 2015 to 2022.

Introduction The gender disparity in orthopaedic surgery is well-established. According to our analysis, only 7.4% of practicing orthopaedic surgeons in the US are female in 2022. While there are several theories attempting to explain this gender gap, our eight years of data show that limited female representation is a self-perpetuating cycle as areas without female representation almost never improve in that regard. It appears that existing female mentorship is critical to the growth of a female orthopaedic presence in an area. In the present work, we aim to describe how gender diversity in orthopaedic surgery differs across the country, how this diversity is changing over time, and how surgeon gender diversity may be affected by the sociodemographic characteristics making up the counties where orthopaedic surgery is practiced. Methods A retrospective study was conducted using publicly available National Provider Identifier (NPI) data from 2015 to 2022. Orthopaedic surgeons and their genders were identified using the Provider Type and Gender data elements associated with an individual NPI. Rural-urban and metro characters were defined using the USDA Economic Research Reserve's rural-urban continuum codes. Python was used for database building and data cleaning. GeoDa, a statistical map-based graphing software, was used to plot and assess demographic, geographic, and socioeconomic trends. Trends in gender diversity from 2015 to 2019 were analyzed for each individual year as well as the time period as an aggregate. Cluster analysis was performed to assess complex spatial patterns of variables that could not be condensed linearly or logarithmically. Moran's I was used to measure the similarity of a Federal Information Processing System (FIPS) area code to its neighbors. Within the clustering analysis, spatial clusters were broken down into four groups of spatial outliers (High-High, High-Low, Low-High, and Low-Low) referencing a given area's relationship with its neighbors. Factorial ANOVA between each of the four cluster types was performed using the variables provided in the article to identify significant demographic variables within the cluster analysis. Results There are relative hotspots of gender diversity in the Northwest, Northeast, and Southwest with relative coldspots in the Midwest and Southern US. In counties that are considered gender diversity hotspots, the total population of orthopaedic surgeons increases by 0.94 each year while the population of female orthopaedic surgeons increases by 0.2, suggesting that in areas with high gender diversity, 4.7 male orthopaedic surgeons are joining practices for every 1.0 female. In areas with low gender diversity, the population of orthopaedic surgeons increases by 0.11 surgeons each year while the slope for an increase in female orthopaedic surgeons is 0. Conclusions  Orthopaedic surgery lags behind other male-dominated surgical specialties in gender parity. Our analysis demonstrates that certain areas of the country including the Northwest, Northeast, and Arizona have improved gender diversity compared to the rest of the country. We also see that the rate of increase of female orthopaedic surgeons in the past seven years is highest in areas with more preexisting female orthopaedic surgeons, suggesting the importance of a "trailblazer" phenomenon in recruiting female surgeons.

Evaluating robotic pedicle screw placement against conventional modalities: a systematic review and network meta-analysis.

OBJECTIVE: Several approaches have been studied for internal fixation of the spine using pedicle screws (PSs), including CT navigation, 2D and 3D fluoroscopy, freehand, and robotic assistance. Robot-assisted PS placement has been controversial because training requirements, cost, and previously unclear benefits. This meta-analysis compares screw placement accuracy, operative time, intraoperative blood loss, and overall complications of PS insertion using traditional freehand, navigated, and robot-assisted methods. METHODS: A systematic review was performed of peer-reviewed articles indexed in several databases between January 2000 and August 2021 comparing ≥ 2 PS insertion methods with ≥ 10 screws per treatment arm. Data were extracted for patient outcomes, including PS placement, misplacement, and accuracy; operative time, overall complications, intraoperative blood loss, postoperative hospital length of stay, postoperative Oswestry Disability Index (ODI) score, and postoperative visual analog scale (VAS) score for back pain. Risk of bias was assessed using the Newcastle-Ottawa score and Cochrane tool. A network meta-analysis (NMA) was performed to estimate PS placement accuracy as the primary outcome. RESULTS: Overall, 78 studies consisting of 6262 patients and > 31,909 PSs were included. NMA results showed that robot-assisted and 3D-fluoroscopy PS insertion had the greatest accuracy compared with freehand (p < 0.01 and p < 0.001, respectively), CT navigation (p = 0.02 and p = 0.04, respectively), and 2D fluoroscopy (p < 0.01 and p < 0.01, respectively). The surface under the cumulative ranking (SUCRA) curve method further demonstrated that robot-assisted PS insertion accuracy was superior (S = 0.937). Optimal screw placement was greatest in robot-assisted (S = 0.995) placement, and misplacement was greatest with freehand (S = 0.069) approaches. Robot-assisted placement was favorable for minimizing complications (S = 0.876), while freehand placement had greater odds of complication than robot-assisted (OR 2.49, p < 0.01) and CT-navigation (OR 2.15, p = 0.03) placement. CONCLUSIONS: The results of this NMA suggest that robot-assisted PS insertion has advantages, including improved accuracy, optimal placement, and minimized surgical complications, compared with other PS insertion methods. Limitations included overgeneralization of categories and time-dependent effects.