Modified Clavien-Dindo-Sink Classification System for operative complications in adult spine surgery.

OBJECTIVE: Currently there is no standardized mechanism to describe or compare complications in adult spine surgery. Thus, the purpose of the present study was to modify and validate the Clavien-Dindo-Sink complication classification system for applications in spine surgery. METHODS: The Clavien-Dindo-Sink complication classification system was evaluated and modified for spine surgery by four fellowship-trained spine surgeons using a consensus process. A distinct group of three fellowship-trained spine surgeons completed a randomized electronic survey grading 71 real-life clinical case scenarios. The survey was repeated 2 weeks after its initial completion. Fleiss' and Cohen's kappa (κ) statistics were used to evaluate interrater and intrarater reliabilities, respectively. RESULTS: Overall, interobserver reliability during the first and second rounds of grading was excellent with a κ of 0.847 (95% CI 0.785-0.908) and 0.852 (95% CI 0.791-0.913), respectively. In the first round, interrater reliability ranged from good to excellent with a κ of 0.778 for grade I (95% CI 0.644-0.912), 0.698 for grade II (95% CI 0.564-0.832), 0.861 for grade III (95% CI 0.727-0.996), 0.845 for grade IV-A (95% CI 0.711-0.979), 0.962 for grade IV-B (95% CI 0.828-1.097), and 0.960 for grade V (95% CI 0.826-1.094). Intraobserver reliability testing for all three independent observers was excellent with a κ of 0.971 (95% CI 0.944-0.999) for rater 1, 0.963 (95% CI 0.926-1.001) for rater 2, and 0.926 (95% CI 0.869-0.982) for rater 3. CONCLUSIONS: The Modified Clavien-Dindo-Sink Classification System demonstrates excellent interrater and intrarater reliability in adult spine surgery cases. This system provides a useful framework to better communicate the severity of spine-related complications.

To Cross the Cervicothoracic Junction? Terminating Posterior Cervical Fusion Constructs Proximal to the Cervicothoracic Junction Does Not Impart Increased Risk of Reoperation in Patients With Cervical Spondylotic Myelopathy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To evaluate the effect of caudal instrumentation level on revision rates following posterior cervical laminectomy and fusion. METHODS: A retrospective review of a prospectively collected database was performed. Minimum follow-up was one year. Patients were divided into two groups based on the caudal level of their index fusion construct (Group 1-cervical and Group 2- thoracic). Reoperation rates were compared between the two groups, and preoperative demographics and radiographic parameters were compared between patients who required revision and those who did not. Multivariate binomial regression analysis was performed to determine independent risk factors for revision surgery. RESULTS: One hundred thirty-seven (137/204) patients received fusion constructs that terminated at C7 (Group 1), while 67 (67/204) received fusion constructs that terminated at T1 or T2 (Group 2). The revision rate was 8.33% in the combined cohort, 7.3% in Group 1, and 10.4% in Group 2. There was no significant difference in revision rates between the 2 groups (P = .43). Multivariate regression analysis did not identify any independent risk factors for revision surgery. CONCLUSION: This study shows no evidence of increased risk of revision in patients with fusion constructs terminating in the cervical spine when compared to patients with constructs crossing the cervicothoracic junction. These findings support terminating the fusion construct proximal to the cervicothoracic junction when indicated. LEVEL OF EVIDENCE: III.

Use of L5-S1 transdiscal screws in the treatment of isthmic spondylolisthesis: a technical note.

Surgical treatment of L5-S1 isthmic spondylolisthesis consists of a combination of decompression and fusion. One previously discussed mode of fusion is via transdiscal screws. Biomechanical studies of transdiscal screws have demonstrated greater rigidity than traditional pedicle screw fixation, which theoretically translates to a higher fusion rate. Furthermore, when compared to pedicle screw fixation, transdiscal screw fixation also demonstrates improved functional and radiographic outcomes. However, transdiscal screw placement can be technically difficult. At this time, a detailed surgical technique has yet to be reported in the literature. Our surgical technique for transdiscal screw placement using intraoperative C-arm at L5-S1 is described. We include considerations for preoperative planning including necessary imaging and appropriate patient selection. We also discuss intraoperative concerns such as setup, surgical approach, proper screw trajectory, and our method for achieving indirect decompression. The results of thirteen consecutive patients treated with transdiscal screw fixation are described. One patient had subcutaneous seroma requiring reoperation (7.7%), three patients had implant failure (23.1%), and one patient had nonunion (7.7%). Our results suggest that transdiscal screw fixation is a safe and acceptable alternative for stabilization and indirect decompression of L5-S1 isthmic spondylolisthesis. Recent innovation in intraoperative navigation and robotic surgery may lessen the technical difficulty of transdiscal screw placement and make it even more effective.

Bilateral Hypoglossal Nerve Palsy After Occipitocervical Fusion.

A 63-year-old man sustained a Jefferson fracture and was treated nonoperatively by a separate treating surgeon. Because of the symptomatic malalignment and nonunion after 6 months of nonsurgical management, the patient was seen for a second opinion. Occiput to C3 arthrodesis was performed. Postoperatively, the patient was diagnosed with a bilateral hypoglossal nerve palsy. Hypoglossal nerve injuries after cervical spine fractures and posterior cervical procedures are a very rare occurrence. This is the first case report of a bilateral hypoglossal nerve palsy following occipitocervical arthrodesis.

Lessons Learned From Bundled Payment Programs.

To encourage the shift to value-based health care, the Center for Medicare & Medicaid Innovation created bundled payment programs in which episodes of care are paid for in a bundled fashion. Hip arthroplasty and knee arthroplasty were believed to be good procedures to pilot in bundled payment programs because these procedures had an easily defined episode of care and accounted for a considerable amount of the Medicare budget. Cost savings for hip and knee arthroplasty in bundled payment programs can be divided into cost savings achieved in the operating room, in the hospital, and in the postacute care period. Orthopaedic surgeons should be aware of the clinical results of hip and knee arthroplasty in bundled payment programs in various practice settings, including large healthcare systems, large academic centers, and private practices. Cost savings have been achieved in all phases of hip and knee arthroplasty in bundled payment programs. Almost all successful practice settings have developed an infrastructure to organize, administer, and manage patients through the different phases of patient care in bundled payment programs. Patient-reported outcomes and quality measures are being developed to determine the quality of the services provided in bundled payment programs.

Temperature-dependent regioselectivity of nucleophilic aromatic photosubstitution. Evidence that activation energy controls reactivity.

Irradiation (λ > 330 nm) of 2-chloro-4-nitroanisole (1) at 25 °C in aqueous NaOH forms three substitution photoproducts: 2-methoxy-5-nitrophenol (2), 2-chloro-4-nitrophenol (3), and 3-chloro-4-methoxyphenol (4), in chemical yields of 69.2%, 14.3%, and 16.5%. The activation energies for the elementary steps from the triplet state at 25 °C were determined to be 1.8, 2.4, and 2.7 kcal/mol, respectively. The chemical yields of each of the three products were determined for exhaustive irradiations at 0, 35, and 70 °C. The variation with temperature of the experimental yields is reproduced almost exactly by the yields calculated with the Arrhenius equation. This indicates that activation energy is the fundamental property related to regioselectivity in nucleophilic aromatic photosubstitution of the S(N)2 Ar* type. The many methods proposed for predicting regioselectivity in reactions of this type have had limited success and have not been related to activation energy.