Is neck pain treatable with surgery?

INTRODUCTION: Neck pain is one of the most common complaints in clinical practice and can be caused by a wide variety of conditions. While cervical spine surgery is a well-accepted option for radicular pain and myelopathy, surgery for isolated neck pain is controversial. The identification of the source of pain is challenging and subtle, and misdiagnosis can lead to inappropriate treatment. MATERIALS AND METHODS AND RESULTS: We conducted a thorough literature review to discuss and compare different causes of neck pain. We then supplemented the literature with our senior author's expert analysis of treating cervical spine pathology. CONCLUSIONS: This study provides an in-depth discussion of neck pain and its various presentations, as well as providing insight into treatment strategies and diagnostic pearls that may prevent mistreatment of cervical spine pathology.

Adult spinal deformity patients revised for pseudarthrosis have comparable two-year outcomes to those not undergoing any revision surgery.

PURPOSE: This study aimed to evaluate whether adult spinal deformity patients undergoing revision for symptomatic pseudarthrosis have comparable two-year outcomes as patients who do not experience pseudarthrosis. METHODS: Patients whose indexed procedure was revision for pseudarthrosis (pseudo) were compared with patients who underwent a primary procedure and did not have pseudarthrosis by 2Y post-op (non-pseudo). Patients were propensity-matched (PSM) based on baseline (BL) sagittal alignment, specifically C7SVA and CrSVA-Hip. Key outcomes were 2Y PROs (SRS and ODI) and reoperation. All patients had a minimum follow-up period of two years. RESULTS: A total of 224 patients with min 2-year FU were included (pseudo = 42, non-pseudo = 182). Compared to non-pseudo, pseudo-patients were more often female (P = 0.0018) and had worse BL sagittal alignment, including T1PA (P = 0.02], C2-C7 SVA [P = 0.0002], and CrSVA-Hip [P = 0.004]. After 37 PSM pairs were generated, there was no significant difference in demographics, BL and 2Y alignment, or operative/procedural variables. PSM pairs did not report any significantly different PROs at BL. Consistently, at 2Y, there were no significant differences in PROs, including SRS function [3.9(0.2) vs 3.7(0.2), P = 0.44], pain [4.0 (0.2) vs. 3.57 (0.2), P = 0.12], and ODI [25.7 (5.2) vs 27.7 (3.7), P = 0.76]. There were no differences in 1Y (10.8% vs 10.8%, P > 0.99) and 2Y (13.2% vs 15.8%, P = 0.64) reoperation, PJK rate (2.6% vs 10.5%, P = 0.62), or implant failure (2.6% vs 10.5%, P = 0.37). Notably, only 2 patients (5.4%) had recurrent pseudarthrosis following revision. Kaplan-Meier curves indicated that patients undergoing intervention for pseudarthrosis had comparable overall reoperation-free survival (log-rank test, χ2 = 0.1975 and P = 0.66). CONCLUSIONS: Patients undergoing revision for pseudarthrosis have comparable PROs and clinical outcomes as patients who never experienced pseudarthrosis. Recurrence of symptomatic pseudarthrosis was infrequent.

Think and Talk Like You Went to Business School.

Most orthopaedic surgeons do not have formal training in business education. We have learned that success comes to those who study hard, choose the correct answer on multiple-choice tests, and focus on patient care and operating. In contrast, business school graduates learned that success comes to those who apply interpersonal skills to build relationships and trust, in addition to taking risks. Medical school and business school teach one to confront the "real world" with quite a different perspective. In this manuscript, we will touch on a few things that we can learn from business school graduates.

Advanced Glycation End Product Inhibitor Pyridoxamine Attenuates IVD Degeneration in Type 2 Diabetic Rats.

Type 2 diabetes mellitus (T2DM) is associated with advanced glycation end product (AGE) enrichment and considered a risk factor for intervertebral disc (IVD) degeneration. We hypothesized that systemic AGE inhibition, achieved using pyridoxamine (PM), attenuates IVD degeneration in T2DM rats. To induce IVD degeneration, lumbar disc injury or sham surgery was performed on Zucker Diabetic Sprague Dawley (ZDSD) or control Sprague Dawley (SD) rats. Post-surgery, IVD-injured ZDSD rats received daily PM dissolved in drinking water or water only. The resulting groups were SD uninjured, SD injured, ZDSD uninjured, ZDSD injured, and ZDSD injured + PM. Levels of blood glycation and disc degeneration were investigated. At week 8 post-surgery, glycated serum protein (GSP) levels were increased in ZDSDs compared to SDs. PM treatment attenuated this increase. Micro-MRI analysis demonstrated IVD dehydration in injured versus uninjured SDs and ZDSDs. In the ZDSD injured + PM group, IVD dehydration was diminished compared to ZDSD injured. AGE levels were decreased and aggrecan levels increased in ZDSD injured + PM versus ZDSD injured rats. Histological and immunohistochemical analyses further supported the beneficial effect of PM. In summary, PM attenuated GSP levels and IVD degeneration processes in ZDSD rats, demonstrating its potential to attenuate IVD degeneration in addition to managing glycemia in T2DM.

Do adult spinal deformity patients who achieve and maintain PI-LL < 10 have better patient-reported and clinical outcomes compared to patients with PI-LL ≥ 10? A propensity score-matched analysis.

PURPOSE: To investigate whether patients with spinopelvic mismatch (PI-LL ≥ 10) report worse patient-reported outcomes (PROs) compared to patients who achieve PI-LL < 10 at 2-year postop. METHODS: In this retrospective study, propensity score matching (PSM) was used to analyze patients who underwent posterior spinal fusion due to deformity, as defined by one or more of the following criteria: PI-LL ≥ 25°, T1 pelvic angle ≥ 30°, sagittal vertical axis ≥ 15 cm, thoracic scoliosis ≥ 70°, thoracolumbar scoliosis ≥ 50°, coronal malalignment ≥ 7 cm, or those who underwent a three-column osteotomy or fusion with ≥ 12 levels. Key outcomes were total Scoliosis Research Society-22r, Oswestry Disability Index (PROs), and reoperation at 1- and 2-year postop. Patients were dichotomized based on their 2-year alignment: PI-LL ≥ 10° and PI-LL < 10°. A multivariable logistic regression model identified factors associated with achieving PI-LL < 10°, and independent predictors were matched using propensity score matching. Binary outcomes within matched cohorts were analyzed using the McNemar test, while continuous outcomes were analyzed using the Wilcoxon rank-sum test. RESULTS: One hundred sixty-four patients with 2-year follow-up were included; mean age was 50.5 (standard error mean (SEM): 1.4) years, body mass index was 24.1(SEM 1.0), and number of operative levels was 13.5 (SEM 0.3). 84 (51.2%) and 80 (48.8%) patients achieved PI-LL < 10 and PI-LL ≥ 10 at 2-year follow-up, respectively. Baseline pelvic incidence [odds ratio (OR): 0.96 (95% CI 0.92-0.99)] and baseline PI-LL [OR: 0.95 (95% CI 0.9-0.99)] were independent predictors of achieving PI-LL < 10 at 2 years. When comparing propensity matched pairs, no significant differences were found in baseline PROs. At both 1- and 2-year follow-up, outcomes on the SRS-22r scale were nearly identical for both groups (function [4.1(0.1) vs 4.0 (0.1), P = 0.75] ,Pain [3.9 (0.2) vs 3.9 (0.2), P = 0.86], appearance [4.2 (0.2) vs 3.8 (0.2), P = 0.08], mental health [4.1 (0.2) vs 4.1 (0.1), P = 0.96], satisfaction [4.4 (0.2) vs 4.4 (0.2), P = 0.72], and total [90.2 (2.5) vs 88.1 (2.5), P = 0.57]). Additionally, ODI scores at 2 years were comparable [18.1 (2.9) vs 22.4 (2.9), P = 0.30]. The 90-day reoperation rate was 2.6% (one patient) in both matched cohorts (P > 0.99). There was no significant difference in 1-year (P > 0.9999) or 2-year (P = 0.2207) reoperation rates between the groups. CONCLUSION: Patients who achieve and maintain PI-LL < 10 2-years postop following adult spinal deformity surgery have nearly identical SRS-22r and ODI outcomes, and comparable 2-year reoperation rates as compared to patients who have PI-LL ≥ 10.

Revision of Harrington rod constructs: a single-center's experience with this homogenous adult spinal deformity population at a minimum 2-year follow-up.

PURPOSE: To evaluate radiographic and clinical outcomes following revision surgery after HRC fusions. METHODS: Single-institution, retrospective study of patients revised following HRC with minimum 2-year follow-up post-revision. Demographics, perioperative information, radiographic parameters, complications, and Oswestry disability index (ODI) scores were collected. Radiographic parameters included global alignment, coronal and sagittal measurements pre and postoperatively, as well as final follow-up time points. RESULTS: 26 patients were included with a mean follow-up of 3.3 ± 1.1 years. Mean age was 55.5 ± 7.8 years, BMI 25.2 ± 5.8, and 22 (85%) were females. Instrumented levels increased from 9.7 ± 2.8 to 16.0 ± 2.2. Five (19.2%) patients underwent lumbar pedicle subtraction osteotomies, and 23 (88.4%) had interbody fusions. Patients significantly improved in all radiographic parameters at immediate and final follow-up (p < 0.005), except for thoracic kyphosis and pelvic incidence (p > 0.05). Correction was maintained from immediate postop to final follow-up (p > 0.05). 20 (76.9%) of patients experienced a complication at some point within the follow-up period with the most common being a lumbar nerve root deficit (n = 7). However, only one patient had a nerve root deficit at final follow-up, that being a 4/5 unilateral anterior tibialis function. 5 (19.2%) patients required further revision within a mean of 1.8 ± 1.1 years. On average, patients had an improvement in ODI score by final follow-up (35.6 ± 16.8 vs 25.4 ± 19.8, p = 0.035). CONCLUSION: Patients revised for HRCs significantly improve, both clinically and radiographically by final follow-up. This group did have a propensity for distal lumbar root neurological issues, which were common but all patients except for one, recovered to full strength by two-year follow-up.

Incidental dural tears during pediatric posterior spinal fusions.

PURPOSE: To characterize the frequency of incidental dural tears in pediatric spine surgery, their treatment, complications, and results of long-term follow-up. METHODS: A retrospective review of all pediatric patients who underwent a posterior spinal fusion (PSF) between 2004-2019 at a tertiary children's hospital was conducted. Electronic medical records were reviewed for patient demographics, intra-operative data, presence of an incidental dural tear, repair method, and patient outcomes. RESULTS: 3043 PSFs were reviewed, with 99 dural tears identified in 94 patients (3.3% overall incidence). Mean follow-up was 35.7 months (range 0.1-142.5). When the cause of the dural tear was specified, 69% occurred during exposure, 5% during pedicle screw placement, 4% during osteotomy, 2% during removal of implants, and 2% during intra-thecal injection of morphine. The rate of dural tears during primary PSF was significantly lower than during revision PSF procedures (2.6% vs. 6.2%, p < 0.05). 86.9% of dural tears were repaired and/or sealed intraoperatively, while 13.1% had spontaneous resolution. Postoperative headaches developed in 13.1% of patients and resolved at a mean of 7.6 days. There was no difference in the incidence of headaches in patients that were ordered bedrest vs. no bedrest (p > 0.99). Postoperative infections occurred in 9.5% of patients and 24.1% patients were identified to have undergone a revision surgery. CONCLUSIONS: Incidence of intra-operative dural tears in pediatric spine surgery is 3.3%. Although complications associated with the dural tear occur, most resolve over time and there were no long-term sequelae in patients with 2 years of follow up. LEVEL OF EVIDENCE: Level IV.

Knee flexion compensation in postoperative adult spinal deformity patients: implications for sagittal balance and clinical outcomes.

PURPOSE: To determine whether maintaining good sagittal balance with significant knee flexion (KF) constitutes a suboptimal outcome after adult spinal deformity (ASD) correction. METHODS: This single-center, single-surgeon retrospective study, assessed ASD patients who underwent posterior spinal fusion between 2014 and 2020. Inclusion criteria included meeting at least one of the following: PI-LL ≥ 25°, T1PA ≥ 20°, or CrSVA-H ≥ 2 cm. Those with lower-extremity contractures were excluded. Patients were classified into four groups based on their 6-week postoperative cranio-hip balance and KF angle, and followed for at least 2 years: Malaligned with Knee Flexion (MKF+) (CrSVA-H > 20 mm + KFA > 10), Malaligned without Knee Flexion (MKF-) (CrSVA-H > 20 mm + KFA < 10), Aligned without Knee Flexion (AKF-) (CrSVA-H < 20 mm + KFA < 10), and Aligned with Knee Flexion (AKF+) (CrSVA-H < 20 mm + KFA > 10). The primary outcomes of this study included one and two year reoperation rates. Secondy outcomes included clinical and patient reported outcomes. RESULTS: 263 patients (mean age 60.0 ± 0.9 years, 74.5% female, and mean Edmonton Frailty Score 3.3 ± 0.2) were included. 60.8% (160/263 patients) exhibited good sagittal alignment at 6-week postop without KF. Significant differences were observed in 1-year (p = 0.0482) and 2-year reoperation rates (p = 0.0374) across sub-cohorts, with the lowest and highest rates in the AKF- cohort (5%, n = 8) and MKF + cohort (16.7%, n = 4), respectively. Multivariable Cox regression demonstrated the AKF- cohort exhibited significantly better reoperation outcomes compared to other groups: AKF + (HR: 5.24, p = 0.025), MKF + (HR: 31.7, p < 0.0001), and MKF- (HR: 11.8, p < 0.0001). CONCLUSION: Our findings demonstrate that patients relying on knee flexion compensation in the early postoperative period have inferior outcomes compared to those achieving sagittal balance without knee flexion. When compared to malaligned patients, those with CrSVA-H < 20 mm and KFA > 10 degrees experience fewer early reoperations but similar delayed reoperation rates. This insight emphasizes the importance of considering knee compensation perioperatively when managing sagittal imbalance in clinical practice.

Rate and risk factors for pediatric cervical spine fusion pseudarthrosis: opportunity for improvement.

PURPOSE: Although the pediatric population typically has a high union rate, the cervical spine has a reputation for frequent pseduarthrosis, as high as 38% in some prior series. Our purpose was to examine the rate and risk factors for pseudarthrosis in pediatric cervical spine fusions. METHODS: Retrospective review of all patients with ≥ 2 years follow-up undergoing cervical spinal fusion between January 2004 and December 2019 at a tertiary pediatric hospital. Pseudarthrosis was defined as an absence of radiographic union as assessed by the attending surgeon for which revision surgery was performed. RESULTS: 64 patients (mean age: 8.4 ± 4.7 years) met inclusion criteria. Mean follow-up was 63.3 ± 41.4 months (range: 24-187 months). 28 fusions (44%) included the occiput. 41 patients (64%) had instrumentation, while 23 patients (36%) had uninstrumented fusions. 48 (75%) patients had a halo for a mean of 97.6 ± 49.5 days. The incidence of pseudarthrosis was as follows: overall = 8/64 (12.5%); posterior fusion = 14.8% (8/54); anterior fusions = 0% (0/4); and anteroposterior fusions = 0% (0/6). The rate of pseudarthrosis was over 8 times higher in fusions involving the occiput (occipitocervical fusion: 25.0%; 7/28 vs. cervical alone: 2.8%; 1/36; p = 0.02). Although not statistically significant, the rate of pseudarthrosis was 3 times higher in uninstrumented fusions (21.7%; 5/23) than instrumented fusions (7.3%; 3/41) (p = 0.12). In patients with uninstrumented fusion to the occiput, pseudarthrosis rate was 35.7% (5/14), which was higher compared to those who did not (6.0%; 3/50) (p = 0.01). Incidence of pseudarthrosis was similar in patients who received autograft (13.0%; 7/54) compared to allograft alone (10.0%; 1/10) (p > 0.999). CONCLUSIONS: The pseudarthrosis rate in pediatric cervical spine fusions remained high despite frequent use of halo immobilization and autograft. Patients with uninstrumented occipitocervical fusions are at particularly high risk with more than 1 in 3 developing a pseudarthrosis. STUDY DESIGN: Retrospective, Comparative. LEVEL OF EVIDENCE: III.

Outcomes and reoperation rates of adult spinal deformity patients with baseline sagittal malalignment based on the cranial axis to the hip at 2 years postoperatively.

OBJECTIVE: The aim of this study was to discern whether patients with a cranial sagittal vertical axis to the hip (CrSVA-H) > 2 cm at 2 years postoperatively exhibit significantly worse patient-reported outcomes (PROs) and clinical outcomes compared with patients with CrSVA-H < 2 cm. METHODS: This was a retrospective, 1:1 propensity score-matched (PSM) study of patients who underwent posterior spinal fusion for adult spinal deformity. All patients had a baseline sagittal imbalance of CrSVA-H > 30 mm. Two-year patient-reported and clinical outcomes were assessed in unmatched and PSM cohorts, including Scoliosis Research Society-22r (SRS-22r) and Oswestry Disability Index scores as well as reoperation rates. The study compared two cohorts based on 2-year alignment: CrSVA-H < 20 mm (aligned cohort) vs CrSVA-H > 20 mm (malaligned cohort). For the matched cohorts, binary outcome comparisons were carried out using the McNemar test, while continuous outcomes used the Wilcoxon rank-sum test. For unmatched cohorts, categorical variables were compared using chi-square/Fisher's tests, while continuous outcomes were compared using Welch's t-test. RESULTS: A total of 156 patients with mean age of 63.7 (SEM 1.09) years underwent posterior spinal fusion spanning a mean of 13.5 (0.32) levels. At baseline, the mean pelvic incidence minus lumbar lordosis mismatch was 19.1° (2.01°), the T1 pelvic angle was 26.6° (1.20°), and the CrSVA-H was 74.9 (4.33) mm. The mean CrSVA-H improved from 74.9 mm to 29.2 mm (p < 0.0001). At the 2-year follow-up, 129 (78%) of 164 patients achieved CrSVA-H < 2 cm (aligned cohort). Patients who had CrSVA-H > 2 cm (malaligned cohort) at the 2-year follow-up had worse preoperative CrSVA-H (p < 0.0001). After performing PSM, 27 matched pairs were generated. In the PSM cohort, the aligned and malaligned cohorts demonstrated comparable preoperative patient-reported outcomes (PROs). However, at the 2-year postoperative follow-up, the malaligned cohort reported worse outcomes in SRS-22r function (p = 0.0275), pain (p = 0.0012), and mean total score (p = 0.0109). Moreover, when patients were stratified based on their magnitude of improvement in CrSVA-H (< 50% vs > 50%), patients with > 50% improvement in CrSVA-H had superior outcomes in SRS-22r function (p = 0.0336), pain (p = 0.0446), and mean total score (p = 0.0416). Finally, patients in the malaligned cohort had a higher 2-year reoperation rate (22% vs 7%; p = 0.0412) compared with patients in the aligned cohort. CONCLUSIONS: Among patients who present with forward sagittal imbalance (CrSVA-H > 30 mm), patients with CrSVA-H exceeding 20 mm at the 2-year postoperative follow-up have inferior PROs and higher reoperation rates.

Chronic Warfarin Anticoagulation in Hip Fracture Patients Delays Surgery and Is Associated With Increased Risk of Postoperative Complications: A Multicenter Propensity-Score-Matched Analysis.

OBJECTIVE: To evaluate the effect of warfarin on blood transfusion and postoperative complications in a low-energy hip fracture population compared with a non-anticoagulated comparison group. DESIGN: Multicenter Retrospective Cohort. SETTING: Three Urban Level I Academic Trauma Centers. PATIENTS: Acute, low-energy, native hip fractures in patients 55 years of age or older on chronic warfarin anticoagulation, propensity score matched 1:2 to non-anticoagulated hip fracture patients meeting all other inclusion criteria. MAIN OUTCOME MEASUREMENTS: Transfusion and postoperative complication rates. RESULTS: Two hundred ten anticoagulated hip fracture patients were matched to 420 nonanticoagulated patients. A higher proportion of patients required blood transfusion in the warfarin cohort (52.4% vs. 43.3%, P < 0.001), attributable mostly to the subgroup of patients undergoing arthroplasty. Warfarin patients had higher incidence of overall 90-day complications (47% vs. 38%, P = 0.039) and readmissions (31.4% vs. 8.9%, P < 0.001). Day of surgery international normalized ratio (INR) did not influence transfusions or complications among warfarin patients. Warfarin patients undergoing surgery within 24 hours had no difference in transfusions and had fewer complications compared with those undergoing surgery after 24 hours. On multivariable logistic regression analysis, warfarin use and day of surgery INR were not predictors of transfusion or complications. CONCLUSIONS: Patients on warfarin experienced longer time to surgery and higher incidence of overall transfusion and postoperative complications within 90 days of surgery. However, warfarin use and day of surgery INR was not independently associated with transfusions or complications. The reason for poorer outcomes in warfarin patients remains a topic of further investigation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intervertebral disc human nucleus pulposus cells associated with back pain trigger neurite outgrowth in vitro and pain behaviors in rats.

Low back pain (LBP) is often associated with the degeneration of human intervertebral discs (IVDs). However, the pain-inducing mechanism in degenerating discs remains to be elucidated. Here, we identified a subtype of locally residing human nucleus pulposus cells (NPCs), generated by certain conditions in degenerating discs, that was associated with the onset of discogenic back pain. Single-cell transcriptomic analysis of human tissues showed a strong correlation between a specific cell subtype and the pain condition associated with the human degenerated disc, suggesting that they are pain-triggering. The application of IVD degeneration-associated exogenous stimuli to healthy NPCs in vitro recreated a pain-associated phenotype. These stimulated NPCs activated functional human iPSC-derived sensory neuron responses in an in vitro organ-chip model. Injection of stimulated NPCs into the healthy rat IVD induced local inflammatory responses and increased cold sensitivity and mechanical hypersensitivity. Our findings reveal a previously uncharacterized pain-inducing mechanism mediated by NPCs in degenerating IVDs. These findings could aid in the development of NPC-targeted therapeutic strategies for the clinically unmet need to attenuate discogenic LBP.

Adjacent Segment Impingement: A New Type of Adjacent Segment Disease?: A Report of 3 Cases.

CASE: We present 3 cases in which spinal rods extending beyond the intended level of fusion caused injury to adjacent structures, which we term "adjacent segment impingement." All cases presented as back pain with no neurological symptoms, with a minimum 6 years of follow-up from the initial procedure. Treatment consisted of extending the fusion to include the affected adjacent segment. CONCLUSION: We recommend surgeons check to ensure spinal rods are not abutting adjacent level structures at the time of the initial implant while considering that adjacent levels may move closer to the rod during spine extension or twisting.

Delayed Surgery Does Not Reduce Transfusion Rates in Low-Energy Hip Fractures on Direct Oral Anticoagulants.

OBJECTIVES: To compare transfusion rates in patients on direct oral anticoagulants (DOACs) with nonanticoagulated patients undergoing hip fracture surgery and, secondarily, to determine whether time to surgery or complications differ between these groups. DESIGN: Multicenter retrospective cohort. SETTING: Three tertiary care, academic, Level I trauma centers. PATIENTS: Acute, operatively treated, low-energy hip fracture patients 55 years of age and older were included. Anticoagulated patients were matched in a 1:2 ratio to "control" nonanticoagulated hip fracture patients using propensity score matching. MAIN OUTCOME MEASUREMENTS: The primary outcome was incidence of perioperative transfusion. The secondary outcomes included time to surgery, length of stay, and 90-day complications, readmissions, reoperations, and mortality. RESULTS: One hundred thirty-two patients with hip fracture admitted on DOACs were identified (107 factor Xa inhibitors, 25 dabigatran) and were matched to 262 "control" nonanticoagulated patients. There was no difference in overall transfusion rates between anticoagulation and control groups (43.2%; n = 57 DOAC vs. 39.7%; n = 104 control; P = 0.517). The median time from admission to surgery was 41.7 hours in the DOAC group and 26.0 hours in the control group (P < 0.001). There were no differences in 90-day complication, readmission, reoperation, or mortality rates between DOAC and control groups. Comparing DOAC patients undergoing surgery within 24 hours and after 24 hours, there were no differences in transfusion rates (P = 0.558) or overall complication rates (P = 0.179). CONCLUSIONS: This study supports growing evidence that DOAC use should not be a determining factor in delaying surgery for patients with hip fracture who are otherwise medically optimized. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Stem Cells and Spinal Fusion.

BACKGROUND: This manuscript is a review of the literature investigating the use of mesenchymal stem cells (MSCs) being applied in the setting of spinal fusion surgery. We mention the rates of pseudarthrosis, discuss current bone grafting options, and examine the preclinical and clinical outcomes of utilizing MSCs to assist in successfully fusing the spine. METHODS: A thorough literature review was conducted to look at current and previous preclinical and clinical studies using stem cells for spinal fusion augmentation. Searches for PubMed/MEDLINE and ClinicalTrials.gov through January 2021 were conducted for literature mentioning stem cells and spinal fusion. RESULTS: All preclinical and clinical studies investigating MSC use in spinal fusion were examined. We found 19 preclinical and 17 clinical studies. The majority of studies, both preclinical and clinical, were heterogeneous in design due to different osteoconductive scaffolds, cells, and techniques used. Preclinical studies showed promising outcomes in animal models when using appropriate osteoconductive scaffolds and factors for osteogenic differentiation. Similarly, clinical studies have promising outcomes but differ in their methodologies, surgical techniques, and materials used, making it difficult to adequately compare between the studies. CONCLUSION: MSCs may be a promising option to use to augment grafting for spinal fusion surgery. MSCs must be used with appropriate osteoconductive scaffolds. Cell-based allografts and the optimization of their use have yet to be fully elucidated. Further studies are necessary to determine the efficacy of MSCs with different osteoconductive scaffolds and growth/osteogenic differentiation factors. LEVEL OF EVIDENCE: 3.

Surgical Site Infection Following Neuromuscular Posterior Spinal Fusion Fell 72% After Adopting the 2013 Best Practice Guidelines.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study is to investigate the incidence of surgical site infection in neuromuscular scoliosis (NMS) patients at a tertiary children's hospital before and after the implementation of strategies mentioned in the 2013 Best Practice Guideline. SUMMARY OF BACKGROUND DATA: Patients with NMS are at high risk for surgical site infection following spine surgery. In 2013, a Best Practice Guideline for surgical site infection prevention in high-risk pediatric spine surgery patients reported strategies to decrease incidence. To date, no studies have looked at the efficacy of these strategies. METHODS: A retrospective review of surgical site infection in NMS patients was performed. NMS patients undergoing primary posterior spinal fusion from January 2008 to December 2012 (Group 1) and January 2014 to December 2018 (Group 2) were included, with 2013 excluded as a transition year. The primary outcome was incidence of surgical site infection within 1 year of surgery, as defined by the Centers for Disease Control and National Healthcare Safety Network. All patients had at least 1 year of documented follow-up. RESULTS: One hundred ninety eight patients were included, 62 in Group 1 and 136 in Group 2. Age, BMI, sex, fusion to pelvis, preoperative Cobb angle, incontinence, drain use, blood loss, surgical time, and other perioperative values were similar (P > 0.05). Deep surgical site infection occurred in 10 (16.1%) patients in Group 1 and six (4.4%) patients in Group 2 (P = 0.005). Thirteen (59.1%) identified organisms were gram-negative, with 11 (84.6%) isolated from Group 1 (P = 0.047). Polymicrobial infections accounted for six (37.5%) infections overall. CONCLUSION: The incidence of surgical site infection in NMS patients decreased significantly (16.1% vs. 4.4%) after the implementation of the strategies mentioned in the 2013 Best Practice Guideline. Further studies are required to continue to decrease the incidence in this high-risk population.Level of Evidence: 3.

C1-C2 Distraction Ligamentous Injury Treated with Halo-Vest Application: A Case Report.

CASE: There is a paucity of literature regarding pediatric upper cervical spine traumatic instability, atlanto-occipital dislocations, and fractures, with no clear treatment algorithm. We present a 12-year-old girl with significant posterior C1-C2 distraction and resultant ligamentous injury after a motor vehicle collision who was treated with a halo vest for 3 months. At 8-month follow-up, follow-up magnetic resonance imaging demonstrated complete ligamentous healing without instability on dynamic radiographs, and at 18-month follow-up, the patient made a full recovery. CONCLUSION: In some pediatric patients with isolated posterior ligamentous injury, as long as anatomic alignment can be achieved with halo-vest application, a fusion may be avoided.

Outpatient Versus Inpatient Anterior Lumbar Spine Surgery: A Multisite, Comparative Analysis of Patient Safety Measures.

BACKGROUND: The frequency and complexity of spinal surgery performed in an ambulatory surgery center (ASC) is increasing. However, safety and efficacy data of most spinal procedures adapted to the ASC are sparse and have focused on anterior cervical surgery. The purpose of this study was to compare the 90-day complication and readmission rates of anterior lumbar spine surgery performed in an ASC or inpatient setting. METHODS: We performed a retrospective comparative analysis of 226 consecutive anterior lumbar surgeries (283 levels treated) completed in an ASC (n = 124) or in an inpatient tertiary care hospital (n = 102) over a 3-year period. These included anterior lumbar interbody fusion (ALIF), artificial disc replacement (ADR), and hybrids. Patients undergoing simultaneous or staged posterior procedures within 3 months were excluded. Patient demographics and surgical parameters between the two surgical settings were compared. Ninety-day medical complications and readmission rates were assessed. One-way analysis of variance and Chi-square analysis were used. A P value of less than .05 was considered statistically significant. RESULTS: The two study groups had similar baseline characteristics. While there was a trend toward fewer complications, reoperations, and readmissions for the ASC cohort, the differences were not statistically significant. There were 7 intraoperative complications (5.6% minor vascular injury) in the inpatient cohort and 0 in the ASC cohort. The overall 90-day postoperative complication rate was 5.6% for the inpatient cohort and 0.9% for the ASC cohort. The 90-day readmission rate was 1.9% in the ASC cohort and 1.6% in the inpatient cohort. The 90-day reoperation rate was 0.8% for the inpatient cohort and 0% in the ASC cohort. The average hospital stay was 2.3 ± 1.5 days for the inpatient cohort. CONCLUSION: The 90-day readmission rates were lower for outpatients than for inpatients, while the complication and reoperation rates were similar. Our results demonstrate that anterior lumbar procedures, including single-level and multilevel ALIF, ADR, and hybrid procedures, can be performed safely in an ASC. This has significant cost savings implications for the ASC setting.

Severe Chin-on-Chest Cervical Spine Deformity in the Setting of Stiff-Person Syndrome: A Case Report.

CASE: Stiff-person syndrome (SPS) presents with progressive muscle rigidity, postural instability, and periodic debilitating spasms. Reports of axial hyperextension exist, but kyphotic deformities have not been described. We surgically treated a patient with debilitating SPS and severe cervicothoracic hyperkyphosis with posterior spinal fusion and instrumentation. At 1-year follow-up, the patient displayed better upright gait and forward gaze, 18° cervical lordosis, and improved patient-reported outcome scores. CONCLUSION: SPS can lead to extreme spinal deformity and disease, including hyperkyphosis of the cervicothoracic spine, and can successfully be managed with a multidisciplinary team and a posterior-only correction with spinal instrumentation and fusion.

Pain Management with Early Regional Anesthesia in Geriatric Hip Fracture Patients.

BACKGROUND: Geriatric hip fracture patients are susceptible to the adverse effects of opioid-induced analgesia. Fascia iliaca blocks (FIBs) have emerged as an analgesic technique for this population. There are limited data on a preoperative FIB's effect on perioperative opioid intake. We hypothesized that preoperative FIB would reduce perioperative opioid consumption, measured in morphine milliequivalents (MMEs). DESIGN: This is a prospective observational study. SETTING: A level 1 trauma center in California. PARTICIPANTS: From March 2017 to December 2017, patients 65 years and older presenting with a hip fracture received a preoperative FIB and were prospectively observed. This cohort was compared with a historical control. INTERVENTION: All prospectively enrolled patients were given FIBs. For a single-shot FIB, a 30- to 40-mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine was injected. For a continuous FIB, a bolus of 10 to 20 mL of 0.2% bupivacaine was injected, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1. RESULTS: A total of 725 patients were included in this study, with 92 in the prospectively collected cohort. The mean age of this cohort was 84.2 (standard deviation = 8.4) years, and 69.2% were female. Patients who received a preoperative FIB consumed less MME preoperatively, 18.0 (interquartile range = 6.0-44.5) versus 29.5 (interquartile range = 6.0-56.5) (P = .007), with no change in pain scores. No differences were found in postoperative opioid consumption between groups. There was no difference in MME or pain score in patients with dementia. Subgroup analysis based on fracture pattern (femoral neck and intertrochanteric) demonstrated a significant decrease in preoperative MME consumption in femoral neck fractures only, 12.0 (interquartile range = 5.0-24.0) versus 29.0 (interquartile range = 12.0-59.0) (P < .001). CONCLUSION: FIBs reduce preoperative opioid intake and have low rates of opioid-related adverse events in geriatric hip fracture patients. LEVEL OF EVIDENCE: The level of evidence was II.