Hospital outcomes in pediatric patients with Prader-Willi syndrome (PWS) undergoing orthopedic surgery: A 12-year analysis of national trends in surgical management and inpatient hospital outcomes.

BACKGROUND: The incidence of orthopedic disorders amongst patients with Prader-Willi Syndrome (PWS) is high when compared to the general pediatric population. The purpose of this retrospective study was to define the most commonly performed orthopedic procedures in pediatric patients with PWS and to characterize the peri-operative outcomes of these patients. METHODS: The Kids Inpatient Database (KID) was queried to collect data and identify all pediatric patients with PWS who underwent orthopedic procedures from 2001 to 2012. A total of 3684 patients with PWS were identified, 334 of who underwent an orthopedic procedure. Population demographics, comorbidities, and specific procedures undergone were defined. The incidences of postoperative complications and length of associated hospital stay were additionally evaluated. RESULTS: Mean age of patients in this sample was 10.33 years (SD 4.5). The most common comorbidities included obesity (18.1%), chronic pulmonary disease (14.1%), hypothyroidism (5.1%), hypertension (5.1%), and uncomplicated diabetes (4%). Common procedures were spinal fusion (165/334, 49%) and lower extremity procedures (50/334, 15%). Complications included acute blood loss anemia, device related complications, pneumonia, sepsis, and urinary tract infections. The overall complication rate was 35.6%. Average hospital lengths of stay for patients undergoing spinal fusion was 6.68 days (SD 4.13), lower extremity orthopedic procedure was 5.65 days (SD 7.4), and all other orthopedic procedures was 7.74 days (SD 16.3). CONCLUSIONS: Orthopedic disorders are common in patients with PWS. Consequently, spinal fusions and lower extremity procedures are commonly performed in this patient population. Associated comorbid conditions may negatively impact surgical outcomes in these patients. This information should prove useful in the peri-operative management of patients with PWS undergoing orthopedic surgery and for shared decision making with families.

Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial.

BACKGROUND: Interscalene brachial plexus blocks are a common modality used to provide adjunctive pain relief with shoulder replacement surgery. In 2018, the Federal Drug Administration approved the use of liposomal bupivacaine (LB) for such nerve blocks. We sought to evaluate whether this formulation of bupivacaine would provide superior pain relief for shoulder replacement patients over standard bupivacaine alone. Our hypotheses were that in the LB cohort the average postoperative pain score over the first 72 hours would be significantly lower, time to block cessation would be longer, total opioid consumption would be lower, and the average patient satisfaction score regarding their pain management would be higher. MATERIALS AND METHODS: A randomized, double-blinded study was designed comparing primary shoulder replacement surgery after an interscalene block with 25 mL of 0.5% plain bupivacaine vs. 133 mg of LB with 7.5 mL of 0.5% and 7.5 mL of 0.25% plain bupivacaine. A total of 104 patients were included in the study, with an equal number in each study arm. Patients' visual analog pain scores (VAPS) were followed for their inpatient stay, first 3 full outpatient days, and at a 3-week follow-up. Use of opioid medication was recorded for the same intervals and converted to morphine milligram equivalents. The time to first opioid rescue was documented, as well as the patients' satisfaction with their pain management at both the 3-day and 3-week intervals. RESULTS: No clinically relevant advantage to the use of LB over plain bupivacaine was found. During the second postoperative day, the mean VAPS was 2.4 with LB vs. 3.3 in the standard cohort (P = .0409). The only other statistically significant finding was a higher VAPS with LB during the third full day home compared with standard bupivacaine (4.0 vs. 2.8, respectively, P = .0197). Both of these differences were less than the minimal clinically important difference of 2 for the VAPS. Analysis of the VAPS for the first and third postoperative days, the first and second full days home, and at 3 weeks revealed no significant difference. Similarly, there was no significant difference in time to first opioid rescue, total morphine milligram equivalent use, and patient satisfaction with pain management. CONCLUSION: When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine.

Superior capsule reconstruction for irreparable rotator cuff tears: a systematic review of biomechanical and clinical outcomes by graft type.

BACKGROUND: Superior capsular reconstruction (SCR) has recently been proposed as a surgical solution to the irreparable rotator cuff tear and has gained popularity because of promising early results. Therefore, the purpose of this study is to review the biomechanical and clinical outcomes in shoulders with this condition treated with SCR. METHODS: A systematic review was conducted following PRISMA guidelines using PubMed, EMBASE, and Cochrane databases. Studies were included if they reported biomechanical, radiographic, or clinical outcomes data after undergoing SCR in shoulders with irreparable rotator cuff tears. Studies were broken down into 3 categories: cadaveric biomechanical studies, autograft clinical outcome studies, and allograft clinical outcome studies. Biomechanical, radiographic, patient-reported, and functional outcomes data were recorded for each study. RESULTS: Eight cadaveric biomechanical studies, 5 autograft clinical studies, and 4 allograft clinical studies met inclusion criteria. In biomechanical studies, subacromial contact pressure and superior humeral translation were decreased in most tested scenarios. An increase in American Shoulder and Elbow Surgeons (ASES) scores, forward elevation and external rotation values, and acromiohumeral distance (AHD) were found in all autograft clinical studies reporting. Allograft clinical studies reported increases in ASES scores, forward elevation values, and AHD but decreases in visual analog scale scores in all studies reporting. CONCLUSIONS: SCR is emerging as a viable surgical option to address the irreparable rotator cuff tear. Biomechanical studies suggest that the humeral head-stabilizing effect of SCR appears to translate into improved clinical outcomes. Future research should focus on further defining the indications, limitations, and optimal technique.

Implementing the Lever Sign in the Emergency Department: Does it Assist in Acute Anterior Cruciate Ligament Rupture Diagnosis? A Pilot Study.

BACKGROUND: Within the emergency department (ED) setting, anterior cruciate ligament (ACL) rupture is commonly misdiagnosed, leading to improper treatment and potential meniscal injury and total joint replacement. Utilizing traditional clinical tests to diagnosis ACL rupture leads to the correct diagnosis in about 30% of cases. The lever sign is a new and effective clinical test used to diagnose ACL rupture with 100% sensitivity. OBJECTIVE: We aim to study if the lever sign used in the ED setting is more sensitive to diagnose ACL rupture than traditional tests. METHODS: Patients between 12 and 55 years of age were examined utilizing either traditional methods or the lever sign. Diagnostic findings in the ED were compared with those of a sports medicine specialist using magnetic resonance imaging as the diagnostic standard. A survey was given to ED providers to collect data on diagnosis and physician confidence in diagnosis. RESULTS: The sensitivity of the lever sign was 100% (94.7% accuracy, 93.75% specificity), whereas the sensitivity of the anterior drawer/Lachman test was 40% (87.5% accuracy, 100% specificity). Physician confidence in diagnosis was higher utilizing the lever sign vs. the anterior drawer/Lachman test at 8.45 (±1.82) compared with 7.72 (±1.82) out of 10, respectively. There was no statistically significant association between diagnostic accuracy with either test and level of training of the ED provider. CONCLUSION: Implementation of the lever sign in the ED setting resulted in a higher sensitivity, higher physician confidence in screening test diagnosis, and a decrease in the number of undiagnosed ACL ruptures.

Two-Stage Debridement With Prosthesis Retention for Acute Periprosthetic Joint Infections.

BACKGROUND: Historically, infection control rates with debridement and component retention have been poor in the management of acute prosthetic joint infections. We previously described a 2-stage debridement with prosthesis retention protocol for acute periprosthetic joint infection and reported a 90% success rate in a sample of 20 patients. METHODS: A retrospective review of 83 patients who underwent a 2-stage debridement with implant retention with a minimum 1-year follow-up was performed. Patient data were primarily analyzed to determine infection control rates. Infections were considered controlled when patients had not undergone a reoperation for infection, and demonstrated lack of any clinical signs or symptoms of infection (a well healed wound, diminishing swelling and warmth, absence of erythema, improvement in baseline pain symptoms) A secondary goal of this study was to examine the effects of symptom duration on infection control rate. RESULTS: Average patient follow-up was 41.8 months (range 12-171) for all patients. The overall protocol success rate was 86.7% (72/83): 82.9% in hips and 89.6% in knees. Additionally, protocol success was observed in 45 of 48 primary joints (93.8%) and 27 of 35 (77.1%) revision joints (P = .046). Average time from onset of symptoms to surgery was 6.2 days for successfully treated patients (range 0-27 days) compared to 10.7 days for those who failed treatment (range 1-28 days, P = .070). CONCLUSION: This 2-stage retention protocol resulted in a higher likelihood of infection control compared to prior reports of single stage debridement and modular part exchange.

The future of disc surgery and regeneration.

Low back and neck pain are among the top contributors for years lived with disability, causing patients to seek substantial non-operative and operative care. Intervertebral disc herniation is one of the most common spinal pathologies leading to low back pain. Patient comorbidities and other risk factors contribute to the onset and magnitude of disc herniation. Spine fusions have been the treatment of choice for disc herniation, due to the conflicting evidence on conservative treatments. However, re-operation and costs have been among the main challenges. Novel technologies including cage surface modifications, biologics, and 3D printing hold a great promise. Artificial disc replacement has demonstrated reduced rates of adjacent segment degeneration, need for additional surgery, and better outcomes. Non-invasive biological approaches are focused on cell-based therapies, with data primarily from preclinical settings. High-quality comparative studies are needed to evaluate the efficacy and safety of novel technologies and biological therapies.

Peripheral Nerve Blocks vs Periarticular Injections in Total Knee Arthroplasty.

In patients undergoing surgery, optimal pain management is associated with improved perioperative outcomes, patient satisfaction with surgery, and a more rapid functional recovery. In recent years, the employment of multimodal pain management strategies has become increasingly widespread. In particular, there has been an explosion in the use of peripheral nerve blockade and periarticular injections in total knee arthroplasty. However, there is significant variability in the administration of either modality of anesthesia. As such, a critical evaluation of the current literature is warranted to elucidate the advantages and disadvantages of each technique with the ultimate goal of further refining current pain control strategies. In this symposium, we review each of these modalities and their association with pain management, narcotic consumption, length of hospital stay, and adverse events.

Comparison of Different Osteobiologics in Terms of Imaging Modalities and Time Frames for Fusion Assessment in Anterior Cervical Discectomy and Fusion: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVES: The study's primary objective was to determine how osteobiologic choice affects fusion rates in patients undergoing anterior cervical discectomy and fusion (ACDF). The study's secondary objectives were to 1) determine the optimal timing of fusion assessment following ACDF and 2) determine if osteobiologic type affects the timing and optimal modality of fusion assessment. METHODS: A systematic search of PubMed/MEDLINE was conducted for literature published from 2000 through October 2020 comparing anterior fusion in the cervical spine with various osteobiologics. Both comparative studies and case series of ≥10 patients were included. RESULTS: A total of 74 studies met the inclusion criteria. Seventeen studies evaluated the efficacy of autograft on fusion outcomes, and 23 studies assessed the efficacy of allograft on fusion outcomes. 3 studies evaluated the efficacy of demineralized bone matrix, and seven assessed the efficacy of rhBMP-2 on fusion outcomes. Other limited studies evaluated the efficacy of ceramics and bioactive glasses on fusion outcomes, and 4 assessed the efficacy of stem cell products. Most studies utilized dynamic radiographs for the assessment of fusion. Overall, there was a general lack of supportive data to determine the optimal timing of fusion assessment meaningfully or if osteobiologic type influenced fusion timing. CONCLUSIONS: Achieving fusion following ACDF appears to remain an intricate interplay between host biology and various surgical factors, including the selection of osteobiologics. While alternative osteobiologics to autograft exist and may produce acceptable fusion rates, limitations in study methodology prevent any definitive conclusions from existing literature.

Minimally Invasive Intradural Tumor Resection.

In conjunction with neurofibromas, schwannomas are the second most commonly occurring intradural extramedullary tumor. They are a benign encapsulated nerve sheath tumor that are typically slow growing. They occur equally as frequently in the cervical and lumbar spine. If symptomatic, surgical resection may be warranted. In this surgical technique video, we present a case of a 70-year-old woman who presented with worsening symptoms consistent with cauda equina syndrome secondary to intradural masses at the L1-2 level. A minimally invasive resection of the intradural lesions was performed without any complication. Final pathology of the resected masses revealed schwannoma.

Scientific View on Endoscopic Spine Surgery: Can Spinal Endoscopy Become a Mainstream Surgical Tool?

With the health care environment becoming increasingly patient centric and cost-conscious, interest levels in spinal endoscopy are at an all-time high. Patient demand for the least invasive procedures combined with surgeon desire to maximally shorten the postoperative recovery period has further driven this surgical evolution. Mounting scientific evidence demonstrates the noninferiority and perhaps even superiority of endoscopic techniques to more conventional spinal surgery for the treatment of spinal stenosis and disc herniations. Although higher level evidence is much needed to support the clinical utility of the latest endoscopic techniques and surgical indications, it appears that the entrance of spinal endoscopy into the mainstream arena of spinal surgery is inevitable.

Does Interbody Support at L5-S1 Matter in Long Fusions to the Pelvis?: A 5-year Analysis.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine if the addition of L5-S1 interbody support in long fusion deformity constructs is associated with superior long-term clinical and radiographic outcomes. To compare the 5-year clinical and radiographic outcomes and complications between long fusion constructs with L5-S1 interbody support versus posterolateral fusion (PLF) alone. SUMMARY OF BACKGROUND DATA: Cadaveric biomechanical studies have suggested that an interbody fusion at L5-S1 is beneficial in long fusion constructs with sacropelvic fixation. However, there is limited data reflecting the superiority of interbody support augmentation in optimizing arthrodesis and deformity correction relative to PLF alone. METHODS: Eighty-eight consecutive adults with spinal deformity who underwent at minimum T11-pelvis posterior pedicle screw instrumentation with 5-year follow-up were included. Two cohorts were compared based on technique used at the lumbosacral junction (L5-S1): (A) no interbody (PLF; n = 23), or (B) interbody support at L5-S1 (IB; n = 65). Radiographic measurements and clinical outcome measures were compared at multiple time points. Complications were recorded and compared. RESULTS: No differences in baseline patient characteristics between cohorts. One nonunion occurred at L5-S1 in the PLF group (P = 0.091). Initial postop sagittal alignment was better in the IB group (PLF: 6.46 cm, IB: 2.48 cm, P = 0.007); however, this was not maintained over long-term follow-up. No significant differences in proximal junctional kyphosis (PLF: 7/23, IB: 9/65, P = 0.076). Proximal junctional failure was more frequent in the PLF group (PLF: 6/23, IB: 6/65, P = 0.043). No significant differences in complications were found. Both cohorts had improvement from baseline pain and functional scores. CONCLUSION: There is no absolute long-term advantage for lumbar interbody support in adult spinal deformity patients undergoing spinal arthrodesis to the pelvis.Level of Evidence: 3.

Is Less Really More? Economic Evaluation of Minimally Invasive Surgery.

STUDY DESIGN: Review. OBJECTIVE: A comparative overview of cost-effectiveness between minimally invasive versus and equivalent open spinal surgeries. METHODS: A literature search using PubMed was performed to identify articles of interest. To maximize the capture of studies in our initial search, we combined variants of the terms "cost," "minimally invasive," "spine," "spinal fusion," "decompression" as either keywords or MeSH terms. PearlDiver database was queried for open and minimally invasive surgery (MIS; endoscopic or percutaneous) reimbursements between Q3 2015 and Q2 2018. RESULTS: In general, MIS techniques appeared to decrease blood loss, shorten hospital lengths of stay, mitigate complications, decrease perioperative pain, and enable quicker return to daily activities when compared to equivalent open surgical techniques. With regard to cost, primarily as a result of these latter benefits, MIS was associated with lower costs of care when compared to equivalent open techniques. However, cost reporting was sparse, and relevant methodology was inconsistent throughout the spine literature. Within the PearlDiver data sets, MIS approaches had lower reimbursements than open approaches for both lumbar posterior fusion and discectomy. CONCLUSIONS: Current data suggests that overall cost-savings may be incurred with use of MIS techniques. However, data reporting on costs lacks in uniformity, making it difficult to formulate any firm conclusions regarding any incremental improvements in cost-effectiveness that may be incurred when utilizing MIS techniques when compared to equivalent open techniques.

Does Local Administration of Liposomal Bupivacaine Reduce Pain and Narcotic Consumption in Adult Spinal Deformity Surgery?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine if local administration of liposomal bupivacaine (LB) reduces postoperative pain scores and narcotic use in spinal deformity patients. METHODS: Adult patients undergoing elective spinal fusion (7 or more levels) for scoliosis or kyphosis were selected for inclusion. Patients received either periincisional injections of combined liposomal and standard bupivacaine (n = 90, group L) or standard bupivacaine only (n = 69, group C). Perioperative pain scores (VAS [visual analogue scale]), opioid use, length of stay, functional outcome (ODI [Oswestry Disability Index]), and perioperative complications were recorded. No external funding was received for this study. RESULTS: A total of 159 patients met inclusion criteria (mean age was 54.2 years of age). No significant baseline demographic differences were noted between the 2 groups. Group L experienced slight improvements in pain control on postoperative day (POD) 1 (P = .02). No difference in pain scores were otherwise noted. Group L transitioned off of intravenous (IV) narcotics faster with 52.6% less IV use by POD3 (P = .03). No differences in total narcotic consumption, perioperative complications, lengths of stay, and functional outcome scores were otherwise noted between the 2 cohorts. CONCLUSIONS: The use of LB in adult spinal deformity surgery does not appear to provide clinically important improvements in postoperative pain at the manufacturer's recommended dosage. Furthermore, while patients receiving LB may transition more quickly off of IV narcotics, this does not appear to translate into an overall decrease in narcotic consumption, hasten return of bowel function, or decrease hospital lengths of stay. Future prospective randomized control trials are warranted. The use of varying dosages of LB may also help further clarify the true efficacy of LB in the setting of spinal deformity surgery.

Comparison of Two-level Cervical Disc Replacement Versus Two-level Anterior Cervical Discectomy and Fusion in the Outpatient Setting.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to evaluate the safety of two-level cervical disc replacement (CDR) in the outpatient setting. SUMMARY OF BACKGROUND DATA: Despite growing interest in CDR, limited data exist evaluating the safety of two-level CDR in the outpatient setting. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried for all two-level anterior cervical discectomy and fusion (ACDF) and CDR procedures between 2015 and 2018. Demographics, comorbidities, and 30-day postoperative complication rates of outpatient two-level CDR were compared to those of inpatient two-level CDR and outpatient two-level ACDF. Radiographic data are not available in the NSQIP. RESULTS: A total of 403 outpatient CDRs were compared to 408 inpatient CDRs and 4134 outpatient ACDFs. Outpatient CDR patients were older and more likely to have pulmonary comorbidities compared to inpatient CDR (P < 0.03). Outpatient CDR patients were less likely to have an American Society of Anesthesiologists class ≥2 and have hypertension compared to outpatient ACDF patients (P < 0.0001). Outpatient CDR had a lower 30-day readmission rate (0.5% vs. 2.5%, P = 0.02) and lower 30-day reoperation rate (0% vs. 1%, P = 0.047) compared to inpatient CDR. Outpatient CDR had a lower readmission rate (0.5% vs. 2.1%, P = 0.03) compared to outpatient ACDF, but there was no difference in reoperation rates between the two procedures (0% vs. 0.8%, P = 0.07). Outpatient CDR had an overall complication rate of 0.2%, inpatient CDR had a complication rate of 0.9%, and outpatient ACDF had a complication rate of 1.3%. These differences were not significant. CONCLUSION: To our knowledge, this is the largest multicenter study examining the safety of two-level outpatient CDR procedures. Outpatient two-level CDR was associated with similarly safe outcomes when compared to inpatient two-level CDR and outpatient two-level ACDF. This suggests that two-level CDR can be performed safely in the outpatient setting.Level of Evidence: 3.

Autologous Stem Cells in Cervical Spine Fusion.

STUDY DESIGN: Systematic review. OBJECTIVES: To systematically review, critically appraise and synthesize evidence on use of stem cells from autologous stem cells from bone marrow aspirate, adipose, or any other autologous sources for fusion in the cervical spine compared with other graft materials. METHODS: A systematic search of PubMed/MEDLINE was conducted for literature published through October 31, 2018 and through February 20, 2020 for EMBASE and ClinicalTrials.gov comparing autologous cell sources for cervical spine fusion to other graft options. RESULTS: From 36 potentially relevant citations identified, 10 studies on cervical fusion met the inclusion criteria set a priori. Two retrospective cohort studies, one comparing cancellous bone marrow (CBM) versus hydroxyapatite (HA) and the other bone marrow aspirate (BMA) combined with autograft and HA versus autograft and HA alone, were identified. No statistical differences were seen between groups in either study for improvement in function, symptoms, or fusion; however, in the study evaluating BMA, the authors reported a statistically greater fusion rate and probability of fusion over time in the BMA versus the non-BMA group. Across case series evaluating BMA, authors reported improved function and pain and fusion ranged from 84% to 100% across the studies. In general, complications were poorly reported. CONCLUSIONS: The overall quality (strength) of evidence of effectiveness and safety of autologous BMA for cervical arthrodesis in the current available literature was very low. Based on currently available data, firm conclusions regarding the effectiveness or safety of BMA in cervical fusions cannot be made.

Adult spine deformity surgery in elderly patients: are outcomes worse in patients 75 years and older?

STUDY DESIGN: Retrospective study of a prospectively collected database at one center. OBJECTIVES: Assess the outcomes and complications of adult spinal deformity (ASD) surgery in patients that are 75 years and older compared with patients of 65-75 years of age. With increasing amounts of ASD surgery being performed on elderly patients, it is important to assess how age plays a factor in corrective reconstruction surgery. METHODS: Inclusion criteria for the study were all patients ≥ 65 years of age that underwent thoracolumbar deformity correction involving ≥ four levels at a single institution by two surgeons. Patients were divided based on age into 65-74.9 or ≥ 75 groups. Radiographic parameters were measured preoperatively, postoperatively, and at 2 years. The Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI) were collected preoperatively, at 1 year, and 2 years. Comorbidities included were based around the Charlson Comorbidity Index (CCI) and compared to the incidence of complications and need for further surgery. RESULTS: Both age groups had improvements in their radiographic parameters postoperatively which was maintained at 2 years. Comparing the different age groups with similar comorbidity burden in regard to complications and need for additional surgery yielded no statistically significant difference between groups. Both groups had comparable decreases in NRS and increases in ODI at 2 years. CONCLUSIONS: Analysis of our study population indicates that there is no difference between the outcomes and complications of deformity surgery in patients 75 years and older when compared to a younger elderly population. It also does not appear that a ≥ 3 comorbidity burden has a significant impact on the complications or need for additional surgery in our elderly spinal deformity surgery population. LEVEL OF EVIDENCE: Level IV.

Immune Checkpoint Inhibition is Safe and Effective for Liver Cancer Prevention in a Mouse Model of Hepatocellular Carcinoma.

Cirrhosis is a high-risk state for hepatocellular carcinoma (HCC) development and represents an opportunity to prevent cancer. In the precancerous state of cirrhosis, there is an accumulation of neoantigens that may be specifically targetable through immunotherapy. We asked whether immune checkpoint inhibition could prevent tumorigenesis in a mouse model of diethylnitrosamine and carbon tetrachloride-induced HCC. We found that initiation of anti-PD-1 therapy prior to tumorigenesis could prevent up to 46% of liver tumors. This significant reduction in tumor burden was accompanied by infiltration of CD4+ Th cells and CD8+ cytotoxic T cells into the liver parenchyma. Importantly, anti-PD-1 therapy did not exacerbate liver dysfunction or worsen overall health in this liver disease model. Given the safety and preservation of quality of life observed with long-term immunotherapy use, an immunotherapy chemoprevention strategy is likely associated with a low risk-to-benefit ratio and high value care in select patients. These results encourage a prevention trial in cirrhotic patients with the highest risk of developing HCC.See related Spotlight by Mohammed et al., p. 897.

Neck and Cervical Spine Injuries in National College Athletic Association Athletes: A 5-Year Epidemiologic Study.

STUDY DESIGN: Descriptive epidemiology study. OBJECTIVE: The purpose of this study was to describe the epidemiology of neck and cervical spine injuries in collegiate athletes over a 5-year period. SUMMARY OF BACKGROUND DATA: The incidence and etiology of neck and cervical spine injuries in National Collegiate Athletic Association (NCAA) athletes has not been well defined in recent years. METHODS: The incidence and characteristics of neck and cervical spine injuries were identified utilizing the NCAA Injury Surveillance Program database. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in one NCAA-sanctioned practice or competition. RESULTS: Nationally, there were an estimated 11,510 neck and cervical spine injuries over the 5-year period. These occurred at a rate of 7.05 per 100,000 athlete-exposures (AEs). The rate of neck and cervical spine injuries in men was 2.66 per 100,000 AEs, while women suffered injuries at a rate of 1.95 per 100,000 AEs. In sex-comparable sports, men were 1.36 times more likely to suffer a neck or cervical spine injury compared with women. Men's football (29.09 per 100,000 AEs) and women's field hockey (11.51 per 100,000 AEs) were the sports with the highest rates of injuries. These injuries were 3.94 times more likely to occur during competition compared with practice. In-season injury rates were the highest, at 8.18 per 100,000 AEs. CONCLUSION: The vast majority of neck and cervical spine injuries in NCAA athletes are minor and uncommon. Across all sports in both sexes, the majority of injuries were new, and occurred during in-season competitions. Most athletes returned to play within 24 hours of injury. These data can inform players, parents, coaches, athletic trainers, and physicians regarding the prevalence and rates of these injuries and potentially inform decision-making regarding injury prevention, treatment, and rehabilitation. LEVEL OF EVIDENCE: 4.

Risk factors for delay in surgery for patients undergoing elective anterior cervical discectomy and fusion.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is well-tolerated by most patients and commonly necessitates only a short hospital admission. Surgical delay after hospital admission, however, may result in longer hospital stays, consequently increasing hospital resource utilization. The current study evaluates risk factors for surgical delay in patients undergoing elective ACDF. METHODS: A retrospective analysis of ACS-NSQIP data from 2006-2015 was performed. Patients undergoing elective ACDF were selected using current procedural terminology (CPT) codes (22251, 22252, 22554). A surgical delay was defined as surgery that occurred one day or later after initial hospital admission. Differences in outcomes between the non-delayed and delayed cohorts were evaluated with univariate analysis. Multivariate logistic regression was performed to identify risk factors for surgical delay. RESULTS: There were a total of 771 (2.0%) surgical delays out of 39,371 patients undergoing elective ACDF from 2006-2015. Multivariate analysis found partially dependent functional status (OR 5.88; 95% CI: 4.48-7.71; P<0.001), totally dependent functional status (OR 18.22; 95% CI: 9.60-34.59; P<0.001), ASA class 4 (OR 2.73; 95% CI: 1.70-4.38; P<0.001), bleeding disorders (OR 1.75; 95% CI: 1.08-2.85; P=0.024), male sex (OR 1.19; 95% CI: 1.03-1.38; P=0.019), and chronic steroid use (OR 1.76; 95% CI: 1.30-2.37; P<0.001) as independent predictors of delay. Univariate analysis found surgical delay was associated with a higher rate of post-operative major adverse events (4.8% vs. 1.1%; P<0.001), mortality (1.0% vs. 0.2%; P<0.001) and greater than five-fold increase in total length of stay (9.52 vs. 1.65 days; P<0.001). CONCLUSIONS: Impaired pre-operative functional status, a higher comorbidity burden, and chronic steroid use are risk factors for surgical delay, increased complications, and length of stay in patients undergoing elective ACDF. This is helpful information to consider given a rising incidence of cervical fusions in the Medicare population, a wide variation in costs, and increasing popularity of bundled-payment models. LEVEL OF EVIDENCE: 3.

Clinical Efficacy of Liposomal Bupivacaine: A Systematic Review of Prospective, Randomized Controlled Trials in Orthopaedic Surgery.

BACKGROUND: There has been a surge in interest with regard to the utility of liposomal bupivacaine as part of a perioperative pain management protocol. The current study was proposed to critically assess the efficacy of liposomal bupivacaine as a local anesthetic for pain relief following orthopaedic procedures. METHODS: A systematic review of prospective, randomized trials involving liposomal bupivacaine was performed using searches of the PubMed, Embase, and Cochrane databases. The primary outcomes of interest included postoperative subjective pain scores and narcotic consumption. The length of stay and postoperative mobility were reviewed as secondary outcomes. RESULTS: Twenty-seven studies met inclusion criteria and were included for review. Twelve of 17 studies concluded that periarticular or local infiltrative liposomal bupivacaine offered no additive benefit compared with other local anesthetic injections. Peripheral nerve blocks without liposomal bupivacaine conferred more optimal pain relief and decreased narcotic consumption in the immediate postoperative period when compared with liposomal bupivacaine, with no differences thereafter. Twelve studies listed a conflict of interest related to the drug manufacturer (Pacira Pharmaceuticals). Eight of these studies (67%) demonstrated clinical superiority of liposomal bupivacaine when compared with the study control. In the 15 studies that did not show a conflict of interest, only 1 study (7%) demonstrated therapeutic superiority with use of periarticular liposomal bupivacaine when compared with a historical cohort that received no local or regional anesthesia. CONCLUSIONS: Current prospective, randomized controlled trials in patients undergoing orthopaedic surgery fail to support the routine use of liposomal bupivacaine compared with other local injectable analgesics, particularly in the setting of knee replacement surgery. We were unable to find consistent support for the potential of superior pain relief and narcotic use reduction with the use of liposomal bupivacaine. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.