Fracture liaison service-a multidisciplinary approach to osteoporosis management.

A fracture liaison service is a systems-level multidisciplinary approach designed to reduce subsequent fracture risk in patients who recently sustained fragility fractures. It is estimated that one in three women and one in five men over the age of 50 years old have osteoporosis. Nonetheless, only 9 to 20% of patients who sustain an initial fragility fracture eventually receive any osteoporosis treatment. With the aim of preventing subsequent fractures, a fracture liaison service (FLS) works through identifying patients presenting with fragility fractures to the hospital and providing them with easier access to osteoporosis care through referrals for bone health and fracture risk assessment and recommendation or initiation of osteoporosis treatment. Currently, there are four major types of FLS models ranging from services that only identify at-risk patients and inform and educate the patient but take no further part in communicating their findings to other stakeholders in patients' care, to services that identify, investigate, and initiate treatment at the other end of the spectrum. In this article, we review the benefits, challenges, and outcomes of FLS in the American healthcare system with further exploration of the roles each member of the multidisciplinary team can play in improving patients' bone health.

Incidence and predictive factors of double crush syndrome in patients undergoing cervical surgery: a database study.

BACKGROUND: Double crush syndrome (DCS) is characterized by multiple compression sites along a single peripheral nerve. It commonly presents with persistent distal symptoms despite surgical treatment for cervical radiculopathy. Management typically involves nerve release of the most symptomatic site. However, due to overlapping symptoms with cervical radiculopathy, patients may undergo cervical surgery prior to DCS diagnosis. Due to its rarity and frequent misdiagnosis, the authors aim to utilize a large national database to investigate the incidence and associations of DCS. METHODS: The Pearldiver database was utilized to identify patients undergoing cervical surgery for the management of cervical radiculopathy. Patients were stratified into three cohorts based on their clinical course before and after cervical surgery. The primary outcome was the prevalence of DCS, and secondary outcomes included an evaluation of predictive factors for each Group, using a significance level of P < 0.05. RESULTS: Among 195,271 patients undergoing cervical surgery for cervical radiculomyelopathy, 97.95% were appropriately managed, 1.42% had potentially mids-diagnosed DCS, and 0.63% were treatment-resistant. Diabetes and obesity were significant predictors of potentially misdiagnosed DCS (P < 0.05). CONCLUSION: This study presents data indicating that 1.42% of patients who receive cervical surgery may have underlying DCS and potentially benefit from nerve release prior to undergoing surgery. A concurrent diagnosis of diabetes and obesity may predict an underlying DCS.

Preserving privacy in big data research: the role of federated learning in spine surgery.

PURPOSE: Integrating machine learning models into electronic medical record systems can greatly enhance decision-making, patient outcomes, and value-based care in healthcare systems. Challenges related to data accessibility, privacy, and sharing can impede the development and deployment of effective predictive models in spine surgery. Federated learning (FL) offers a decentralized approach to machine learning that allows local model training while preserving data privacy, making it well-suited for healthcare settings. Our objective was to describe federated learning solutions for enhanced predictive modeling in spine surgery. METHODS: The authors reviewed the literature. RESULTS: FL has promising applications in spine surgery, including telesurgery, AI-based prediction models, and medical image segmentation. Implementing FL requires careful consideration of infrastructure, data quality, and standardization, but it holds the potential to revolutionize orthopedic surgery while ensuring patient privacy and data control. CONCLUSIONS: Federated learning shows great promise in revolutionizing predictive modeling in spine surgery by addressing the challenges of data privacy, accessibility, and sharing. The applications of FL in telesurgery, AI-based predictive models, and medical image segmentation have demonstrated their potential to enhance patient outcomes and value-based care.

Language-adaptive artificial intelligence: assessing CHATGPT'S answer to frequently asked questions on total hip arthroplasty questions.

ChatGPT is reported to be an acceptable tool to answer a majority of frequently asked patient questions. ChatGPT also converses in other languages including Urdu, which offers immense potential for the education of Pakistani patients. Therefore, this study evaluated ChatGPT's Urdu answers to the ten most frequently asked questions on Total Hip Arthroplasty, which were then rated by an expert. Out of 10 answers in English, 9 (90%) were satisfactory requiring minimal clarification and 1 (10%) was satisfactory requiring moderate clarification. In both Roman and Nastaliq script Urdu, 1 (10%) answer was satisfactory requiring moderate clarification, while 9 (90%) were unsatisfactory requiring substantial clarification. In conclusion, as opposed to ChatGPT English responses, Urdu responses were much less rigorous, generic, and lacked scientific rigor. We have a long way to go before Pakistani patients with limited English language skills could benefit from AI chatbots like ChatGPT.

A comprehensive exploration of artificial intelligence in orthopaedics within lower-middle-income countries: a narrative review.

Integrating Artificial Intelligence (AI) in orthopaedic within lower-middle-income countries (LMICs) promises landmark improvement in patient care. Delving into specific use cases-fracture detection, spine imaging, bone tumour classification, and joint surgery optimisation-the review illuminates the areas where AI can significantly enhance orthopaedic practices. AI could play a pivotal role in improving diagnoses, enabling early detection, and ultimately enhancing patient outcomes- crucial in regions with constrained healthcare services. Challenges to the integration of AI include financial constraints, shortage of skilled professionals, data limitations, and cultural and ethical considerations. Emphasising AI's collaborative role, it can act as a complementary tool working in tandem with physicians, aiming to address gaps in healthcare access and education. We need continued research and a conscientious approach, envisioning AI as a catalyst for equitable, efficient, and accessible orthopaedic healthcare for patients in LMICs.

Incidence of subsequent surgical decompression following minimally invasive approaches to treat lumbar spinal stenosis: A retrospective review.

BACKGROUND CONTEXT: Surgical decompression is the definitive treatment for managing symptomatic lumbar spinal stenosis; however, select patients are poor surgical candidates. Consequently, minimally invasive procedures have gained popularity, but there exists the potential for failure of therapy necessitating eventual surgical decompression. PURPOSE: To evaluate the incidence and characteristics of patients who require surgical decompression following minimally invasive procedures to treat lumbar spinal stenosis. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: Patients who underwent minimally invasive procedures for lumbar spinal stenosis (Percutaneous Image-guided Lumbar Decompression [PILD] or interspinous spacer device [ISD]) and progressed to subsequent surgical decompression within 5 years. OUTCOME MEASURES: The primary outcome was the rate of surgical decompression within 5 years following the minimally invasive approach. Secondary outcomes included demographic and comorbid factors associated with increased odds of requiring subsequent surgery. METHODS: Patient data were collected using the PearlDiver-Mariner database. The rate of subsequent decompression was described as a percentage while univariable and multivariable regression analysis was used for the analysis of predictors. RESULTS: A total of 5278 patients were included, of which 3222 (61.04%) underwent PILD, 1959 (37.12%) underwent ISD placement, and 97 (1.84%) had claims for both procedures. Overall, the incidence of subsequent surgical decompression within 5 years was 6.56% (346 of 5278 patients). Variables associated with a significantly greater odds ratio (OR) [95% confidence interval (CI)] of requiring subsequent surgical decompression included male gender and a prior history of surgical decompression by 1.42 ([1.14, 1.77], p = 0.002) and 2.10 times ([1.39, 3.17], p < 0.001), respectively. In contrast, age 65 years and above, a diagnosis of obesity, and a Charlson Comorbidity Index score of three or greater were associated with a significantly reduced OR [95% CI] by 0.64 ([0.50, 0.81], p < 0.001), 0.62 ([0.48, 0.81], p < 0.001), and 0.71 times ([0.56, 0.91], p = 0.007), respectively. CONCLUSIONS: Minimally invasive procedures may provide an additional option to treat symptomatic lumbar spinal stenosis in patients who are poor surgical candidates or who do not desire open decompression; however, there still exists a subset of patients who will require subsequent surgical decompression. Factors such as gender and prior surgical decompression increase the likelihood of subsequent surgery, while older age, obesity, and a higher Charlson Comorbidity Index score reduce it. These findings aid in selecting suitable surgical candidates for better outcomes in the elderly population with lumbar spinal stenosis.

Impact of Postoperative Antibiotic Prophylaxis on Surgical Site Infections Rates After Mastectomy with Drains but Without Immediate Reconstruction: A Multicenter, Double-Blinded, Randomized Control Superiority Trial.

BACKGROUND: There is no consensus on the use of postoperative antibiotic prophylaxis (PAP) after mastectomy with indwelling drains. We explored the utility of continued PAP in reducing surgical site infection (SSI) rates after mastectomy without immediate reconstruction and with indwelling drains. PATIENTS AND METHODS: A multicenter, two-armed, randomized control superiority trial was conducted in Pakistan. We enrolled all consenting adult patients undergoing mastectomy without immediate reconstruction. All patients received a single preoperative dose of cephalexin within 60 min of incision, and postoperatively were randomized to receive either continued PAP using cephalexin (intervention) or a placebo (control) for the duration of indwelling, closed-suction drains. The primary outcome was the development of SSI within 30 days and 90 days postoperatively. Secondary outcomes included study-drug-associated adverse events. Intention-to-treat analysis was performed using multivariable Cox regression. RESULTS: A total of 369 patients, 180 (48.8%) in the intervention group and 189 (51.2%) in the control group, were included in the final analysis. Overall cumulative SSI rates were 3.5% at 30 days and 4.6% at 90 days postoperatively. PAP was not associated with SSI reduction at 30 (hazard ratio, HR 1.666 [95% confidence interval CI 0.515-5.385]) or 90 (1.575 [0.558-4.448]) days postoperatively, or with study-drug-associated adverse effects (0.529 [0.196-1.428]). CONCLUSIONS: Continuing antibiotic prophylaxis for the duration of indwelling drains after mastectomy without immediate reconstruction offers no additional benefit in terms of SSI reduction. There is a need to update existing guidelines to provide clearer recommendations regarding use of postoperative antibiotic prophylaxis after mastectomy in the setting of indwelling drains.

Practice Patterns of Antibiotic Prophylaxis in Patients Undergoing Mastectomy: A Survey of Members of the American Society of Breast Surgeons.

BACKGROUND: Surgical site infections after breast surgery range from 1 to 16%. Both the American Society of Breast Surgeons (ASBrS) and the American Association of Plastic Surgeons guidelines lack clarity on postoperative antibiotic prophylaxis (AP) after mastectomy. We surveyed the ASBrS membership to understand their practice patterns of AP after mastectomy and familiarity with ASBrS guidelines. METHODS: A self-designed, 19-question survey was emailed to all 2934 ASBrS members. Information was obtained on the participants' training, familiarity with ASBrS guidelines, and practices of prescribing perioperative AP after mastectomy with/without reconstruction and with indwelling drains. RESULTS: In total, 556 (19%) responses were analyzed. Half were fellowship-trained breast surgeons/surgical oncologists (50.2%), with 55.6% having practiced for > 15 years and 66.9% in community/private practice. Only 53.6% reported familiarity with ASBrS guidelines for perioperative AP. Most (> 90%) surgeons reported "always" placing drains after mastectomy and "always" prescribing preoperative AP. Postoperatively, preference for continuing AP in cases with drains in place varied by procedure: 7.7% when no reconstruction, 29.1% when autologous-only, and 52.5% when implant reconstruction. Academic surgeons were less likely than surgeons in community/private practice to continue postoperative AP, whether for the duration of indwelling drains (5.1% versus 9.4%) or even till 7 days postoperatively (0.6% versus 3.2%) (p < 0.05). CONCLUSIONS: Surgeons uniformly adhere to ASBrS guidelines for preoperative AP. However, there is wide variation in AP postoperatively in patients with/without reconstruction and with indwelling drains. Our results highlight the need for high-quality evidence based on which guidelines must be updated, and the need to familiarize surgeons with current guidelines.

Perceived risk and distress related to COVID-19 in healthcare versus non-healthcare workers of Pakistan: a cross-sectional study.

BACKGROUND: Healthcare workers (HCWs) have found themselves and their families more susceptible to contracting COVID-19. This puts them at a higher risk of psychological distress, which may compromise patient care. In this study, we aim to explore the risk perceptions and psychological distress between HCWs and non-healthcare workers (NHCWs) in Pakistan. METHODS: A cross-sectional study was conducted using an online self-administered questionnaire. Psychological distress was assessed through The Hospital Anxiety and Depression Scale (HADS). Comparisons were made between HCWs (front/backend, students/graduates) and NHCWs related to risk perceptions and stress levels related to COVID-19. Following tests for normality (Shapiro-Wilk test), variables that fulfilled the normality assumption were compared using the independent samples t-test, while for other variables Mann-Whitney U-test was employed. Pearson Chi-square test was used to compare categorical data. Multiple logistic regression techniques examined the association of participant age, gender, household income, and the presence of COVID-19 symptoms with depression and anxiety levels. RESULTS: Data from 1406 respondents (507 HCWs and 899 NHCWs) were analyzed. No significant difference was observed between HCWs and NHCWs' perception of susceptibility and severity towards COVID-19. While healthcare graduates perceived themselves (80% graduates vs 66% students, p-value 0.011) and their family (82% graduates vs 67% students, p-value 0.008) to be more susceptible to COVID-19, they were less likely to experience depression than students. Frontline HCWs involved in direct patient care perceived themselves (83% frontline vs. 70% backend, p-value 0.003) and their family (84% frontline vs. 72% backend, p-value 0.006) as more susceptible to COVID-19 than backend healthcare professionals. Over half of the respondents were anxious (54% HCWs and 55% NHCWs). Female gender, younger age, lower income, and having COVID-19 related symptoms had a significant effect on the anxiety levels of both HCWs and NHCWs. CONCLUSION: Frontline HCWs, young people, women, and individuals with lower income were at a higher risk of psychological distress due to the pandemic. Government policies should thus be directed at ensuring the mental well-being of frontline HCWs and improving their satisfaction to strengthen the health care delivery system. The findings suggest the need to provide mental health support for health workers.

Telementoring for breast surgeons practicing in remote areas.

Telementorship allows an expert surgeon to mentor another surgeon through an advanced procedure from a remote location via 2-way audio-visual communication. The current article was planned to review the existing literature and evaluate the utility of telementorship regarding educating rural surgeons in Pakistan about multidisciplinary breast cancer care. Publications from 2016 to 2020 were searched on PubMed and GoogleScholar and 10 most recent publications were selected. Review of literature revealed that even though telementorship in this context might be comparable to onsite mentorship, multiple concerns need to be addressed before its implementation. These include lack of concrete evidence regarding its effectiveness, legal, security and financial issues. Thus, a pilot project evaluating the efficacy of telementorship needs to be conducted for rural breast surgeons working in Pakistan. If these studies show promise and an affordable, convenient and effective method of telementorship is devised, then it may become the future of breast surgery training in far-flung regions of Pakistan.

Ankle fracture surgery in patients experiencing homelessness: a national evaluation of one-year rates of reoperation.

Objectives: To evaluate the impact of homelessness on surgical outcomes following ankle fracture surgery. Design: Retrospective cohort study. Setting: Mariner claims database. Patients/Participants: Patients older than 18 years who underwent open reduction and internal fixation (ORIF) of ankle fractures between 2010 and 2021. A total of 345,759 patients were included in the study. Intervention: Study patients were divided into two cohorts (homeless and nonhomeless) based on whether their patient record contained International Classification of Disease (ICD)-9 or ICD-10 codes for homelessness/inadequate housing. Main Outcome Measures: One-year rates of reoperation for amputation, irrigation and debridement, repeat ORIF, repair of nonunion/malunion, and implant removal in isolation. Results: Homeless patients had significantly higher odds of undergoing amputation (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.08-2.27, P = 0.014), irrigation and debridement (aOR 1.22, 95% CI 1.08-1.37, P < 0.001), and repeat ORIF (aOR 1.16, 95% CI 1.00-1.35, P = 0.045). Implant removal was less common in homeless patients (aOR 0.65, 95% CI 0.59-0.72, P < 0.001). There was no significant difference between homeless and nonhomeless patients in the rate of nonunion/malunion repair (aOR 0.87, 95% CI 0.63-1.18, P = 0.41). Conclusions: Homelessness is a significant risk factor for worse surgical outcomes following ankle fracture surgery. The findings of this study warrant future research to identify gaps in surgical fracture care for patients with housing insecurity and underscore the importance of developing interventions to advance health equity for this vulnerable patient population. Level of Evidence: Prognostic Level III.

Comparing opioid utilization and costs for surgical management of single-level spondylolisthesis: A national claims database analysis.

Introduction: The rise in degenerative lumbar spondylolisthesis (DLS) cases has led to a significant increase in fusion surgeries, which incur substantial hospitalization costs and often necessitate chronic opioid use for pain management. Recent evidence suggests that single-level low-grade DLS outcomes are comparable whether a fusion procedure or decompression alone is performed, sparking debate over the cost-effectiveness of these procedures, particularly with the advent of minimally invasive techniques reducing the morbidity of fusion. This study aims to compare chronic opioid utilization and associated costs between decompression alone and decompression with instrumented fusion for single-level degenerative lumbar spondylolisthesis. Material and methods: Using data from the PearlDiver database, a retrospective database analysis was conducted. We analyzed records of Medicare and Medicaid patients undergoing lumbar fusion or decompression from 2010 to 2022. Patient cohorts were divided into decompression alone (DA) and decompression with instrumented fusion (DIF). Chronic opioid use, pain clinic visits, and total costs were compared between the two groups at 90 days, 1 year, and 2 years post-surgery. Theory: Does DIF offer a more cost-effective approach to managing DLS in terms of chronic opioid use in single-level DLS patients. Results: The study revealed comparable chronic opioid use and pain clinic visits between DA and DIF groups at 90 days and 1 year. However, total costs associated with opioid prescriptions as well as surgical aftercare were significantly higher in the DIF group at 90 days (p < 0.05), 1 year (p < 0.05), and 2 years (p < 0.05) post-surgery compared to the DA group. Conclusions: This study highlights the higher costs associated with DIF up to 2 years post-surgery despite comparable symptom improvement when compared to DA and DIF at the 1-year interval. DA emerges as a more financially favorable option, challenging the notion of fusion's cost-offsetting benefits. While further investigation is needed to understand underlying cost drivers and optimize outcomes, our findings emphasize the necessity of integrating clinical and economic factors in the management of single-level DLS.

Predictive factors of symptomatic lumbar pseudoarthrosis following multilevel primary lumbar fusion.

Background: Lumbar spinal fusion surgery is a well-established treatment for various spinal disorders. However, one of its complications, pseudoarthrosis, poses a significant concern. This study aims to explore the incidence, time and predictive factors contributing to pseudoarthrosis in patients who have undergone lumbar fusion surgery over a 10-year period. Methods: Data for this research was sourced from the PearlDiver database where insurance claims of patients who underwent multilevel lumbar spinal fusion between 01/01/2010 and 10/31/2022 were examined for claims of pseudoarthrosis within the 10 years of their index procedure. A variety of demographic, comorbid, and surgical factors were assessed, including age, gender, Elixhauser Comorbidity Index (ECI), surgical approach, substance use disorders and history of spinal disorders. Statistical analyses, including chi-squared tests, multivariate analysis, and cox survival analysis were employed to determine significant associations. Results: Among the 76,337 patients included in this retrospective study, 2.70% were diagnosed with symptomatic lumbar pseudoarthrosis at an average of 7.38 years in a 10-year follow-up. Multivariate and Cox hazard analyses revealed that significant predictors of symptomatic pseudoarthrosis development following multilevel primary lumbar fusion include vitamin D deficiency, osteoarthritis, opioid and NSAID use, tobacco use, and a prior history of congenital spine disorders. Conclusions: In summary, this study revealed a 2.70% incidence of symptomatic lumbar pseudoarthrosis within 10 years of the index procedure. It highlighted several potential predictive factors, including comorbidities, surgical approaches, and substance use disorders, associated with the development of symptomatic pseudoarthrosis. Future research should focus on refining our understanding of these factors to improve patient outcomes and optimize healthcare resource allocation.

Management of Breast Intraductal Papilloma Diagnosed on Core Needle Biopsy: Excision or Follow-up?

Introduction Management of intraductal papillomas (IDPs) diagnosed on core needle biopsy (CNB) remains controversial. We report our experience of IDPs identified on CNB, our institutional rates of upgradation to atypia/malignancy as well as radiologic/pathologic features that may allow selection for surgery as well as those for safe observation. Methods The study is a retrospective review of patient records from 2012 to 2019, at a tertiary care hospital in Pakistan. Data was analyzed using Statistical Package for Social Sciences (SPSS), version 21.0 (IBM Corp., Armonk, NY). Associations between various patient factors were assessed using Pearson's chi-square test. Results This study included a total of 55 female patients with IDPs, with a mean age of 54.67 ± 15.57 years. On CNB, 69.1% (n = 38) of patients had IDP without atypia while 30.9% (n = 17) had IDP with atypia, with single IDPs being the most common lesions on excisional biopsy. Overall, of all CNB-diagnosed IDPs, only 4/55 (7.3%) demonstrated upgradation (3/4 to DCIS, 1/4 showed atypia) on excisional biopsy, and all these upgraded cases had failed to demonstrate atypia on initial CNB. Conclusion CNB-identified cases of IDPs are rarely upgraded on excision and thus routine excision in all cases may be unnecessary. Appropriate patient selection based on radiology-pathology findings should be done. Those with suspicious findings on imaging as well as those that demonstrate atypia on CNB must be excised.

Exploring the incidence and risk factors of reoperation for symptomatic adjacent segment disease following cervical decompression and fusion.

Background: Patients with long-term follow-up after cervical decompression and fusion have often been noted to have development of adjacent segment degeneration with a smaller subset of these patients progressing to adjacent segment disease (ASD), which results in the development of new symptomatic radiculopathy or myelopathy referable to a site either directly above or below a prior fused segment. The cause of ASD is multifactorial often involving natural age-related progression of spondylosis, accelerated progression following cervical decompression and fusion, operative technique, and patient-related factors. The effect of age at the time of index cervical decompression and fusion on the need for reoperation for ASD is not fully understood. This study aims to establish underlying risk factors for the development of symptomatic cervical ASD following cervical decompression and fusion requiring reoperation in patients of various age groups. Methods: A retrospective database review of patients aged 20 or greater with insurance claims of primary cervical decompression and fusion over the course of 11 years and 10 months (January 01, 2010-October 31, 2022) was conducted using an insurance claims database. The primary outcome was to evaluate the incidence of cervical ASD requiring reoperation amongst patients stratified by age at the time of their primary procedure. Secondary outcomes included an evaluation of various risk factors for ASD following cervical decompression and fusion including surgeon-controlled factors such as the number of levels fused and approach taken, patient cervical pathology including cervical disc disorder and cervical spondylosis, and underlying patient medical comorbidities including osteoporosis and vitamin D deficiency, and substance use. Results: A total of 60,292 patient records were analyzed, where the overall reoperation incidence for symptomatic ASD was 6.57%, peaking at 8.12% among those aged 30 to 39 and decreasing with age. Regression analysis revealed ages lower than 50 years as more predictive for the development of symptomatic ASD requiring reoperation. Multivariate regression analysis identified predictive factors for reoperation, including age, Elixhauser Comorbidity Index (ECI), multiple-level surgery, cervical spondylosis, cervical disc disorder, osteoporosis, and vitamin D deficiency. Notably, these factors had a variable impact across various age groups, as revealed by subgroup analysis. Conclusions: The incidence of reoperation secondary to symptomatic ASD is 6.57%, highest in those aged 30 to 39. The surgical approach had no significant impact on the need for reoperation, but multiple-level fusions posed a consistent risk in the development of symptomatic ASD requiring reoperation. Patient factors like degenerative disc disease, spondylosis, osteoporosis, and vitamin D deficiency were associated, urging further age-specific risk assessment and nonoperative intervention exploration.

Osteoporosis Treatment and Outcomes in Patients Undergoing Adult Spinal Deformity Surgery.

INTRODUCTION: Adult spinal deformity (ASD) treatment for patients with osteoporosis presents a unique challenge for spine surgeons, particularly with ensuring adequate fixation and correction during surgery and due to the risk of treatment failure and complications thereafter. Osteoporosis is characterized by low bone mineral density (BMD) which may increase the risk for fractures. Approximately 12.6% of all adults over 50 years old in the United States are affected by osteoporosis, and the prevalence is predicted to increase with the aging population.1 ASD patients experience substantially higher rates of osteoporosis compared to the general population.2,3 One study discovered an osteoporosis prevalence of nearly 33% in a cohort of ASD patients undergoing long spinal fusion at two academic medical centers, with slightly over one- third of those patients receiving osteoporosis pharmacotherapy prior to surgery.3 Similarly, patients with osteoporosis experience ASD at higher rates than the general population, with one study finding that 9.5% of patients with osteoporosis suffer from ASD symptoms.3 Gupta et al. discovered that obtaining a DEXA scan of the forearm in addition to the hip allowed physicians to detect an additional 17% incidence of osteoporosis in ASD patients, suggesting that osteoporosis may be missed when there is only one DEXA scan available.4In addition to being potentially underdiagnosed and undertreated, ASD patients with osteoporosis experience higher rates of post-surgical complications. Pseudarthrosis, or nonunion after spinal fusion, is a painful and potentially debilitating complication following ASD surgery that ultimately requires additional surgical correction. Proximal junctional kyphosis (PJK), which is defined as proximal junctional sagittal Cobb angle ≥ 10° and at least 10° greater than the preoperative measurement, is another complication of ASD surgery.5 Though this condition may be clinically silent and manifest purely as a radiographic diagnosis, it is often a precursor to proximal junctional failure (PJF), a more severe form of PJK that ultimately increases the risk for intractable pain, neurological deficit, and revision surgery.6 ASD patients with osteoporosis experience significantly higher rates of pseudarthrosis, PJK, PJF, and postoperative fractures, as well as other forms of instrumentation failure requiring additional surgical treatment.7-11 This ultimately increases the pain, emotional burden, and morbidity experienced by patients. There is currently conflicting data regarding the impact of perioperative osteoporosis pharmacotherapy on outcomes in ASD patients. Bisphosphonates are considered first-line treatment for osteoporosis, though alternatives such as teriparatide, denosumab, and calcitonin may be used as well.12 Multiple studies have found that preoperative bisphosphonate treatment did not affect lumbar fusion nonunion rates.13,14 In contrast, a meta-analysis of randomized control trials found that postoperative bisphosphonates had no effect on lumbar fusion rates but did significantly reduce the risk of vertebral compression fracture (VCF) and pedicle screw loosening at 12-month follow-up.15 Prophylactic teriparatide treatment has been associated with improved BMD and lower incidence of PJK type-2 in osteoporosis patients who underwent ASD surgery.16 Evidence for perioperative treatment of teriparatide as a preventative step to increase fusion rates and reduce PJK and PJF is strongest.17 However, the percentage of ASD patients who are actually being treated perioperatively with these medications requires further evaluation, and a comparison of outcomes with osteoporosis and non-osteoporosis counterparts has yet to be explored. The purpose of this study was to evaluate the prevalence and treatment of osteoporosis among patients undergoing long spinal fusion for ASD, as well as compare the impact of osteoporosis treatment on surgical and radiographic outcomes following fusion surgery. Additionally, we sought to examine the differences in radiographic outcomes of osteoporotic patients receiving various pharmacologic regimens such as monotherapy vs combination therapy.

Osteobiologics and Value-Based Care: Challenges and Opportunities.

BACKGROUND: Autologous bone grafts, sourced from the iliac crest, are the gold standard for bone substitution in spine surgery. However, harvesting autografts increases the risk of postoperative complications. Bone allografts are another popular source of graft material, but their use is rapidly surpassing their availability. There has been considerable interest in manufactured bone graft substitutes, commonly referred to as osteobiologics, which mimic the properties of autologous bone and may be osteoconductive, osteoinductive, osteogenic, or a combination. OBJECTIVE: Osteobiologics have been developed to mimic the properties of autologous bone, but their high cost and variable effectiveness raise questions about their value. This article explores the challenges and opportunities associated with the use of osteobiologics used to aid in bone healing in spinal fusion surgery within a value-based care framework. Spinal fusion treatments such as bone morphogenetic proteins, platelet-rich plasma, autologous conditioned serum, demineralized bone matrix, biomaterial scaffolds, stem cells, and cellular bone matrices are compared. SUMMARY: Bone morphogenetic proteins are highly effective but often associated with serious risks; platelet-rich plasma shows promising results but lacks standardization in research protocols. Autologous conditioned serum is inconclusive and cost-effective, while demineralized bone matrix has variable effectiveness and limited data to use in anterior spinal fusions. Biomaterial scaffolds have limited application in the anterior spine but demonstrate high efficacy when it comes to spinal fusion. Stem cells demonstrate improved postsurgical outcomes but have low yield from bone marrow and potential risks associated with genetic engineering and cell therapy. Cellular bone matrices show promising results and have high fusion rates, yet there is currently no US Food and Drug Adminstration requirement for preclinical or clinical data before commercial usage. Although osteobiologics have considerable potential, their high price and uncertain efficiency raise questions concerning their usefulness in spinal fusion surgery. To ensure better patient outcomes, extensive research is needed to explore their utilization within a value-based care framework.

Unlocking the Healing Potential: Cannabinoids in Spine Surgery for Pain Relief and Recovery.

¼ Cannabinoids, such as D9-tetrahydrocannabinol and cannabidiol, interact with endocannabinoid receptors in the central nervous system and immune system, potentially offering pain relief. The entourage effect, resulting from the interaction of multiple cannabis components, may enhance therapeutic impact and efficacy, making them promising candidates for exploring pain relief in spine operations, known to be among the most painful operative procedures.¼ The use of cannabinoids in pain management requires careful consideration of safety, including their cognitive and psychomotor effects, potential cardiovascular risks, risk of dependence, mental health implications, and drug interactions.¼ Few studies have analyzed cannabinoid use in relation to spine surgery, with variable results reported, indicating possible effects on reoperation rates, mortality, complications, postoperative opioid use, and length of hospital stay.¼ Current knowledge gaps exist in the understanding of cannabinoid effects on spine surgery, including the exploration of different administration routes, timing, dosage, and specific outcomes. In addition, mechanistic explanations for the observed results are lacking.¼ Ethical considerations related to informed consent, medical expertise, societal impact, and legal compliance must also be thoroughly addressed when considering the utilization of cannabinoids in spinal pathologies and back pain treatment.