Biomechanical and ergonomic risks associated with cervical musculoskeletal dysfunction amongst surgeons: A systematic review

INTRODUCTION

Surgeons are at high risk of developing musculoskeletal symptoms due to a range of factors including, maladaptive positioning and surgical ergonomics. Cervical muscle strain and biomechanical load is most prevalent due to repetitive motions and prolonged static neck positioning. This issue is apparent through reports of prevalence between 10 and 74.4% among surgeons. The aim of this systematic review is to provide an objective assessment of the clinical evidence available and a descriptive analysis of the effects of kinematics and surgical ergonomics on the prevalence of surgeons' cervical musculoskeletal pain.

METHODS

This is PRISMA-compliant systematic review of clinical studies assessing the prevalence of cervical musculoskeletal dysfunction in surgeons by searching PUBMED and Ovid EMBASE databases from inception to 19th October 2023. Study quality was graded according to the National Institutes of Health study quality assessment tools.

RESULTS

A total of 9 studies were included in the final qualitative analysis. The use of loupes, open surgery and excessive neck flexion (>30°) were associated with cervical dysfunction. Comparison of study outcomes was challenging due to heterogeneity within study methods and the paucity of methodological quality.

CONCLUSION

The current literature assessing ergonomic and biomechanical factors predisposing surgeons to cervical musculoskeletal dysfunction is insufficient to provide reliable guidance for clinicians. Although the literature identifies factors contributing to work-related cervical dysfunction, few attempt to evaluate interventions for improved surgical ergonomics. An objective assessment of interventions that prompt postural correction with the aim to improve neck pain in surgeon cohorts is warranted.

Comparative surgical outcomes of navigated vs non-navigated posterior spinal fusions in ankylosing spondylitis patients

INTRODUCTION

Ankylosing Spondylitis (AS) patients with acute spinal fractures represent a challenge for practicing spine surgeons due to difficult operative anatomy and susceptibility to complications.

RESEARCH QUESTION

Does intraoperative CT-navigation improve outcomes in patients with ankylosing spondylitis undergoing surgery?

METHODS

A retrospective review was carried out at our centre from 05/2016-06/2021 to identify AS patients presenting with a traumatic spinal fracture, managed surgically with posterior spinal fusion (PSF). Cohorts were categorised and compared for outcomes based on those who underwent PSF with intraoperative CT-navigation versus those surgically managed with traditional intraoperative fluoroscopy.

RESULTS

37 AS patients were identified. 29/37 (78.4%) underwent PSF. Intraoperative navigation was used in 14 (48.3%) cases. Mean age of the entire cohort was 67.6 years. No difference existed between the navigated and non-navigated groups for mean levels fused (5.35 vs 5.07; p ​= ​0.31), length of operation (217.9mins vs 175.3mins; p ​= ​0.07), overall length-of-stay (12 days vs 21.9 days; p ​= ​0.16), patients requiring HDU (3/14 vs 5/15; p ​= ​0.09) or ICU (5/14 vs 9/15; p ​= ​0.10), postoperative neurological improvement (1/14 vs 1/15; p ​= ​0.48) or deterioration (1/14 vs 0/15; p ​= ​0.15), intraoperative complications (2/14 vs 3/15; p ​= ​0.34), postoperative complications 4/14 vs 4/15; p ​= ​0.46), revision surgeries (3/14 vs 1/15; p ​= ​0.16) and 30-day mortality (0/14 vs 0/15).

CONCLUSION

This is the first study that compares surgical outcomes of navigated vs non-navigated PSFs for AS patients with an acute spinal fracture. Although limited by its retrospective design and sample size, this study highlights the non-inferiority of intraoperative navigation as a surgical aid in a challenging cohort.

An Assessment of the World's Contribution to Spine Trauma Care: A Bibliometric Analysis of Classifications and Surgical Management; An AO Spine Knowledge Forum Trauma Initiative

STUDY DESIGN

Bibliometric analysis.

OBJECTIVES

An analysis of the literature related to the assessment and management of spinal trauma was undertaken to allow the identification of top contributors, collaborations and research trends.

METHODS

A search to identify original articles published in English between 2011 and 2020 was done using specific keywords in the Web of Science database. After screening, the top 300 most cited articles were analyzed using Biblioshiny R software.

RESULTS

The highest number of contributions were from the Thomas Jefferson University, USA, University of Toronto and University of British Columbia, Canada. The top 3 most prolific authors were Vaccaro AR, Arabi B, and Oner FC. The USA and Canada were among the top contributing countries; Switzerland and Brazil had most multiple country co-authored articles. The most relevant journals were the European Spine Journal, Spine and Spine Journal. Three of the 5 most cited articles were about classification systems of fractures. The keyword analysis included clusters for different spinal regions, spinal cord injury, classification agreement and reliability studies, imaging related studies, surgical techniques and outcomes.

CONCLUSIONS

The study identified the most impactful authors and affiliations, and determined the journals where most impactful research is published in the field. Study also compared the productivity and collaborations across countries. The study highlighted the impact of development of new classification systems, and identified research trends including instrumentation, fixation and decompression techniques, epidemiology and recovery after spinal trauma.

The correlation between altmetric score and traditional measures of article impact for studies pertaining to spine trauma

PURPOSE

It is becoming increasingly common for researchers to share scientific literature via social media. Traditional bibliometrics have long been utilized to measure a study's academic impact, but they fail to capture the impact generated through social media sharing. Altmetric Attention Score (AAS) is a weighted count of all the online attention garnered by a study, and it is currently unclear whether a relationship with traditional bibliometrics exists.

METHODS

We identified the five highest-rated spine-specific and five highest-rated general orthopedic journals by Scopus CiteScore 2020. We then identified all the spine trauma studies across a 5-year span (2016-2020) within these journals and compared AAS with traditional bibliometrics using Independent t-tests and Pearson's correlational analyses.

RESULTS

No statistically significant relationships were identified between AAS and traditional bibliometrics for articles pertaining to spine trauma: Level of Evidence (R = - 0.02, p = 0.34), H-Index Primary Author (R =  < - 0.01, p = 0.50), H-Index Senior Author (R = - 0.04, p = 0.24), and Number of Citations (R = 0.01, p = 0.40). The top five articles by AAS include those pertaining to motorcycle injuries (AAS = 687), orthosis in thoracolumbar fractures (AAS = 199), golfing injuries (AAS = 166), smartphone-based teleradiology (AAS = 41), and auto racing injuries (AAS = 39).

CONCLUSION

The lack of overlap between these types of metrics suggests that AAS or similar alternative metrics should be used to measure an article's social impact. The social impact of an article should likewise be a factor in determining an article's overall impact along with its academic impact as measured by bibliometrics.

Accuracy of augmented reality-assisted pedicle screw placement: a systematic review

OBJECTIVE

Conventional freehand methods of pedicle screw placement are associated with significant complications due to close proximity to neural and vascular structures. Recent advances in augmented reality surgical navigation (ARSN) have led to its adoption into spine surgery. However, little is known regarding its overall accuracy. The purpose of this study is to delineate the overall accuracy of ARSN pedicle screw placement across various models.

METHODS

A systematic review was conducted of Medline/PubMed, Cochrane and Embase Library databases according to the PRISMA guidelines. Relevant data extracted included reports of pedicle screw placement accuracy and breaches, as defined by the Gertzbein-Robbins classification, in addition to deviation from pre-planned trajectory and entry point. Accuracy was defined as the summation of grade 0 and grade 1 events per the Gertzbein-Robbins classification.

RESULTS

Twenty studies reported clinically accurate placed screws. The range of clinically accurate placed screws was 26.3-100%, with 2095 screws (93.1%) being deemed clinically accurate. Furthermore, 5.4% (112/2088) of screws were reported as grade two breaches, 1.6% (33/2088) grade 3 breaches, 3.1% (29/926) medial breaches and 2.3% (21/926) lateral breaches. Mean linear deviation ranged from 1.3 to 5.99 mm, while mean angular/trajectory deviation ranged 1.6°-5.88°.

CONCLUSION

The results of this study highlight the overall accuracy of ARSN pedicle screw placement. However, further robust prospective studies are needed to accurately compare to conventional methods of pedicle screw placement.

The correlation between altmetric score and traditional measures of article impact for studies published within the Surgeon Journal

Alternative metrics, or altmetrics, have emerged as a promising tool for measuring the social impact of research, which is increasingly important in today's digital and social media-driven world. Altmetric Attention Score (AAS) is a weighted count of all the online attention garnered by a study, and it is currently unclear whether a relationship with traditional bibliometrics exists. The purpose of this article was to retrospectively review articles published in the Surgeon Journal from 2003 to 2020 to compare AAS with bibliometric parameters using an Independent t-test and Pearson's correlation analysis. There were statistically significant weakly positive relationships between AAS and sample size, number of reads, and number of citations. There was no statistically significant relationship between AAS and number of authors, H-index, or level of evidence. This study highlights the potential value of altmetrics by measuring the social impact of research as altmetrics can provide valuable information not captured by traditional metrics. It is currently unclear what the optimal balance of social and academic impact is in evaluating research impact and how altmetrics can be integrated into existing research frameworks.

The efficacy of anchored stand-alone spacers in comparison to conventional cage and plate in anterior cervical discectomy and fusion surgery: A meta-analysis of randomised controlled trials for clinical and radiological outcomes

Introduction

Anterior cervical discectomy and fusion (ACDF) is commonly performed with cage and plate constructs to stabilise diseased or injured cervical segments. Despite it being a commonly performed procedure, there are notable rates of associated morbidity reported in the literature. Stand-alone spacers represent a novel form of instrumentation to conventional cage and plate constructs.

Research question

Do stand-alone spacers have improved operative characteristics and postoperative outcomes in ACDF cohorts when compared to cage and plate constructs?

Methods

A systematic review and meta-analysis was conducted of PubMed/Medline, Embase and Google Scholar databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. Studies of interest included cage and plate instrumentation versus anchored stand-alone spacers for patients undergoing ACDF. Pre- and post-operative clinical and radiological outcomes were collated and compared for significance between cohorts.

Results

10 RCTs were identified and included with 779 patients total. Mean age of the entire cohort was 50.1 years. 62% (483/779) of the cohort were male. 384 patients underwent ACDF with stand-alone cage, while 395 had ACDF with conventional cage and plate. Stand-alone spacers significantly outperformed conventional instrumentation in terms of estimated blood loss (p < 0.01), total postoperative complications (p < 0.01), dysphagia rates (p = 0.04) and adjacent segment disease (p = 0.04). Non-inferiority was evident in both patient reported outcome measures and radiological outcomes.

Conclusion

This meta-analysis highlights the efficacy of stand-alone spacers for the management of primarily cervical spondylitic disease for both single-level and multi-level pathology, and thus presents an attractive alternative to conventional instrumentation for patients undergoing ACDF surgery.

Iliac crest bone graft versus cell-based grafts to augment spinal fusion: a systematic review and meta-analysis

INTRODUCTION

Despite successful fusion rates with iliac crest bone graft (ICBG), donor-site morbidity and increased operating time remain a considerable limitation and drive the search for alternatives. In this systematic review, grafts with additional cellular supplementation were compared with ICBG for spinal arthrodesis. We compared safety, efficacy and long-term outcomes, thus providing the current and relevant evidence for orthopaedic surgeons to make informed choices regarding this rapidly developing field.

METHODS

An electronic literature search was conducted according to the PRISMA guidelines by two independent reviewers for articles published up to 1st March 2023 using PubMed, EMBASE and the Cochrane Central Register of Controlled Trial. Cellular allografts were not included. The following data were extracted: Number of patients, type of graft, fusion assessment method, follow-up duration, fusion rates, clinical outcomes and complications. The methodological quality of evidence (MQOE) was assessed using the Risk of Bias 2 (RoB-2) tool and Risk of Bias In Non-Randomised Studies (ROBINS) tool developed by Cochrane for evaluating bias in randomised and non-randomised studies.

RESULTS

Ten studies fulfiled the inclusion criteria, including 465 patients. The mean number of patients per study was 43.8 (std dev. 28.81, range 12-100). Two studies demonstrated cell-based therapy to be significantly more successful in terms of fusion rates compared to ICBG. However, the remaining eight demonstrated equivocal results. No study found that cell-based therapy was inferior. No difference was seen between the two groups in three studies who focused on degenerative cohorts. No difference in functional outcome scores was seen between the groups. A number of different preparation techniques for cell-based grafts were used throughout the studies.

CONCLUSION

Cell-based therapy offers a promising alternative to ICBG in spinal fusion surgery, which could help reduce the associated morbidity to patients. This review found that cell-based therapy is non-inferior to iliac crest bone graft and may offer patients an alternative treatment option with fewer complications and reduced post-operative pain. However, the literature to date is limited by heterogeneity of the cell preparation and grafting process. Future research with a unified approach to the cell preparation process is required to fully delineate the potential advantages of this technology.

Biomimetic Inspired Hydrogels for Regenerative Vertebral Body Stenting

PURPOSE OF REVIEW

This review aims to explore the potential of biomimetic hydrogels as an alternative to bone cement in vertebral body stenting (VBS), a minimally invasive treatment for vertebral compression fractures.

RECENT FINDINGS

The use of bone cement in VBS procedures can lead to complications such as incomplete fracture reduction and cement leakage. Biomimetic hydrogels have gained significant attention as potential biomaterial alternatives for VBS due to their unique properties, including tuneable therapeutic and mechanical properties. Over the past decade, there has been significant advancements in the development of biomimetic hydrogels for bone regeneration, employing a wide range of approaches to enhance the structural and functional properties of hydrogels. Biomimetic hydrogels hold significant promise as safer and reparative alternatives to bone cement for VBS procedures. However, further research and development in this field are necessary to explore the full potential of hydrogel-based systems for vertebral bone repair.

Preclinical to clinical translation for intervertebral disc repair: Effects of species-specific scale, metabolism, and matrix synthesis rates on cell-based regeneration

Background

A significant hurdle for potential cell-based therapies is the subsequent survival and regenerative capacity of implanted cells. While many exciting developments have demonstrated promise preclinically, cell-based therapies for intervertebral disc (IVD) degeneration fail to translate equivalent clinical efficacy.

Aims

This work aims to ascertain the clinical relevance of both a small and large animal model by experimentally investigating and comparing these animal models to human from the perspective of anatomical scale and their cellular metabolic and regenerative potential.

Materials and Methods

First, this work experimentally investigated species-specific geometrical scale, native cell density, nutrient metabolism, and matrix synthesis rates for rat, goat, and human disc cells in a 3D microspheroid configuration. Second, these parameters were employed in silico to elucidate species-specific nutrient microenvironments and predict differences in temporal regeneration between animal models.

Results

This work presents in silico models which correlate favorably to preclinical literature in terms of the capabilities of animal regeneration and predict that compromised nutrition is not a significant challenge in small animal discs. On the contrary, it highlights a very fine clinical balance between an adequate cell dose for sufficient repair, through de novo matrix deposition, without exacerbating the human microenvironmental niche.

Discussion

Overall, this work aims to provide a path towards understanding the effect of cell injection number on the nutrient microenvironment and the "time to regeneration" between preclinical animal models and the large human IVD. While these findings help to explain failed translation of promising preclinical data and the limited results emerging from clinical trials at present, they also enable the research field and clinicians to manage expectations on cell-based regeneration.

Conclusion

Ultimately, this work provides a platform to inform the design of clinical trials, and as computing power and software capabilities increase in the future, it is conceivable that generation of patient-specific models could be used for patient assessment, as well as pre- and intraoperative planning.

Morbidity and mortality of traumatic cervical spinal cord injuries in a geriatric cohort

BACKGROUND

Traumatic injuries are among the leading causes of death and disability worldwide. Major trauma presentations have seen a demographic shift recently from the young to the elderly, with significant associated neurological deficit.

AIMS

To review the presentation and outcome of elderly patients presenting with cervical spinal injuries and associated neurological deficit that underwent surgical intervention in order to optimise treatment strategies.

METHODS

A retrospective review was conducted at a national tertiary referral centre to analyse admission trends from June 2016 to July 2020 for outcomes of elderly patients (≥ 65) presenting with traumatic cervical spine injuries associated with spinal cord injuries (SCI). Demographic, clinical, and radiological characteristics were collected and analysed.

RESULTS

Forty-two patients met the inclusion criteria. The most common mechanisms of injury (MOIs) were falls from standing (38.1%) and falls from height (≥ 2 m) (33.3%). Complete SCIs had increased mean LOS (57.6 vs 21.6 days; p = 0.013), postoperative complications (100% vs 60.6%; p = 0.022), life-threatening complications (57.1% vs 9.1%; p = 0.001), and 90-day mortality (37.5% vs 5.9%; p = 0.007) compared to incomplete SCIs.

CONCLUSION

Elderly patients with complete SCIs have poorer outcomes and mortality than those with less extensive SCIs. They require more resources, have greater risk of complications, and have higher mortality than those with incomplete SCIs, with subsequent implications on optimal treatment strategies. More robust studies are needed to derive improved risk stratification tools for geriatric patients with spinal injuries.

Risk factors for distal junctional failure in long-construct instrumentation for adult spinal deformity

PURPOSE

The aim of this study is to identify risk factors associated with postoperative DJF in long constructs for ASD.

METHODS

A retrospective review was performed at a tertiary referral spine centre from 01/01/2007 to 31/12/2016. Demographic, clinical and radiographic parameters were collated for patients with DJF in the postoperative period and compared to those without DJF. Survival analyses were performed using univariate logistic regression to identify variables with a p value < 0.05 for inclusion in multivariate analysis. Spearman's correlations were performed where applicable.

RESULTS

One hundred two patients were identified. 41 (40.2%) suffered DJF in the postoperative period, with rod fracture being the most common sign of DJF (13/65; 20.0%). Mean time to failure was 32.4 months. On univariate analysis, pedicle subtraction osteotomy (p = 0.03), transforaminal lumbar interbody fusion (p < 0.001), pre-op LL (p < 0.01), pre-op SVA (p < 0.01), pre-op SS (p = 0.02), postop LL (p = 0.03), postop SVA (p = 0.01), postop PI/LL (p < 0.001), LL correction (p < 0.001), SVA correction (p < 0.001), PT correction (p = 0.03), PI/LL correction (p < 0.001), SS correction (p = 0.03) all proved significant. On multivariate analysis, pedicle subtraction osteotomy (OR 27.3; p = 0.03), postop SVA (p < 0.01) and LL correction (p = 0.02) remained statistically significant as independent risk factors for DJF.

CONCLUSION

Recently, DJF has received recognition as its own entity due to a notable postoperative incidence. Few studies to date have evaluated risk factors for DJF. The results of our study highlight that pedicle subtraction osteotomy, poor correction of lumbar lordosis, and sagittal vertical axis are significantly associated with postoperative occurrence of DJF.

The Incidence, Characteristics and Outcomes of Vertebral Artery Injury Associated with Cervical Spine Trauma: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

Vertebral Artery Injury (VAI) is a potentially serious complication of cervical spine fractures. As many patients can be asymptomatic at the time of injury, the identification and diagnosis of VAI can often prove difficult. Due to the high rates of morbidity and mortality associated with VAI, high clinical suspicion is paramount. The purpose of this review is to elucidate incidence, diagnosis, treatment and outcomes of VAI associated with cervical spine injuries.

METHODS

A systematic search of electronic databases was performed using 'PUBMED', 'EMBASE','Medline (OVID)', and 'Web of Science, for articles pertaining to traumatic cervical fractures with associated VAI.

RESULTS

24 studies were included in this systematic review. Data was included from 48 744 patients. In regards to the demographics of the focus groups that highlighted information on VAI, the mean average age was 46.6 (32.1-62.6). 75.1% (169/225) were male and 24.9% (56/225) were female. Overall incidence of VAI was 596/11 479 (5.19%). 190/420 (45.2%) of patients with VAI had fractures involving the transverse foramina. The right vertebral artery was the most commonly injured 114/234 (48.7%). V3 was the most common section injured (16/36 (44.4%)). Grade I was the most common (103/218 (47.2%)) injury noted. Collective acute hospital mortality rate was 32/226 (14.2%), ranging from 0-26.2% across studies.

CONCLUSION

VAI secondary to cervical spine trauma has a notable incidence and high associated mortality rates. The current available literature is limited by a low quality of evidence. In order to optimise diagnostic protocols and treatment strategies, in addition to reducing mortality rates associated with VAI, robust quantitative and qualitative studies are needed.

Preoperative Considerations for the Frail Patient

Frailty is a common geriatric syndrome, the relevance of which is becoming increasingly apparent in the clinical setting. It is often accompanied by varying degrees of sarcopenia and/or osteoporosis, leading to a decline in physical function, decreased levels of physical activity, and overall poorer health outcomes in older adults. Identifying this cohort of patients before stressor events such as spinal surgery can prove paramount to improving the postoperative outcomes of these patients. This review provides a pertinent descriptive analysis to aid identification of frailty in a clinical setting, in addition to outlining methods of preoperative intervention that may improve postoperative outcomes.

Pharmacogenetic profiling and individualised therapy in the treatment of degenerative spinal conditions

Patients presenting with degenerative spinal changes are often poor surgical candidates due to associated co-morbidities, frailty, or sarcopenia. Additionally, surgeries of a degenerative spine can prove difficult due to the distortion of normal surgical anatomy. Therefore, many patients are managed conservatively with a variety of modalities, including over-the-counter and prescription medications. Nevertheless, several patients do not experience adequate relief from pain with analgesic medications, precipitating multiple hospital visits, and usage of resources. As a result, back pain is regarded as a major economic burden, with total costs of associated treatment exceeding $100 billion annually. Pharmacogenetics is a relatively novel method of evaluating an individual's response to analgesic medications, through analysis of germline polymorphisms. It entails obtaining a genetic sample, often via buccal swab or peripheral blood sample, and genetic analysis achieved through either polymerase chain reaction +/- Sanger sequencing, microassays, restriction length fragment polymorphism analysis, or genetic library preparation and next generation sequencing. The potential efficacy of pharmacogenetic analysis has been highlighted across several specialities to date. However, a paucity of evidence exists regarding spine surgery populations. Nevertheless, regular prospective pharmacogenetic analysis may ultimately prove beneficial when concerning degenerative spinal cohorts due to aforementioned surgical and economic considerations. The purpose of this narrative review is to outline how metaboliser profile variants affect the pharmacokinetics of specific analgesia used to treat back pain, and to discuss the current potential and limitations of employing regular pharmacogenetic analysis for spine surgery populations with degenerative conditions.

The relationship between radiological paraspinal lumbar measures and clinical measures of sarcopenia in older patients with chronic lower back pain

Objectives

Sarcopenia is postulated to be an influential factor in chronic low back pain. The aim of this study is to evaluate the relationship between traditional clinical measures of sarcopenia and novel radiographic methods which evaluate overall muscle status, such as adjusted psoas cross-sectional area (APCSA) and degree of fat infiltration (%FI) in paraspinal muscles, in patients with chronic low back pain.

Methods

Prospective study performed at our institution from 01/01/19-01/04/19. Inclusion criteria were patients ≥65 years old not requiring surgical intervention presenting to a low back pain assessment clinic.

Results

25 patients were identified (mean age: 73 years, 62% male). On spearman's analyses, %FI shared a significant relationship with hand grip strength (r = -0.37; p=0.03), chair rise (r=0.38; p=0.03), SC (r=0.64; p<0.01), and visual analogue scale scores (r=-0.14; p=0.02). Comparably, a statistically significant correlation was evident between APCSA and %FI (r=-0.40; p=0.02) on analysis.

Conclusion

The results of our study demonstrate a statistically significant relationship between APCSA and %FI in the multifidus and erector spinae muscles. Further significant associations of relatability were depicted with traditional clinical measures of sarcopenia. Thus, %FI may be a supplemental indicator of the sarcopenic status of patients presenting with chronic low back pain.

The Incidence, Risk Factors, and Complications Associated With Surgical Delay in Multilevel Fusion for Adult Spinal Deformity

STUDY DESIGN

Retrospective database review.

OBJECTIVES

The incidence and risk factors for surgical delay of multilevel spine fusion for adult spinal deformity (ASD), and the complications corresponding therewith, remain unknown. The objectives of this study are to assess the incidence and risk factors for unexpected delay of elective multilevel spinal fusions on the date of surgery as well as the postoperative complications associated with these delays.

METHODS

We conducted a retrospective review of the ACS-NSQIP database on patients undergoing elective spinal instrumentation of greater than 7 levels for ASD between the years 2005 and 2015. Preoperative risk factors for delay and postoperative complications were compared between the cohorts of patients with and without surgical delays.

RESULTS

Multivariate analysis of 1570 (15.6%) patients identified advanced age, male sex, American Society of Anesthesiologists (ASA) Class 4, and history of smoking as independent risk factors for delay. Patients experiencing surgical delay demonstrated longer operative times, increased intraoperative bleeding, longer hospitalizations, and significantly higher rates of postoperative complications. Patients experiencing delay demonstrated an almost 7-fold increase in mortality rate (3.4% vs 0.5%, P < .001).

CONCLUSIONS

Delays in elective surgical care for spinal deformity are negatively related to patient outcomes. Advanced age, male sex, increased ASA class, and a history of smoking cigarettes place patients at risk for surgical delay of multilevel spinal fusion. Patients experiencing surgical delay are at higher risk for postoperative complications, including a 7-fold increase in mortality. These findings suggest that ASD surgery should be postponed in patients experiencing a delay, until modifiable risk factors can be medically optimized, and perhaps postponed indefinitely in those with nonmodifiable risk factors.

The Impact of COVID-19 and Lockdown on Spinal Services at a National Level: Lessons Learned and Areas of Service Improvement for Future Health Care Delivery

The coronavirus disease 2019 (COVID-19) pandemic has had a dramatic impact on the provision of health care worldwide. The delivery of national spinal service for emergent surgery, elective surgery, and outpatient assessment has been incredibly challenging. A variety of innovative measures were undertaken to facilitate the safe provision of acute service and are outlined in this review, along with a number of key learning points which will improve the quality of health care delivered over the coming years. The challenges facing the spinal surgery community with regard the reintroduction of elective surgery is discussed, and a potential roadmap for the safe resumption of services is presented.

A Systematic Review of Risk Factors Associated With Distal Junctional Failure in Adult Spinal Deformity Surgery

BACKGROUND

The surgical management of adult spinal deformity (ASD) is a major surgical undertaking associated with considerable perioperative risk and a substantial complication profile. Although the natural history and risk factors associated with proximal junctional kyphosis (PJK) and proximal junctional failure are widely reported, distal junctional failure (DJF) is less well understood.

STUDY DESIGN

A systematic review was carried out.

OBJECTIVES

The primary objective is to identify the risk factors associated with DJF. The secondary objective is to delineate the incidence rate and causative factors associated with DJF.

METHODS

A systematic review of articles in Medline/PubMed and The Cochrane Library databases was performed according to preferred reporting items for systematic reviews and meta-analyses guidelines. Data was collated to determine the prevalence of DJF and overall revision rates, and identify potential risk factors for development of DJF.

RESULTS

Twelve studies were included for systematic review. There were 81/2261 (3.6%) cases of DJF. Overall, DJF represented 27.3% of all revision surgeries. Anterior-posterior surgery had a reduced incidence of postoperative DJF [5.0% vs. 8.7%; P=0.08; relative risk (RR)=1.73], as did patients below 60 years of age at the time of surgery (2.9% vs. 3.9%; P=0.09; RR=1.34). There was a higher incidence of DJF among those patients who received interbody fusion (9.9% vs. 5.1%; P=0.06; RR=1.93) compared with those who did not. However, none of these findings reached statistical significance. There were significantly more rates of DJF for fusions ending on L5 compared with constructs fused to the sacrum (11.7% vs. 3.6%; P=0.02; RR=3.28).

CONCLUSIONS

Cohorts 60 years and above of age at the time of surgery and patients managed with posterior-only fusion or interbody fusion have increased incidences of DJF. Fusion to L5 instead of the sacrum significantly influences DJF rates. However, the quality of available evidence is low and further high-quality studies are required to more robustly analyze the clinical, radiographic, and surgical risk factors associated with the development of DJF after ASD surgery.

A meta-analysis of the diagnostic accuracy of Hounsfield units on computed topography relative to dual-energy X-ray absorptiometry for the diagnosis of osteoporosis in the spine surgery population

BACKGROUND

The preoperative identification of osteoporosis in the spine surgery population is of crucial importance. Limitations associated with dual-energy x-ray absorptiometry, such as access and reliability, have prompted the search for alternative methods to diagnose osteoporosis. The Hounsfield Unit(HU), a readily available measure on computed tomography, has garnered considerable attention in recent years as a potential diagnostic tool for reduced bone mineral density. However, the optimal threshold settings for diagnosing osteoporosis have yet to be determined.

METHODS

We selected studies that included comparison of the HU(index test) with dual-energy x-ray absorptiometry evaluation(reference test). Data quality was assessed using the standardised QUADAS-2 criteria. Studies were characterised into 3 categories, based on the threshold of the index test used with the goal of obtaining a high sensitivity, high specificity or balanced sensitivity-specificity test.

RESULTS

9 studies were eligible for meta-analysis. In the high specificity group, the pooled sensitivity was 0.652 (95% CI 0.526 - 0.760), specificity 0.795 (95% CI 0.711 - 0.859) and diagnostic odds ratio was 6.652 (95% CI 4.367 - 10.133). In the high sensitivity group, the overall pooled sensitivity was 0.912 (95% CI 0.718 - 0.977), specificity was 0.67 (0.57 - 0.75) and diagnostic odds ratio was 19.424 (5.446 - 69.275). In the balanced sensitivity-specificity group, the overall pooled sensitivity was 0.625 (95% CI 0.504 - 0.732), specificity was 0.914 (0.823 - 0.960) and diagnostic odds ratio was 14.880 (7.521 - 29.440). Considerable heterogeneity existed throughout the analysis.

CONCLUSION

In conclusion, the HU is a clinically useful tool to aide in the diagnosis of osteoporosis. However, the heterogeneity seen in this study warrants caution in the interpretation of results. We have demonstrated the impact of differing HU threshold values on the diagnostic ability of this test. We would propose a threshold of 135 HU to diagnose OP. Future work would investigate the optimal HU cut-off to differentiate normal from low bone mineral density.

Changing Demographic Trends in spine trauma: The presentation and outcome of Major Spine Trauma in the elderly

INTRODUCTION

Major trauma has seen a demographic shift in recent years and it is expected that the elderly population will comprise a greater burden on the major trauma service in the near future. However, whether a similar trend exists in those undergoing operative intervention for spinal trauma remains to be elucidated.

AIMS

To compare the presentation and outcomes of patients ≥65 years of age sustaining spine trauma to those <65 years at a national tertiary referral spine centre.

METHODS

The local Trauma Audit Research Network (TARN) database was analysed to identify spinal patients referred to our institution, a national tertiary referral centre, between 01/2016 and 05/2019. Patients were divided into a young cohort (16-64 years old) and an elderly cohort (> 64 years old). No explicit distinction was made between major and minor spine trauma cases. Variables analysed included patient demographics, injury severity, mortality, interventions, mechanism of injury and length of hospital stay.

RESULTS

A total of 669 patients were admitted of which 480 patients underwent operative intervention for spinal trauma. Within the elderly cohort, this represented 75.3% of cases. Among the younger population, road traffic collisions were the most common mechanism of injury (37.1%), while low falls (<2 m) (57.4%) were the most common mechanism among the older population. Patients ≥65 years old had significantly longer length of stay (21 days [1-194] v 14 days [1-183]) and suffered higher 30-day mortality rates (4.6% [0-12] v 0.97% [0-4]).

CONCLUSION

Orthopaedic spinal trauma in older people is associated with a significantly higher mortality rate as well as a longer duration of hospitalization. Even though severity of injury is similar for both young and old patients, the mechanism of injury for the older population is of typically much lower energy compared to the high energy trauma affecting younger patients.

The diagnostic and prognostic value of artificial intelligence and artificial neural networks in spinal surgery : a narrative review

In recent years, machine learning (ML) and artificial neural networks (ANNs), a particular subset of ML, have been adopted by various areas of healthcare. A number of diagnostic and prognostic algorithms have been designed and implemented across a range of orthopaedic sub-specialties to date, with many positive results. However, the methodology of many of these studies is flawed, and few compare the use of ML with the current approach in clinical practice. Spinal surgery has advanced rapidly over the past three decades, particularly in the areas of implant technology, advanced surgical techniques, biologics, and enhanced recovery protocols. It is therefore regarded an innovative field. Inevitably, spinal surgeons will wish to incorporate ML into their practice should models prove effective in diagnostic or prognostic terms. The purpose of this article is to review published studies that describe the application of neural networks to spinal surgery and which actively compare ANN models to contemporary clinical standards allowing evaluation of their efficacy, accuracy, and relatability. It also explores some of the limitations of the technology, which act to constrain the widespread adoption of neural networks for diagnostic and prognostic use in spinal care. Finally, it describes the necessary considerations should institutions wish to incorporate ANNs into their practices. In doing so, the aim of this review is to provide a practical approach for spinal surgeons to understand the relevant aspects of neural networks. Cite this article: Bone Joint J 2021;103-B(9):1442-1448.

Response to "isolated head tremor: A DAT SPECT and somatosensory temporal discrimination study."

In response to Ferrazano and colleagues' observation of normal DAT binding in patients with isolated head tremor but with abnormal STDT, we report normal 123-IBZM SPECT in a cohort of patients with adult-onset idiopathic focal dystonia with cervical dystonia and their unaffected first-degree relatives both with normal and abnormal TDTs. We discuss molecular imaging findings in dystonia.

931 COVID-19 and the Irish National Spinal Injuries Unit: Impact on Service Provision and Strategies to Protect Urgent Care

Introduction

The COVID-19 pandemic has had a dramatic impact on the provision of healthcare worldwide. The delivery of a national spinal service for emergent surgery, elective surgery and outpatient assessment has been incredibly challenging.

Method

Prospectively collected data regarding referrals to, and operative workload of, the Irish National Spinal Injuries Unit (NSIU) during the period of national lockdown in response to the COVID-19 pandemic was compared to the same period in 2019.

Results

During the period of national lockdown there was a 47% decrease in the number of urgent referrals to the NSIU and a 61% reduction in the number of surgical cases performed. A particularly concerning finding was that for surgical cases there was a 400% increase in attempted suicide as the cause of injury with this cohort representing 11% of all surgical cases performed during the pandemic lockdown. The introduction of a national instant messaging application (Siilo) referral group resulted in a median time to first response by a National Spinal Injuries Unit (NSIU) surgeon of 15.5 minutes.

Conclusions

The COVID-19 pandemic has had a significant impact on the provision of a national spinal service, however innovative strategies have been adopted to protect the capacity to provide urgent care.

Methods to Mitigate Industry Influence in Industry Sponsored Research

Medical and surgical research has always had a long-standing relationship with industry-based funding from sources, such as drug and device companies. Concerns exist surrounding the association between funding sources, outcome from studies and publication bias. Studies demonstrating increased odds ratios associated with positive results in industry sponsored studies across medicine have stimulated Cochrane reviews, literature reviews and other articles to examine this relationship further. In spine surgery in particular, studies with positive results have an odds ratio of 3.3 of being published. This article discusses the biases associated with industry sponsorship, possible ways to reduce such biases and ways to improve transparency in research relationships. This article explores the types of bias that can be encountered at different stages of research including previous trials in spine surgery. The means of improving transparency including the Physician Payment Sunshine Act of 2010 and International Committee of Medical Journal Editors (ICJME) accreditation are discussed. We recognize that physicians undertaking industry sponsored research should be protected and not be liable to perverse incentives. We conclude that mitigating bias in industry sponsored research is a multistep process and needs a multifaceted approach. The main beneficiary of research should be patients and as such a collective effort from medical professionals, health care institutions, journals and industry should approach research, and publications with that in mind.

A randomised trial of bilateral erector spinae plane block vs. no block for thoracolumbar decompressive spinal surgery

Major spinal surgery causes significant postoperative pain. We tested the efficacy and safety of bilateral erector spinae block on quality of recovery and pain after thoracolumbar decompression. We randomly allocated 60 adults to standard care or erector spinae block. Erector spinae block improved the mean (SD) quality of recovery-15 score at 24 postoperative hours, from 119 (20) to 132 (14), an increase (95%CI) of 13 (4-22), p = 0.0044. Median (IQR [range]) comprehensive complication index was 1 (0-3 [0-5]) in the control group vs. 1 (0-1 [0-4]) after block, p = 0.4. Erector spinae block reduced mean (SD) area under the curve pain during the first 24 postoperative hours: at rest, from 78 (49) to 50 (39), p = 0.018; and on sitting, from 125 (51) to 91 (50), p = 0.009. The cumulative mean (SD) oxycodone consumption to 24 h was 27 (18) mg in the control group and 19 (26) mg after block, p = 0.20. In conclusion, erector spinae block improved recovery and reduced pain for 24 h after thoracolumbar decompression surgery.

Radiographic Measures of Spinal Alignment Are Not Predictive of the Development of C5 Palsy Following Anterior Cervical Discectomy and Fusion Surgery

BACKGROUND

Postoperative C5 palsy is a common complication following cervical decompression, occurring more frequently after posterior-based procedures. It has been theorized that this is the result of C5 nerve stretch resulting from spinal cord drift with these procedures. As such, it is thought to be less common after anterior cervical decompression and fusion (ACDF). However, no consensus has been reached on its true etiology. The purpose of this study is to assess the rate of C5 palsy following ACDF and to determine whether any radiographic or demographic parameters were predictive of its development.

METHODS

Two hundred and twenty-six patients who received ACDF between September 2015 and September 2016 were reviewed, and 122 were included in the final analysis. Patient demographic, surgical, and radiographic data were analyzed, including preoperative and postoperative radiographic and motor examination results. The Mann-Whitney U test was used to compare continuous variables between independent groups, and Fisher's exact test was used to compare categorical variables between groups.

RESULTS

Seven patients developed a C5 palsy in the postoperative period, an incidence rate of 5.7%. Among the radiographic parameters evaluated, there were no statistically significant differences between the C5 palsy and nonpalsy groups. Additionally, there were no statistically significant differences in age, patient sex, or numbers of vertebral levels fused between groups.

CONCLUSIONS

Ultimately, we did not identify any statistically significant demographic or radiographic predictive factors for the development of C5 palsy following ACDF surgery.

LEVEL OF EVIDENCE

3.

Impact of Sarcopenia on Degenerative Lumbar Spondylosis

Sarcopenia is characterized by progressive age-related and systematic loss of skeletal muscle mass, strength, and function. It was classified as an independent disease in 2016; thus, there is a sparsity of research on the association of sarcopenia with lower back pain and spinal diseases. Its prevalence is around 10% worldwide and it has been shown to be detrimental to quality of life in the elderly. Sarcopenia can be clinically identified by assessing muscle mass and physical performance measurements to show reduced strength (eg, grip strength chair rise and knee extensions) or function (eg, walking speed or distance). Radiographic imaging techniques such as computed tomography, ultrasound, or magnetic resonance imaging help diagnose sarcopenia in the lumbar spine by measuring either the cross-sectional area or the fatty infiltrate of the lumbar musculature. The presence of sarcopenia in patients preoperatively may lead to worse postoperative outcomes. Research in the treatment options for sarcopenia presurgery is still in its infancy but exercise (both aerobic and resistance exercise have been found to slow down the rate of decline in muscle mass and strength with aging) and nutrition have been utilized to varying success and show great promise in the future.

A Comparison of Revision Rates and Patient-Reported Outcomes for a 2-Level Posterolateral Fusion Augmented With Single Versus 2-Level Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective, single institution, multisurgeon case control series.

OBJECTIVE

To determine whether there are differences in reoperation rates or outcomes for patients undergoing 2-level posterolateral fusion (PLF) augmented by a transforaminal lumbar interbody fusion (TLIF) at only one of the levels or at both.

METHODS

A total of 416 patients were identified who underwent 2-level PLF with a TLIF at either one of those levels (n = 183) or at both (n = 233) with greater than 1-year follow-up. Demographic, surgical, radiographic, and clinical data was reviewed for each patient. These included age, sex, race, body mass index, smoking status, Charleston Comorbidity Index, operative time, estimated blood loss, length of stay, and patient-reported outcome measures.

RESULTS

Each cohort underwent 24 reoperations. Although the number of overall reoperations was not significantly different (P > .05), among the reoperation types, there were significantly more reoperations for adjacent segment disease in the 2-level group compared to the 1-level group (19 vs 12, P = .04). There was no difference in reoperation for pseudarthrosis between the groups (P > .05). Although both groups experienced significant improvements in Oswestry Disability Index (P < .001) and Short Form-12 health questionnaire (P < .001), there were no differences between improvements for 1- versus 2-level cohorts.

CONCLUSIONS

For patients undergoing 2-level PLF in the setting of a TLIF, using a TLIF at one versus both levels does not seem to influence reoperation rates or outcomes. However, reoperation rates for adjacent segment disease are increased in the setting of a 2-level PLF augmented by a 2-level TLIF.

Two-stage anterior and posterior fusion versus one-stage posterior fusion in patients with Scheuermann's kyphosis

AIMS

Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann's kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion.

METHODS

A retrospective review of patients treated surgically for Scheuermann's kyphosis between 2006 and 2014 was performed. A total of 62 patients were identified, with 31 in each group. Parameters were compared to evaluate postoperative outcomes using chi-squared tests, independent-samples t-tests, and z-tests of proportions analyses where applicable.

RESULTS

There were six postoperative infections in the two-stage anteroposterior group compared with three in the one-stage posterior-only group. A total of four patients in the anteroposterior group required revision surgery, compared with six in the posterior-only group. There was a significantly higher incidence of junctional failure associated with the one-stage posterior-only approach (12.9% vs 0%, p = 0.036). Proximal junction kyphosis (anteroposterior fusion (74.2%) vs posterior-only fusion (77.4%); p = 0.382) and distal junctional kyphosis (anteroposterior fusion (25.8%) vs posterior-only fusion (19.3%), p = 0.271) are common postoperative complications following both surgical approaches.

CONCLUSION

A two-stage anteroposterior fusion was associated with a significantly greater correction of the kyphosis compared with a one-stage posterior-only fusion, with a reduced incidence of junctional failure (0 vs 3). There was a notably greater incidence of infection with two-stage anteroposterior fusion; however, all were medically managed. More patients in the posterior-only group required revision surgery. Cite this article: Bone Joint J 2020;102-B(10):1368-1374.

Auto-Decompression - Preserved Neurological Function in Bilateral Cervical Facet Dislocations

Introduction Bilateral cervical facet dislocation (BCFD) is an uncommon injury with a high incidence of severe neurological impairment. We describe 4 cases of BCFD with preserved neurological function. Cases Case 1: A 78-year-old female who suffered two ground level falls (GLFs). Pre-operative American Spinal Injury Association (ASIA) Score was C5D. Imaging revealed a BCFD at C6/C7 and a C6 laminar fracture. Case 2: A 63-year-old male suffered a fall down 14 steps. Pre-operative ASIA score was E. Imaging demonstrated a BCFD at C7/T1, and a C6 laminar fracture. Case 3: A 46-year-old male collided with a tree while descending a hill on a bicycle. Pre-operative ASIA score was C6D. Imaging revealed a BCFD at C7/T1 and a C7 laminar fracture. Case 4: A 67-year-old male suffered a GLF while exiting a stationary car. Pre-operative ASIA score on admission was E. Imaging revealed a BCFD at C6/C7 with bilateral laminar fractures at C5 and C6. Outcome All cases underwent 2-stage surgical fixation. All cases maintained or had an improved ASIA score post-operatively. Conclusion In all cases, the presence of concurrent laminar fractures resulted in an auto-decompression of the spinal canal, preserving neurological function.

Timing of surgical fixation in traumatic spinal fractures

Aims

The timing of surgical fixation in spinal fractures is a contentious topic. Existing literature suggests that early stabilization leads to reduced morbidity, improved neurological outcomes, and shorter hospital stay. However, the quality of evidence is low and equivocal with regard to the safety of early fixation in the severely injured patient. This paper compares complication profiles between spinal fractures treated with early fixation and those treated with late fixation.

Methods

All patients transferred to a national tertiary spinal referral centre for primary surgical fixation of unstable spinal injuries without preoperative neurological deficit between 1 July 2016 and 20 October 2017 were eligible for inclusion. Data were collected retrospectively. Patients were divided into early and late cohorts based on timing from initial trauma to first spinal operation. Early fixation was defined as within 72 hours, and late fixation beyond 72 hours.

Results

In total, 86 patients underwent spinal surgery in this period. Age ranged from 16 to 88 years. Mean Injury Severity Score (ISS) was higher in the early stabilization cohort (p = 0.020). Age was the sole significant independent variable in predicting morbidity on multiple regression analysis (p < 0.003). There was no significant difference in complication rates based on timing of surgical stabilization (p = 0.398) or ISS (p = 0.482).

Conclusion

Our results suggest that these patients are suitable for early appropriate care with spinal precautions and delayed definitive surgical stabilization. Earlier surgery conferred no morbidity benefit and had no impact on length of stay. Cite this article: Bone Joint J 2020;102-B(5):627–631.

Surgeon proficiency in robot-assisted spine surgery

Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal.

There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced.

Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described.

The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery.

Cite this article: Bone Joint J 2020;102-B(5):568–572.

Current Strategies for Reconstruction of Soft Tissue Defects of the Spine

Spinal surgery has been revolutionized by advances in instrumentation, bone graft substitutes, and perioperative care. Extensive dissection, creation of large areas of dead space, and the use of instrumentation in compromised patients, however, predisposes to high rates of wound complications. Postoperative wound complications in patients undergoing complex spinal surgery can have devastating sequelae, including hardware exposure, meningitis, and unplanned reoperation. Recognition of high-risk patients and prediction of wound closure difficulties, combined with preemptive reconstructive surgical strategies may prevent complications. The purpose of this review is to discuss the principles of spine wound management and provide a synopsis of the soft tissue reconstructive strategies utilized in spinal surgery. We review the senior author's preferred reconstructive algorithm for the management of these complex wounds, in addition to outcomes data relating to the timing of reconstructive surgery.

360-Degree Complex Primary Reconstruction Using Porous Tantalum Cages for Adult Degenerative Spinal Deformity

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To assess both implant performance and the amount of correction that can be achieved using multilevel anterior lumbar interbody fusion (ALIF).

METHODS

Retrospective cohort study (n = 178) performed over a 4-year period. Surgical variables examined included blood loss, operative time, perioperative complications, and secondary/revision procedures. Follow-up radiographic assessment was performed to record implant-related problems. Radiographic parameters were examined pre- and postoperatively. Health-related quality of life (HRQOL) outcome measures were collected preoperatively and at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Descriptive and comparative statistical analysis, using paired-sample t test and repeated-measures analysis of variance (rANOVA), was performed.

RESULTS

Lumbar lordosis increased from 42° ± 17° preoperatively to 55° ± 11° postoperatively (P < .001). The visual analog scale back pain mean score improved from 8.3 ± 1.5 preoperatively to 2.6 ± 2.4 at 2 years (P < .001). The mean Oswestry Disability Index improved from 69.5 ± 21.5 preoperatively to 19.9 ± 15.2 at 2 years (P < .001). The EQ-5D mean score improved from 0.2 ± 0.2 preoperatively to 0.8 ± 0.1 at 2 years (P = .02). There were no neurological, vascular, or visceral approach-related injuries reported. No rod breakages and no symptomatic nonunions occurred. There was one revision procedure performed for fracture.

CONCLUSIONS

The use of porous tantalum cages as part of a 360-degree fusion to treat adult degenerative spinal deformity has been demonstrated to be a safe and effective strategy, leading to good clinical, functional, and radiographic outcomes in the short term.

Timing of surgical fixation in traumatic spinal fractures: A systematic review

BACKGROUND

The optimal timing of fracture fixation following spinal injury is controversial. Many spinal fractures occur as part of polytrauma requiring a complex management strategy. Whilst the decision to stabilize unstable spinal column injuries is without debate, the duration between injury and definitive fixation can impact on the incidence of post-operative complications. This study was designed to systemically summarize and compare the complication profile of early vs late stabilization of spinal injuries, in an attempt to unveil an appropriate treatment protocol for traumatic spinal fractures.

METHODS

A comprehensive search strategy was performed on the PubMed, Cochrane, and Google Scholar databases using key words. The search strategy provided 1120 results. Forty-six articles were reviewed for full-text. Reference lists were analysed for potential additional texts.

RESULTS

Sixteen articles met the inclusion criteria and were included for systematic review. Studies were controversial and the overall result was inconclusive. Several studies favour early stabilisation to reduce post-surgical complication rates, especially in cases of patients with high Injury Severity Scale (ISS) scores. However, this is challenged by a small number of studies reporting a higher mortality rate in the early-stabilisation cohort.

CONCLUSION

Due to limited studies and a small overall cohort, the authors would cautiously recommend the early surgical fixation of unstable spine fractures in the stable trauma patient. For severely injured patients, the discordance among literature warrants the need for further investigation.

Operative Management of Perinatal Lumbar Disc Herniation and Cauda Equina Syndrome: A Case Series

Introduction Perinatal lumbar discectomy for lumbar disc herniation or cauda equina syndrome is a rare clinical scenario. This case series outlines the surgical management of this clinical scenario at a national tertiary referral centre over a 10-year period Methods A retrospective review of all females who underwent discectomy / decompression for lumbar disc herniation or cauda equina syndrome in the perinatal period at a national tertiary referral centre for spine surgery over a 10-year period between January 2008 to December 2017. Results 6 cases required surgical intervention. All patients were successfully managed with surgical decompressive procedures and recovered well in the postoperative period without complication. Conclusions The principles of management remain the same in the pregnant and non-pregnant populations, although treatment options are complicated by the desire to avoid risk to the developing foetus. Surgical intervention is safe to both mother and baby and if performed promptly is associated with an excellent functional outcome.

Managing the cervical spine in multiple myeloma patients

Discuss the relevant literature on surgical and nonsurgical treatments for multiple myeloma (MM) and their complementary effects on overall treatment. Existing surgical algorithms designed for neoplasia of the spine may not suit the management of spinal myeloma. Less than a fifth of metastatic, including myelomatous lesions, occur in the cervical spine but have a poorer prognosis and surgery in this area carries a higher morbidity. With the advances of chemotherapy, early access to radiotherapy, early orthosis management, and high definition imaging, including CT and MRI, surgical indications in MM have changed. Medical decompression (or oncolysis), including in the presence of neurological deficit and orthotic stabilization, are proving viable nonsurgical options to manage MM. A key to decision making is the assessment and monitoring of biomechanical spinal stability as part of a multidisciplinary approach.

Risk Factors for Adverse Cardiac Events After Lumbar Spine Fusion

Background

To determine the incidence and risk factors for adverse cardiac events after lumbar spine fusion.

Methods

A total of 50 495 patients were identified through the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database who underwent lumbar spine fusion between 2005 and 2015. The 30-day postoperative data were analyzed to assess for the incidence of adverse cardiac events including cardiac arrest or myocardial infarction. Of those who experienced an event, patient- and surgery-specific parameters were evaluated to assess for risk factors.

Results

A total of 240 cardiac events occurred in the studied cohort (4.76 events/1000 patients). Factors that were associated with an increased cardiac risk were age (odds ratio [OR] = 1.039, 95% confidence interval [CI] = 1.03, 1.05, P < .001), male sex (OR = 1.51, 95% CI = 1.17, 1.94, P = .001), insulin-dependent diabetes (OR = 1.83, 95% CI = 1.29, 2.6, P = .001), American Society of Anesthesiologists (ASA) score >3 (OR = 1.92, 95% CI = 1.00, 3.65, P = .048), absolute hematocrit different from 45 (OR = 1.07, 95% CI = 1.04, 1.10, P < .001), and smoking (OR = 1.39, 95% CI = 1.02, 1.90, P = .04). The impact of sustaining a cardiac event in the setting of single-level lumbar fusion is catastrophic as the 30-day postoperative mortality rate for those sustaining an event was 24.6% (59/240 patients), compared to 0.2% (87/50 255) for those not sustaining an event (P < .001).

Conclusions

Cardiac events after lumbar fusion are a rare but devastating series of complications. Several risk factors were identified, including insulin-dependent diabetes mellitus, smoking, advanced age, male sex, ASA score of >3, and anemia/polycythemia. Considering the severity of these consequences, appropriate risk stratification is imperative, and optimization of modifiable risk factors may mitigate this risk.

Severe Lumbar Disability Is Associated With Decreased Psoas Cross-Sectional Area in Degenerative Spondylolisthesis

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

Alterations in lumbar paraspinal muscle cross-sectional area (CSA) may correlate with lumbar pathology. The purpose of this study was to compare paraspinal CSA in patients with degenerative spondylolisthesis and severe lumbar disability to those with mild or moderate lumbar disability, as determined by the Oswestry Disability Index (ODI).

METHODS

We retrospectively reviewed the medical records of 101 patients undergoing lumbar fusion for degenerative spondylolisthesis. Patients were divided into ODI score ≤40 (mild/moderate disability, MMD) and ODI score >40 (severe disability, SD) groups. The total CSA of the psoas and paraspinal muscles were measured on preoperative magnetic resonance imaging (MRI).

RESULTS

There were 37 patients in the SD group and 64 in the MMD group. Average age and body mass index were similar between groups. For the paraspinal muscles, we were unable to demonstrate any significant differences in total CSA between the groups. Psoas muscle CSA was significantly decreased in the SD group compared with the MMD group (1010.08 vs 1178.6 mm², P = .041). Multivariate analysis found that psoas CSA in the upper quartile was significantly protective against severe disability (P = .013).

CONCLUSIONS

We found that patients with severe lumbar disability had no significant differences in posterior lumbar paraspinal CSA when compared with those with mild/moderate disability. However, severely disabled patients had significantly decreased psoas CSA, and larger psoas CSA was strongly protective against severe disability, suggestive of a potential association with psoas atrophy and worsening severity of lumbar pathology.

Intraoperative pedicle screw navigation does not significantly affect complication rates after spine surgery

Various forms of intraoperative computer-assisted navigation technologies exist, and have consistently been shown to improve pedicle screw accuracy. However, the overall clinical effects of inaccurate pedicle screw placement have been debated. We examined the clinical effects of improved pedicle screw accuracy with computer navigation technology in reducing complication rates in patients undergoing multi-level spinal fusion. We retrospectively reviewed the ACS-NSQIP registry utilizing Current Procedural Terminology (CPT) codes 22843 + 22844 to identify patients undergoing spinal instrumentation of greater than 7 levels, as well as the CPT code 61783 to denote the use of intraoperative computer-assisted navigation. The data were then subdivided to into cohorts consisting of instrumentation cases with and without navigation. Demographic information, as well as intraoperative and postoperative complications, were compared between groups. A total of 3168 patients met our inclusion criteria. There were no statistically significant differences in preoperative population data. Surgical time was significantly longer in the navigation group (391.41 versus 350.3 min), but there were no significant improvements in complication rates with the use of navigation. We found that the mean operative time was significantly increased for patients undergoing spinal instrumentation with computer navigation. This increase in operative time was not associated with any increase in surgical or medical complications. However, in this large series, we were unable to show any clinical benefit to intraoperative navigation, and no reductions in short term complications or rates of return to surgery were observed.

Characterization of Community-Acquired Staphylococcus aureus Infections in Children

Background:

Limited data exist concerning characteristics of community-acquired Staphylococcus aureus infections (CA-SAI) in central and eastern Kentucky.

Objective:

To describe the incidence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections from January 1, 2004 through December 31, 2005, compare the number of CA-MRSA infections between years, and contrast treatment interventions and antibiotic susceptibility patterns of CA-SAI.

Methods:

A concurrent and retrospective study was conducted in 125 patients less than 18 years of age with CA-SAI admitted to the hospital/clinic based on criteria from the Centers for Disease Control and Prevention. Data on demographics, length of stay, antibiotic therapy, and antibiotic susceptibilities were collected.

Results:

Seventy patients were included for analysis (CA-MRSA, n = 51; community-acquired methicillin-susceptible S. aureus [CA-MSSA], n = 19). No statistically significant differences were noted between the number of CA-MRSA infections and the total CA-SAI (9/15 in 2004 vs 42/55 in 2005; p = 0.15). Approximately 75% of patients with CA-SAI were admitted to the hospital with no significant difference in length of stay. Ninety percent of CA-SAI were skin and soft tissue infections. There was a significant difference between groups with cutaneous abscesses (CA-MRSA, n = 37 vs CA-MSSA, n = 6; p = 0.002). Greater than 95% of all isolates were susceptible to vancomycin and trimethoprim/sulfamethoxazole. Half of CA-MRSA patients received inappropriate antibiotic therapy with β-lactam antibiotics or clindamycin without confirmatory disk diffusion test. Twenty-five (49%) patients with CA-MRSA received surgical debridement (S/D) and/or incision and drainage (I/D) with concomitant antibiotic therapy. Four patients with CA-MRSA were rehospitalized for subsequent infections; all 4 received appropriate antibiotic therapy.

Conclusions:

A noticeable increase in CA-MRSA infections with cutaneous abscess between 2004 and 2005 was noted. In patients receiving inappropriate antibiotic therapy, treatment success was attributed to concomitant S/D and I/D. Further analysis should focus on the impact of antibiotic therapy alone or in combination with S/D and I/D on the incidence of subsequent CA-MRSA infections.