Timing of Surgery for Thoracolumbar Spine Trauma: Patients With Neurological Injury

STUDY DESIGN

Large multicenter retrospective cohort study.

OBJECTIVE

The objective of this study was to analyze the effect of fusion timing on inpatient outcomes in a nationally representative population with thoracolumbar fracture and concurrent neurological injury.

SUMMARY OF BACKGROUND DATA

Among thoracolumbar trauma admissions, concurrent neurological injury is associated with greater long-term morbidity. There is little consensus on optimal surgical timing for these patients; previous investigations fail to differentiate thoracolumbar fracture with and without neurological injury.

MATERIALS AND METHODS

We analyzed 19,136 nonelective National Inpatient Sample cases (2004-2014) containing International Classifications of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for closed thoracic/lumbar fracture with neurological injury and procedure codes for primary thoracolumbar/lumbosacral fusion, excluding open/cervical fracture. Timing classification from admission to fusion was same-day, 1-2-, 3-6-, and ≥7-day delay. Primary outcomes included in-hospital mortality, complications, and infection; secondary outcomes included total and postoperative length of stay and charges. Logistic regressions and generalized linear models with gamma distribution and log-link evaluated the effect of surgical timing on primary and secondary outcomes, respectively, controlling for age, sex, fracture location, fusion approach, multiorgan system injury severity score, and medical comorbidities.

RESULTS

Patients undergoing surgery ≤72 hours (n=12,845) had the lowest odds of in-hospital cardiac [odds ratio (OR)=0.595; 95% confidence interval (CI), 0.357-0.991] and respiratory complications (OR=0.495; 95% CI, 0.313-0.784) and infection (OR=0.615; 95% CI, 0.390-0.969). No differences were observed between same-day (n=4724) and 1-2-day delay (n=8121) (P>0.05). Lowest odds of hemorrhage or hematoma was observed following 3-6-day delay (OR=0.467; 95% CI, 0.236-0.922). A ≥7-day delay to fusion (n=2,002) was associated with greatest odds of hemorrhage/hematoma (OR=2.019; 1.107-3.683), respiratory complications (OR=1.850; 95% CI, 1.076-3.180), and infection (OR=3.155; 95% CI, 1.891-5.263) and greatest increases in mean postoperative length of stay (4.26% or 35.3% additional days) and charges (163,562 or 71.7% additional US dollars) (P<0.001).

CONCLUSIONS

Patients with thoracolumbar fracture and associated neurological injury who underwent surgery within 3 days of admission experienced fewer in-hospital complications. These benefits may be due to secondary injury mechanism avoidance and earlier mobilization.

LEVEL OF EVIDENCE

Level III.

Critical Assessment of the Contemporary Orthopaedic Surgery Residency Application Process

BACKGROUND

Matching into orthopaedic surgery residency in the United States has become an increasingly competitive process because of the large number of well-qualified applicants. Over the past several years, applicants have sought to maximize their chances of matching by submitting an increasing number of applications. The purpose of this study was to assess trends in application numbers, applicant qualifications, and application reviews, with the goal of obtaining data to help inform future improvements in the orthopaedic surgery residency application process.

METHODS

Applicant data were obtained from the Electronic Residency Application Service (ERAS, www.aamc.org/services/eras/stats) and the National Resident Matching Program (NRMP, www.nrmp.org/report-archives). These included residency application data from 2000 to 2017. In addition, we analyzed available NRMP Applicant Survey Reports between 2008 and 2017, Program Director Survey Reports between 2008 and 2016, and NRMP's Charting Outcomes in the Match between 2006 and 2016.

RESULTS

The number of U.S. senior medical student applicants per orthopaedic surgery residency position was stable from 2000 to 2017 (1.13 vs. 1.16 for 2000 and 2017, respectively). A significant increase in the United States Medical Licensing Examination (USMLE) Step-1 and Step-2 scores and self-reported research activity was present over the same time period. The number of applications submitted per applicant significantly increased, by 71.7%, from 48.4 in 2006 to 83.1 in 2017. Additionally, applications per program increased 46.4% from 457 in 2010 to 669 in 2016. In 2010, programs performed in-depth reviews for 54% of applications; however, in 2016, in-depth reviews had decreased to 45% of applications.

CONCLUSIONS

Orthopaedic residency applicant USMLE scores and research productivity have increased over time. Concurrently, the average number of applications submitted per applicant has increased, with the average applicant applying to nearly half of all orthopaedic residency programs. Consequently, programs have seen more than double the number of applications over this study period. The accompanying decline in the proportion of applications undergoing in-depth review, along with the applicant and program resources associated with these changes, warrants the development of strategies to enhance the efficiency of the application process for orthopaedic residency.

Machine learning modeling for predicting hospital readmission following lumbar laminectomy

In BriefAuthors of this study analyzed hospital readmissions following laminectomy and developed predictive models to identify readmitted patients with an accuracy >95% when using all variables and >79% when using only predischarge variables. A model capable of predicting 40% of readmitted patients was created using only the variables known predischarge. This investigation is important in its provision of data that will assist the development of predictive models for readmission as well as interventions to prevent readmission in high-risk patients.

Longer Operative Time in Elderly Patients Undergoing Posterior Lumbar Fusion Is Independently Associated With Increased Complication Rate

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the effects of operative time on postoperative complications in patients age 65 and older undergoing posterior lumbar fusion.

METHODS

All patients age 65 and older undergoing posterior lumbar fusion were identified in the 2012 to 2015 American College of Surgeons National Surgical Quality Improvement Program database. The primary outcome measures were complications occurring up to 30 days postoperatively, including death, any complication, and complication subtypes. The primary independent variable was operative duration. Both bivariate and multivariate analyses utilized logistic regression and analyzed operative duration as a continuous variable. Statistical significance was considered P < .05.

RESULTS

A total of 4947 patients age 65 and older undergoing posterior lumbar fusion were identified. The mean operative time was 3.3 hours (SD 1.7). The overall complication rate was 13.4% (n = 665). In multivariate analysis, each incremental hour of operative time was associated with increased risk of postoperative thromboembolism (odds ratio [OR] = 1.23; 95% confidence interval [CI] = 1.10-1.37), transfusion (OR= 1.25; 95% CI = 1.18-1.32), urinary tract infection (OR = 1.21; 95% CI = 1.10-1.32), and total postoperative complications (OR = 1.22; 95% CI = 1.16-1.27).

CONCLUSION

For patients age 65 and older undergoing posterior lumbar fusion, longer operative time is associated with greater risk for thromboembolism, transfusion, intubation, kidney injury, urinary tract infection, surgical site infection, and overall postoperative complications. This data highlights several specific complications that are influenced by operative time in older patients, and further supports the need for future protocols that seek to safely minimize operative time for posterior lumbar fusion.

Predictive factors of positive online patient ratings of spine surgeons

BACKGROUND

Online physician rating websites are increasingly used by patients to evaluate their doctors. The purpose of this investigation was to evaluate factors associated with better spine surgeon ratings.

METHODS

Orthopedic spine surgeons were randomly selected from the North American Spine Society directory utilizing a random number generator. Surgeon profiles on three physician rating websites, namely, www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com, were analyzed to gather qualitative and quantitative data on patients' perceptions of the surgeons. Independent variables from the websites were analyzed in relation to overall physician or patient satisfaction rating. Comments were coded by subject into following three categories: professional competence, bedside manner, and practice characteristics.

RESULTS

A total of 250 surgeons were evaluated, and 92% (n=230) of these doctors had at least one rating among the three websites. The surgeons with a higher average rating had significantly better trust (p<.01), scheduling (p<.01), staff (p<.01), helpfulness (p<.01), and punctuality (p<.01) scores but significantly less experience (p<.05). A linear regression model for the average rating of each surgeon (R² value=0.754) yielded only following three significant variables: trustworthiness (p<.01), experience match (p<.05), and the average number of negative comments on surgeon's professional competence (p<.05). Trustworthiness (β=0.749) was the strongest predictor variable of physician rating, followed by the number of negative professional competence comments (β=-0.132) and experience match (β=-0.112).

CONCLUSIONS

This investigation assessed spine surgeon online patient ratings and categorized factors that patients associate with quality care. Trustworthiness was the most significant predictor of positive ratings, whereas ease of scheduling, quality of staff, helpfulness, and punctuality were also associated with higher patient ratings. Understanding what patients value may help optimize care of spine surgery patients.

Early Subspecialization in Orthopedic Surgery Training

Recent studies have shown that applicants to the American Board of Orthopaedic Surgery Part II examination are performing fewer procedures outside of their chosen subspecialty. In this study, the authors assessed whether trainees are beginning their subspecialization during residency. The authors reviewed the chosen fellowships and case logs of 231 residents graduating from 5 academic orthopedic residency training programs from 2002 to 2017. The number of cases logged by residents who chose a specialty was then compared with the number of cases logged by residents who chose other specialties. Residents who chose spine surgery (108.4±50.7 vs 74.4±60.2, P<.01), hand surgery (242.2±92.9 vs 194.3±78.2, P<.01), and sports medicine (278.5±105.8 vs 229.0±93.9, P<.01) performed significantly more procedures in their chosen fields than their colleagues. In contrast, for total joint arthroplasty (P=.18) and foot and ankle surgery (P=.46), there was no significant difference in the number of cases between residents who chose the sub-specialty and those who did not. Residents pursuing careers in spine surgery, hand surgery, and sports medicine obtained additional operative exposure to their chosen field during residency. Formalizing this early experience with specialization tracks during the chief year may be considered. [Orthopedics. 2019; 42(1):e39-e43.].

Trends in the Orthopaedic Surgery Subspecialty Fellowship Match: Assessment of 2010 to 2017 Applicant and Program Data

BACKGROUND

Orthopaedic surgery has become increasingly specialized, and most trainees currently complete subspecialty fellowship training. The purposes of this investigation were to evaluate recent trends in U.S. orthopaedic fellowship matches and to provide relevant analyses for future orthopaedic fellowship applicants and fellowship program directors.

METHODS

This study analyzed data from orthopaedic fellowship match programs from 2010 to 2017. For each fellowship, the following variables were analyzed: numbers of positions offered, participating programs, applicant registrations, rank lists submitted by applicants (i.e., completed applications), applicants matched, and filled positions. Applicant-matching success rate and percentage of total fellowship positions filled for each subspecialty were calculated, and trends were evaluated for significance and difference between subspecialties utilizing ordinary least-square regressions, with p < 0.05 indicating significance.

RESULTS

From 2010 to 2017, the number of fellowship positions that were offered increased in all subspecialties (p < 0.05) except for spine (p = 0.44) and trauma (p = 0.92). Participating fellowship programs increased in all subspecialties (p < 0.05) except spine (p = 0.38) and sports medicine; the latter experienced the only significant decrease (p < 0.05). The largest significant increases (p < 0.05) in both applicant registrations (33.5%) and rank lists submitted by applicants (45.3%) were in adult reconstruction. The subspecialty with the highest applicant-matching success rate during the study period of 2010 to 2017 was sports (mean, 93.5%). Spine and trauma had the lowest applicant-matching success rates in 2016 to 2017. The percentage of positions filled across all subspecialties increased from 2011 to 2017 (p < 0.05); hand had the highest mean (96.6% filled), and adult reconstruction had the largest significant increase from 82.0% in 2010 to 95.5% in 2017 (p < 0.05).

CONCLUSIONS

This investigation provides data with regard to current trends in the orthopaedic fellowship match. Specifically, adult reconstruction fellowship training has recently gained popularity at a more rapid rate than the other subspecialty fellowship pathways, although hand surgery consistently maintains a very high rate of positions filled. Our results for orthopaedic subspecialty fellowship match trends may assist fellowship directors with program planning and career advising and may also assist current residents with fellowship application expectations and career planning.

Late-presenting dural tear: incidence, risk factors, and associated complications

BACKGROUND CONTEXT

Unrecognized and inadequately repaired intraoperative durotomies may lead to cerebrospinal fluid leak, pseudomeningocele, and other complications. Few studies have investigated durotomy that is unrecognized intraoperatively and requires additional postoperative management (hereafter, late-presenting dural tear [LPDT]), although estimates of LPDT range from 0.6 to 8.3 per 1,000 spinal surgeries. These single-center studies are based on relatively small sample sizes for an event of this rarity, all with <10 patients experiencing LPDT.

PURPOSE

This investigation is the largest yet conducted on LPDT, and sought to identify incidence, risk factors for, and complications associated with LPDT.

STUDY DESIGN/SETTING

This observational cohort study employed the American College of Surgeons National Surgical Quality Improvement Program dataset (years 2012-2015).

PATIENT SAMPLE

Patients who underwent spine surgery were identified based on presence of primary listed Current Procedural Terminology (CPT) codes corresponding to spinal fusion or isolated posterior decompression without fusion.

OUTCOME MEASURES

The primary variable in this study was occurrence of LPDT, identified as reoperation or readmission with durotomy-specific CPT or International Classification of Diseases, Ninth Revision, Clinical Modification codes but without durotomy codes present for the index procedure.

METHODS

Descriptive statistics were generated. Bivariate and multivariate analyses were conducted using chi-square tests and multiple logistic regression, respectively, generating both risk factors for LPDT and independent association of LPDT with postoperative complications. Statistical significance was defined as p<.05.

RESULTS

In total, 86,212 patients were analyzed. The overall rate of reoperation or readmission without reoperation for LPDT was 2.0 per 1,000 patients (n=174). Of LPDT patients, 97.7% required one or more unplanned reoperations (n=170), and 5.7% of patients (n=10) required two reoperations. On multivariate analysis, lumbar procedures (odds ratio [OR] 2.79, p<.0001, vs. cervical), procedures involving both cervical and lumbar levels (OR 3.78, p=.0338, vs. cervical only), procedures with decompression only (OR 1.72, p=.0017, vs. fusion and decompression), and operative duration ≥250 minutes (OR 1.70, p=.0058, vs. <250 minutes) were associated with increased likelihood of LPDT. Late-presenting dural tear was significantly associated with surgical site infection (SSI) (OR 2.54, p<.0001), wound disruption (OR 2.24, p<.0001), sepsis (OR 2.19, p<.0001), thromboembolism (OR 1.71, p<.0001), acute kidney injury (OR 1.59, p=.0281), pneumonia (OR 1.14, p=.0269), and urinary tract infection (UTI) (OR 1.08, p=.0057).

CONCLUSIONS

Late-presenting dural tears occurred in 2.0 per 1,000 patients who underwent spine surgery. Patients who underwent lumbar procedures, decompression procedures, and procedures with operative duration ≥250 minutes were at increased risk for LPDT. Further, LPDT was independently associated with increased likelihood of SSI, sepsis, pneumonia, UTI, wound dehiscence, thromboembolism, and acute kidney injury. As LPDT is associated with markedly increased morbidity and potential liability risk, spine surgeons should be aware of best-practice management for LPDT and consider it a rare, but possible etiology for developing postoperative complications.

Sex- and Sport-Specific Epidemiology of Cervical Spine Injuries Sustained During Sporting Activities

BACKGROUND

Although several investigations have examined the epidemiology of cervical spine injuries in sports, few studies have analyzed the nationwide incidence and sex-specific epidemiology of cervical spine injuries.

METHOD

The National Electronic Injury Surveillance System database, which collects information on patients presenting to the emergency department at 100 hospitals across the United States, was queried for neck sprains and cervical fractures associated with sporting activities from 2000-2015.

RESULT

A total of 26,380 neck sprains and 1166 fractures were identified. Compared with females, the incidence for injuries in males was 1.7 times greater for neck sprains and 3.6 times greater for fractures (P < 0.0001). Football was the most common cause of cervical sprains in males, followed by cycling and weightlifting/aerobics. Females sustained most neck sprains in weightlifting/aerobics, trampoline, and cheerleading. From 2000 to 2015, the incidence of neck sprains from aerobics increased from 15.5 to 25.3 per million person-years (P < 0.0001). Similarly, the incidence of cervical fractures from cycling increased from 0.67 to 2.7 per million (P < 0.0001). For males, cycling was the most common cause of fracture, followed by diving/swimming and football. For females, horseback riding was most common, followed by cycling and diving/swimming.

CONCLUSIONS

Football is the leading cause of cervical sprains in the United States. The most common cause of cervical fracture in men is cycling, while in women it is horseback riding. The incidence of sport-related cervical fractures has increased by 35% from 2000 to 2015, which has been driven by an increase in cycling-related injuries.

Physician and patients factors associated with outcome of spinal epidural abscess related malpractice litigation

Spinal epidural abscesses (SEA) can be challenging to diagnose and may result in serious adverse outcomes sometimes leading to neurologic compromise, sepsis, and even death. While SEA may lead to litigation for healthcare providers, little is known about the medicolegal factors predicting case outcome of SEA related litigation cases. Three large medicolegal databases (VerdictSearch, Westlaw, and LexisNexis) were queried for SEA-related malpractice cases. Plaintiff (patient) age, sex, previous infection history and clinical outcomes such as residual paraplegia/quadriplegia, and delay in diagnosis or treatment were examined. The relationship between these variables and the proportion of plaintiff rulings and size of indemnity payments were assessed. Of the 135 cases that met inclusion criteria, 29 (21.5%) settled, 59 (43.7%) resulted in a defendant ruling, and 47 (34.8%) resulted in a plaintiff ruling. Mean award for plaintiff rulings was $4,291,400 (95% CI, $5,860,129 to $2,722,671), which was significantly larger than mean awards for cases that settled out of court, $2,324,170 (95% CI, $3,206,124 to $1,442,217) (P<0.05). The proportion of plaintiff verdicts and size of monetary awards were not significantly related to age or sex of the patient. A previously known infection was not significantly associated with the proportion of plaintiff verdicts or indemnity payments (P>0.05). In contrast, plaintiff verdicts were more common for patients who became paraplegic or quadriplegic (P<0.02) and were associated with significantly higher monetary awards (P<0.05) relative to patients without paralysis. Plaintiff verdicts were also more common when cases had an associated delay in diagnosis (P=0.008) or delay in treatment (P<0.001). Internists were the most commonly sued physician named in 20 (14.8%) suits, followed by anesthesiologists in 13 (9.6%) suits, emergency medicine physicians in 12 (8.9%) suits, family medicine physicians in 9 (6.7%) suits, neurosurgeons and orthopedic surgeons in 6 (4.4%) suits each, and multiple providers in 2 (1.5%) suits. The remaining lawsuits were against a hospital or another specialty not previously listed This investigation examined legal claims associated with SEA and found that the likelihood of a plaintiff verdict was significantly related to patient outcome (paralysis) and physician factors (delay in diagnosis or treatment compared). Additionally, paralyzed plaintiffs receive higher award payouts. Non-operative physicians, who are often responsible for initial diagnosis, were more frequently named in malpractice suits than surgeons. Increased awareness of the medicolegal implications of SEA can better prevent delays in diagnosis and treatment, and thus, alleged negligence-based lawsuits.

Timing of complications following posterior cervical fusion

Study design

Retrospective cohort study.

Objective

To characterize the timing of complications after posterior cervical fusion.

Summary of background data

Understanding the expected timing of postoperative complications facilitates early diagnosis of potential adverse events and is important for optimizing postoperative care. Though studies have examined the incidence of complications after posterior cervical fusion, no study has characterized the timing of these complications.

Methods

Patient data in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset with a primary CPT code 22600, corresponding to posterior cervical fusion, was analyzed for demographics, comorbidities, and ten specific complications. Complication timing was assessed, and univariate analysis was performed to investigate the relationship of patient demographic and clinical variables on the development of postoperative complications.

Results

A total of 2517 patients with a mean age of 59.3 ± 12.5 met inclusion criteria. The overall complication rate was 12.4%. The median day of diagnosis and interquartile range for each complication was: blood transfusion (0.0, 0-0), myocardial infarction (3, 2-7), reintubation (3, 1-9), pneumonia (4, 3-10), deep venous thrombosis (7, 5-16), urinary tract infection (11.5, 5-17.5), sepsis (14, 7-20), pulmonary embolism (14, 8-21), surgical site infection (15, 9-21), and wound dehiscence (15.5, 9-25). Less than 50% deep venous thromboses were diagnosed before discharge, and less than 30% of pulmonary emboli were diagnosed before discharge. On univariate analysis, increased age, decreased functional status, fusing more than one level, current smoker status, diabetes, and CHF were associated with increased complications.

Conclusions

This timing data is useful to the practicing spine surgeon as it provides a guide for when to expect and investigate for specific complications after posterior cervical procedures. It may aid in the early diagnosis of complications and may also assist in healthcare reimbursement negotiations.

S-1 alar/iliac screw technique for spinopelvic fixation

Spinopelvic fixation provides an important anchor for long fusions in spinal deformity surgery, and it is also used in the treatment of other spine pathologies. Iliac screws are known to sometimes require reoperation due to pain resulting from hardware prominence and skin injury. S-2 alar/iliac (S2AI) screws do not often require removal, but they may provide inadequate fixation in select cases. In this paper the authors describe a technique for S-1 alar/iliac screws that may be used independently or as a supplement to S2AI screws. A preliminary biomechanical analysis and 2 clinical case examples are also provided.

Hospital competitive intensity and perioperative outcomes following lumbar spinal fusion

BACKGROUND CONTEXT

Interhospital competition has been shown to influence the adoption of surgical techniques and approaches, clinical patient outcomes, and health care resource use for select surgical procedures. However, little is known regarding these dynamics as they relate to spine surgery.

PURPOSE

This investigation sought to examine the relationship between interhospital competitive intensity and perioperative outcomes following lumbar spinal fusion.

STUDY DESIGN/SETTING

This study used the Nationwide Inpatient Sample dataset, years 2003, 2006, and 2009.

PATIENT SAMPLE

Patients were included based on the presence of the International Classification of Disease, Ninth Edition, Clinical Modification (ICD-9-CM) codes corresponding to lumbar spinal fusion, as well as on the presence of data on the Herfindahl-Hirschman Index (HHI).

OUTCOME MEASURES

The outcome measures are perioperative complications, defined using an ICD-9-CM coding algorithm.

MATERIALS AND METHODS

The HHI, a validated measure of competition within a market, was used to assess hospital market competitiveness. The HHI was calculated based on the hospital cachement area. Multiple regression was performed to adjust for confounding variables including patient age, gender, primary payer, severity of illness score, primary versus revision fusion, anterior versus posterior approach, national region, hospital bed size, location or teaching status, ownership, and year. Perioperative clinical outcomes were assessed based on ICD-9-CM codes with modifications.

RESULTS

In total, 417,520 weighted patients (87,999 unweighted records) were analyzed. The mean cachement area HHI was 0.31 (range 0.099-0.724). The average patient age was 55.4 years (standard error=0.194), and the majority of patients were female (55.8%, n=232,727). The majority of procedures were primary spinal fusions (92.7%, n=386,998) and fusions with a posterior-only technique (81.5%, n=340,271). Most procedures occurred in the South (42.5%, n=177,509) or the Midwest (27.0%, n=112,758) regions. In the multiple regression analysis, increased hospital competitive intensity was associated with an increased total complication rate (odds ratio [OR] 1.52, p<.0001), device-related complications (OR 1.46, p=.0294), genitourinary complications (OR 2.15, p=.0091), infection (OR 3.48, p<.0001), neurologic complications (OR 1.69, p=.0422), total charges (+29%, p=.0034), and inpatient hospital length of stay (LOS) (+16%, p=.0012). The likelihood of complications at state-owned hospitals (OR 2.81, p=.0001) was more highly associated with HHI than at private, non-profit hospitals (OR 1.39, p=.0050). The occurrence of complications at urban teaching hospitals (OR 2.14, p<.0001) was generally more associated with HHI than at urban non-teaching hospitals (OR 1.19, p=.2457).

CONCLUSIONS

Increased interhospital competitive intensity is associated with increased odds of complications, increased total charges, and prolonged LOS following lumbar spine fusion. These differences are generally highest among state-owned and urban teaching hospitals. Differences in outcome related to hospital competition may be due to suboptimal resource allocation. Identifying differences in perioperative outcomes associated with hospital market competition is important in the contemporary environment of health care reimbursement reform and hospital consolidation. Perioperative outcome disparities between highly competitive and minimally competitive areas should be monitored and further studied.

Variability in Treatment for Patients with Cervical Spine Fracture and Dislocation: An Analysis of 107,152 Patients

BACKGROUND

Cervical spine injuries are a common cause of morbidity and mortality; however, the optimal treatment of many of these injuries is debated, and previous studies have shown substantial variation in treatment. We sought to examined treatment variation in arthrodesis and halo/tong placement in cervical spine injury patients over a 12-year period.

METHODS

Data from the Healthcare Cost and Utilization Project National Inpatient Sample, from 2000 to 2011, were used for this study. Patients were identified with a cervical vertebral facture or dislocation based on the International Classification of Diseases, 9th Revision codes. Using χ² analysis, spinal arthrodesis rates and halo/tong placement rates were compared between hospitals based on teaching status for patients with and without spinal cord injury (SCI).

RESULTS

The records of 107,152 patients with cervical fractures were examined. From 2000 to 2011, the overall arthrodesis rates fell from 25.2% to 20.6% (P < 0.001), and halo/tong placement rates fell from 13.2% to 3.6% (P < 0.001). In patients with cervical fracture without SCI, arthrodesis rates fell from 17.6% to 13.9% (P < 0.001), in cervical fracture patients with SCI, arthrodesis rates rose from 50.0% to 58.9% (P < 0.001), and in cervical dislocation patients, arthrodesis rates rose from 47.6% to 57.5% (P < 0.001). During the 12-year period, teaching hospitals had higher arthrodesis rates compared with nonteaching hospitals for patients with cervical fractures with SCI (57.3% vs. 53.4%, P = 0.001) and higher halo/tong placement rates for patients with cervical dislocations (2.7% vs. 1.7%, P = 0.004). Individual hospital variation showed a 3.5-fold variation in arthrodesis rates in 2000 to 2002, which fell to 3.0-fold by 2009 to 2011.

CONCLUSIONS

Arthrodesis rates for cervical fracture patients significantly decreased, and arthrodesis rates for cervical dislocation and SCI patients increased from 2000 to 2011, with variability in treatment based on hospital teaching status. Rates of halo/tong placement rapidly decreased for cervical spine trauma at both teaching and nonteaching hospitals. Individual hospital treatment variation also decreased over the study period. Further clinical studies examining the optimal treatment for spine trauma may lead to continued decreases in treatment variability.

Factors predicting publication of spinal cord injury trials registered on www.ClinicalTrials. gov

OBJECTIVE/BACKGROUND

Treatment options for spinal cord injuries are currently limited, but multiple clinical trials are underway for a variety of interventions, drugs, and devices. The Food and Drug Administration website www.ClinicalTrials.gov catalogues these trials and includes information on the status of the trial, date of initiation and completion, source of funding, and region. This investigation assesses the factors associated with publication and the publication rate of spinal cord injury trials.

DESIGN

Retrospective analysis of publically available data on www.ClinicalTrials.gov.

METHODS

The www.ClinicalTrials.gov was queried for all trials on patients with spinal cord injury, and these trials were assessed for status, type of intervention, source of funding, and region. Multiple literature searches were performed on all completed trials to determine publication status.

RESULTS

There were 626 studies identified concerning the treatment of patients with spinal cord injury, of which 250 (39.9%) were completed. Of these, only 119 (47.6%) were published. There was no significant difference in the rate of publication between regions (p> 0.16) or by study type (p> 0.29). However, trials that were funded by the NIH were more likely to be published than trials funded by industry (p= 0.01).

CONCLUSION

The current publication rate of spinal cord injury trials is only 47.6%, though this rate is similar to the publication rate for trials in other fields. NIH-funded trials are significantly more likely to become published than industry-funded trials, which could indicate that some trials remain unpublished due to undesirable results. However, it is also likely that many trials on spinal cord injury yield negative results, as treatments are often ineffective.

Completion of Multiple Fellowships by Orthopedic Surgeons: Analysis of the American Board of Orthopaedic Surgery Certification Database

Orthopedic surgeons have become increasingly subspecialized, and recent studies have shown that American Board of Orthopaedic Surgery (ABOS) Step II applicants are performing a higher percentage of their cases within their chosen subspecialties. However, these studies focused exclusively on surgeons who have completed a single fellowship; little data exist on those who pursue a second fellowship. All applicants to the ABOS Part II examination from 2004 to 2016 were classified by their self-reported fellowship training history using the ABOS Part II examination database. Trends in the number of applicants completing multiple fellowships and the types of fellowships combined were analyzed. In addition, cases performed by applicants who had performed multiple fellowships were analyzed to determine what percentage were within their chosen subspecialties. A total of 9776 applicants to ABOS Part II were included in the database from 2004 to 2016, including 444 (4.5%) applicants who completed more than one fellowship. There were 43 different combinations of fellowships; the most common additional fellowships were trauma (40.1%), sports medicine (38.7%), and joints (30.4%). The most common combinations were joints and sports medicine (10.6%) and foot and ankle and sports medicine (10.1%). A significant increase occurred in physicians training in both pediatric orthopedics and sports medicine (P=.02). The percentage of cases within the applicants' chosen specialties ranged from 91.4% in sports to 73.6% in tumor. Multiple fellowship applicants represent a small percentage of all applicants, and although subspecialization in orthopedics is increasing, no increasing trend toward multiple fellowships within this dataset was observed. However, the significant increase in applicants who combined pediatric orthopedic and sports medicine fellowships suggests an increasing interest in treating this increasing patient population in addition to social and economic factors. [Orthopedics. 2018; 41(1):e33-e37.].

Adult Spinal Deformity Knowledge in Orthopedic Spine Surgeons: Impact of Fellowship Training, Experience, and Practice Characteristics

STUDY DESIGN

Survey study.

OBJECTIVE

The purpose of this paper was to assess the level of adult spine deformity (ASD) knowledge among orthopedic spine surgeons and identify areas for improvement in spine surgery training.

SUMMARY OF BACKGROUND DATA

ASD is increasingly encountered in spine surgery practice. While ASD knowledge among neurosurgeons has been evaluated, ASD knowledge among orthopedic spine surgeons has not previously been reported.

METHODS

A survey of orthopedic spine surgeon members of North American Spine Society (NASS) was conducted to assess level of spine surgery training, practice experience, and spinal deformity knowledge base. The survey used was previously completed by a group of neurologic surgeons with published results. The survey used 11 questions developed and agreed upon by experienced spinal deformity surgeons.

RESULTS

Complete responses were received from 413 orthopedic spine surgeons. The overall correct-answer rate was 69.0%. Surgeons in practice for less than 10 years had a higher correct-answer rate compared to those who have practiced for 10 years or more (74% vs. 67%; p = .000003). Surgeons with 75% or more of their practice dedicated to spine had a higher overall correct rate compared to surgeons whose practice is less than 75% spine (71% vs. 63%; p = .000029). Completion of spine fellowship was associated with a higher overall correct-answer rate compared to respondents who did not complete a spine fellowship (71% vs. 59%; p < .00001).

CONCLUSIONS

Completion of spine fellowship and having a dedicated spine surgery practice were significantly associated with improved performance on this ASD knowledge survey. Unlike neurosurgeons, orthopedic spine surgeons who have practiced for less than 10 years performed better than those who have practiced for more than 10 years. Ongoing emphasis on spine deformity education should be emphasized to improve adult spinal deformity knowledge base.

Factors Associated With Physician Loss in Anterior Cruciate Ligament Reconstruction Malpractice Lawsuits

Background:

Anterior cruciate ligament (ACL) reconstruction is among the most common orthopaedic procedures, with its incidence doubling over the past decade. To date, no studies have analyzed litigation after ACL reconstruction.

Purpose:

To characterize the causes of malpractice litigation after ACL reconstruction.

Study Design:

Cross-sectional study.

Methods:

A retrospective review of malpractice lawsuits after ACL reconstruction was performed using VerdictSearch, a large legal claims database encompassing nearly 180,000 legal cases, from February 1988 to May 2015. Settlement rates and physician loss rates were calculated along with 95% CIs for each complication type, and analysis of variance was used to compare all indemnity payments.

Results:

Of a total 30 lawsuits, 5 (16.7%) settled out of court. The 3 most common complications leading to litigation were prolonged pain (n = 5, 16.7%), infection (n = 5, 16.7%), and malpositioned graft (n = 5, 16.7%). Of the 25 cases that went to court, 8 (32.0%) ended in favor of the plaintiff (physician loss). Damage to a neurovascular structure resulted in the highest indemnity payment (mean, $2,012,926 ± $1,076,530; P = .021). Lawsuits for which pain or loss of range of motion was the only complication were significantly more likely to end in a physician victory (P = .04) and lower indemnity payments ($87,500 vs $678,715, respectively). Cases that involved a surgical technical error were more likely to result in a physician loss (P = .01), with malpositioned grafts having a significantly higher loss rate than average (75% vs 32%, respectively).

Conclusion:

After ACL reconstruction, physicians are more likely to win malpractice suits if pain or limited range of motion is the only complaint and less likely to win if a surgical error was alleged. These findings may help to set patient expectations and provide adequate guidance during the informed consent process.

Inpatient costs and blood transfusion rates of sarcopenic patients following thoracolumbar spine surgery

OBJECTIVE

Sarcopenia, the muscle atrophy associated with aging and disease progression, accounts for nearly $18.5 billion in health care expenditures annually. Given the high prevalence of sarcopenia in patients undergoing orthopedic surgery, the goal of this study was to assess the impact of sarcopenia on inpatient costs following thoracolumbar spine surgery.

METHODS

Patients older than 55 years undergoing thoracolumbar spine surgery from 2003 to 2015 were retrospectively analyzed. Sarcopenia was measured using total psoas area at the L-4 vertebra on perioperative CT scans. Hospital billing data were used to compare inpatient costs, transfusion rate, and rate of advanced imaging utilization.

RESULTS

Of the 50 patients assessed, 16 were sarcopenic. Mean total hospital costs were 1.75-fold greater for sarcopenic patients compared with nonsarcopenic patients ($53,128 vs $30,292, p = 0.04). Sarcopenic patients were 2.1 times as likely to require a blood transfusion (43.8% vs 20.6%, p = 0.04). Sarcopenic patients had a 2.6-fold greater usage of advanced imaging (68.8% vs 26.5%, p = 0.002) with associated higher diagnostic imaging costs ($2452 vs $801, p = 0.01). Sarcopenic patients also had greater pharmacy, laboratory, respiratory care, and emergency department costs.

CONCLUSIONS

This study is the first to show that sarcopenia is associated with higher postoperative costs and rates of blood transfusion following thoracolumbar spine surgery. Measuring the psoas area may represent a strategy for predicting perioperative costs in spine surgery patients.

Malpractice litigation following spine surgery

OBJECTIVE

Adverse events related to spine surgery sometimes lead to litigation. Few studies have evaluated the association between spine surgical complications and medical malpractice proceedings, outcomes, and awards. The aim of this study was to identify the most frequent causes of alleged malpractice in spine surgery and to gain insight into patient demographic and clinical characteristics associated with medical negligence litigation.

METHODS

A search for “spine surgery” spanning February 1988 to May 2015 was conducted utilizing the medicolegal research service VerdictSearch (ALM Media Properties, LLC). Demographic data for the plaintiff and defendant in addition to clinical data for the procedure and legal outcomes were examined. Spinal cord injury, anoxic/hypoxic brain injury, and death were classified as catastrophic complications; all other complications were classified as noncatastrophic. Both chi-square and t-tests were used to evaluate the effect of these variables on case outcomes and awards granted.

RESULTS

A total of 569 legal cases were examined; 335 cases were excluded due to irrelevance or insufficient information. Of the 234 cases included in this investigation, 54.2% (127 cases) resulted in a defendant ruling, 26.1% (61) in a plaintiff ruling, and 19.6% (46) in a settlement. The awards granted for plaintiff rulings ranged from $134,000 to $38,323,196 (mean $4,045,205 ± $6,804,647). Awards for settlements ranged from $125,000 to $9,000,000 (mean $1,930,278 ± $2,113,593), which was significantly less than plaintiff rulings (p = 0.022). Compared with cases without a delay in diagnosis of the complication, the cases with a diagnostic delay were more likely to result in a plaintiff verdict or settlement (42.9% vs 72.7%, p = 0.007) than a defense verdict, and were more likely to settle out of court (17.5% vs 40.9%, p = 0.008). Similarly, compared with cases without a delay in treatment of the complication, those with a therapeutic delay were more likely to result in a plaintiff verdict or settlement (43.7% vs 68.4%, p = 0.03) than a defense verdict, and were more likely to settle out of court (18.1% vs 36.8%, p = 0.04). Overall, 28% of cases (66/234) involved catastrophic complications. Physicians were more likely to lose cases (plaintiff verdict or settlement) with catastrophic complications (66.7% vs 37.5%, p < 0.001). In cases with a plaintiff ruling, catastrophic complications resulted in significantly larger mean awards than noncatastrophic complications ($6.1M vs $2.9M, p = 0.04). The medical specialty of the provider and the age or sex of the patient were not associated with the case outcome or award granted (p > 0.05). The average time to a decision for defendant verdicts was 5.1 years; for plaintiff rulings, 5.0 years; and for settlements, 3.4 years.

CONCLUSIONS

Delays in the diagnosis and the treatment of a surgical complication predict legal case outcomes favoring the plaintiff. Catastrophic complications are linked to large sums awarded to the plaintiff and are predictive of rulings against the physician. For physician defendants, the costs of settlements are significantly less than those of losing in court. Although this study provides potentially valuable data from a large series of postoperative litigation cases, it may not provide a true representation of all jurisdictions, each of which has variable malpractice laws and medicolegal environments.

Assessment of malpractice claims due to spinal epidural abscess

OBJECTIVE Spinal epidural abscesses (SEAs) can be difficult to diagnose and may result in neurological compromise or even death. Delays in diagnosis or treatment may worsen the prognosis. While SEA presents a high risk for litigation, little is known about the medicolegal ramifications of this condition. An enhanced understanding of potential legal implications is important for practicing spine surgeons, emergency medicine physicians, and internists. METHODS The VerdictSearch database, a large legal-claims database, was queried for "epidural abscess"-related legal cases. Demographic and clinical data were examined for all claims; any irrelevant cases or cases with incomplete information were excluded. The effects of age of the plaintiff, sex of the plaintiff, presence of a known infection, resulting paraplegia or quadriplegia, delay in diagnosis, and delay in treatment on the proportion of plaintiff rulings and size of payments were assessed. RESULTS In total, 56 cases met the inclusion criteria. Of the 56 cases, 17 (30.4%) were settled, 22 (39.3%) resulted in a defendant ruling, and 17 (30.4%) resulted in a plaintiff ruling. The mean award for plaintiff rulings was $5,277,468 ± $6,348,462 (range $185,000-$19,792,000), which was significantly larger than the mean award for cases that were settled out of court, $1,914,265 ± $1,313,322 (range $100,000-$4,500,000) (p < 0.05). The mean age of the plaintiffs was 47.0 ± 14.4 years; 23 (41.1%) of the plaintiffs were female and 33 (58.9%) were male. The proportion of plaintiff verdicts and size of monetary awards were not affected by age or sex (p > 0.49). The presence of a previously known infection was also not associated with the proportion of plaintiff verdicts or indemnity payments (p > 0.29). In contrast, juries were more likely to rule in favor of plaintiffs who became paraplegic or quadriplegic (p = 0.03) compared with plaintiffs who suffered pain or isolated weakness. Monetary awards for paraplegic or quadriplegic patients were also significantly higher (p = 0.003). Plaintiffs were more likely to win if there was a delay in diagnosis (p = 0.04) or delay in treatment (p = 0.006), although there was no difference in monetary awards (p > 0.57). Internists were the most commonly sued physician (named in 13 suits [23.2%]), followed by emergency medicine physicians (named in 8 [14.3%]), and orthopedic surgeons (named in 3 [5.4%]). CONCLUSIONS This investigation is the largest examination of legal claims due to spinal epidural abscess to date. The proportion of plaintiff verdicts was significantly higher in cases in which the patient became paraplegic or quadriplegic and in cases in which there was delay in diagnosis or treatment. Additionally, paralysis is linked to large sums awarded to the plaintiff. Nonsurgeon physicians, who are often responsible for initial diagnosis, were more likely to be sued than were surgeons.

Sarcopenia in Orthopedic Surgery

Sarcopenia is a loss of skeletal muscle mass in the elderly that is an independent risk factor for falls, disability, postoperative complications, and mortality. Although its cause is not completely understood, sarcopenia generally results from a complex bone-muscle interaction in the setting of chronic disease and aging. Sarcopenia cannot be diagnosed by muscle mass alone. Diagnosis requires 2 of the following 3 criteria: low skeletal muscle mass, inadequate muscle strength, and inadequate physical performance. Forty-four percent of elderly patients undergoing orthopedic surgery and 24% of all patients 65 to 70 years old are sarcopenic. Although dual-energy x-ray absorptiometry and bioelectrical impedance analysis may be used to measure sarcopenia and are relatively inexpensive and accessible, they are generally considered less specific for sarcopenia compared with computed tomography and magnetic resonance imaging. Sarcopenia has been shown to predict poor outcomes within the medical and surgical populations and has been directly correlated with increases in taxpayer costs. Strengthening therapy and nutritional supplementation have become the mainstays of sarcopenia treatment. Specifically, the American Medical Directors Association has released guidelines for nutritional supplementation. Although sarcopenia frequently occurs with osteoporosis, it is an independent predictor of fragility fractures. Initiatives to diagnose, treat, and prevent sarcopenia in orthopedic patients are needed. Further investigation must also explore sarcopenia as a predictor of surgical outcomes in orthopedic patients.

Effect of Sarcopenia on Postoperative Morbidity and Mortality After Thoracolumbar Spine Surgery

Sarcopenia is the loss of muscle mass associated with aging and advanced disease. This study retrospectively examined patients older than 55 years (N=46) who underwent thoracolumbar spine surgery between 2003 and 2015. Each patient's comorbidity burden was determined using the Charlson Comorbidity Index, and the Mirza Surgical Invasiveness Index was used to measure procedural complexity. Sarcopenia was diagnosed by measuring the total cross-sectional area of the psoas muscle at the L4 vertebrae using perioperative computed tomography scans. Of the 46 patients assessed, 16 were in the lowest third for L4 total psoas area (sarcopenic). Average follow-up time was 5.2 years (range, 6 days to 12.7 years). The cohort of patients with sarcopenia was significantly older than the cohort without sarcopenia (mean age, 76.4 vs 69.9 years; P=.01) but did not have a significantly different mean Charlson Comorbidity Index (3.3 vs 2.0; P=.32) or mean Mirza Surgical Invasiveness Index (7.1 vs 7.0; P=.49). Patients with sarcopenia had a hospital length of stay 1.7-fold longer than those without sarcopenia (8.1 vs 4.7 days; P=.02) and a 3-fold increase in postoperative in-hospital complications (1.2 vs 0.4; P=.02), and they were more likely to require discharge to a rehabilitation or nursing facility (81.2% vs 43.3%; P=.006). Patients with sarcopenia had a significantly lower cumulative survival (log rank=0.007). All 4 deaths occurred among patients with sarcopenia. Patients with sarcopenia have a significantly increased risk of in-hospital complications, longer length of stay, increased rates of discharge to rehabilitation facilities, and increased mortality following thoracolumbar spinal surgery, making sarcopenia a useful perioperative risk stratification tool. [Orthopedics. 2016; 39(6):e1159-e1164.].

Perpendicular Iliac Screw Placement for Reinforcement of Spinopelvic Stabilization

Iliac fixation is indicated to provide spinopelvic stabilization in select cases of long segment thoracolumbar spine fusion, spinal osteotomy/realignment, trauma, and instability caused by tumor or infection. Traditional iliac fixation with iliac screws or S2 alar/iliac (S2AI) screws may provide inadequate fixation in select clinical scenarios, such as severely compromised bone quality or spinopelvic dissociation. The purpose of this article is to describe the perpendicular iliac screw technique with ipsilateral iliac crest screw plus S2AI fixation. The technique may be applied for select individuals in cases of 3-column osteotomy in the lower lumbar spine, spinopelvic dissociation (caused by trauma, neoplasm, or Charcot arthropathy), and failure of previous iliac fixation and when anatomic constraints limit standard iliac screw or S2AI screw placement. [Orthopedics. 2016; 39(6):e1209-e1212.].

An Evidence-Based Approach to Differentiating the Cause of Shoulder and Cervical Spine Pain

Differentiating the cause of pain and dysfunction due to cervical spine and shoulder pathology presents a difficult clinical challenge in many patients. Furthermore, the anatomic region reported to be painful may mislead the practitioner. Successfully treating these patients requires a careful and complete history and physical examination with appropriate provocative maneuvers. An evidence-based selection of clinical testing also is essential and should be tailored to the most likely underlying cause. When advanced imaging does not reveal a conclusive source of pathology, electromyography and selective injections have been shown to be useful adjuncts, although the sensitivity, specificity, and risk-reward ratio of each test must be considered. This review provides an evidence-based review of common causes of shoulder and neck pain and guidelines for assistance in determining the pain generator in ambiguous cases.

Academic Characteristics of Orthopaedic Surgery Residency Applicants from 2007 to 2014

BACKGROUND

Based on a relatively stable match rate, several authors have concluded that the competition for orthopaedic residency positions has not changed over the past 3 decades. However, the objective measures of applicant competitiveness have not been quantified in detail.

METHODS

National Resident Matching Program (NRMP) data from 2007 to 2014 for U.S. orthopaedic surgery applicants were compared with data for applicants to all specialties. Trends in the United Stated Medical Licensing Examination (USMLE) Step-1 and Step-2 scores, publications and research experiences, Alpha Omega Alpha (AOA) status, and the presence of an advanced degree are reported.

RESULTS

From 2007 to 2014, the match rate for orthopaedic surgery applicants remained stable near 80% (p = 0.14). For orthopaedic applicants who matched, the mean USMLE Step-1 scores increased from 234 points in 2007 to 245 points in 2014 (p = 0.005), and the mean scores increased from 220 points in 2007 to 229 points in 2014 for all applicants (p = 0.019). The mean USMLE Step-2 scores of orthopaedic applicants who matched increased from 235 points in 2007 to 251 points in 2014 (p = 0.005), and the mean scores of all applicants increased from 225 points in 2007 to 242 points in 2014 (p = 0.002). The mean number of research publications, presentations, and abstracts reported by orthopaedic applicants who matched more than doubled from 3.0 in 2007 to 6.7 in 2014 (p = 0.02) and increased less dramatically for all applicants from 2.2 in 2007 to 4.2 in 2014 (p = 0.004). The percentage of orthopaedic applicants elected to AOA or with advanced degrees did not significantly change (p > 0.2). Although orthopaedic applicants with AOA status experienced a very high match rate (97.1% in 2014), those with advanced degrees experienced match rates similar to or slightly lower than the applicant pool (73.7% in 2014).

CONCLUSIONS

The USMLE Step-1 and 2 scores of U.S. orthopaedic surgery residency applicants have increased significantly from 2007 to 2014. Additionally, the number of publications and presentations reported by orthopaedic applicants has more than doubled. These factors signal an increasing level of academic accomplishment in orthopaedic surgery applicants despite a consistent match rate.

Compressive spinal epidural mass caused by Propionibacterium acnes

BACKGROUND CONTEXT

Propionibacterium acnes is a gram-positive and facultative anaerobe bacillus that is found within sebaceous follicles of the human skin and recognized as a cause of infections after spinal surgery. To our knowledge, there has been no previously reported case of symptomatic compressive chronic inflammatory epidural mass caused by P. acnes in a patient with no prior spinal procedures.

PURPOSE

This study aimed to describe a case of primary spinal infection by P. acnes.

STUDY DESIGN

This study is a case report of a condition not previously described in the literature.

METHODS

We present the history, physical examination, laboratory, radiographic, and histopathologic findings of a chronic inflammatory epidural mass caused by P. acnes in an immunocompetent adult male with no history of spinal surgery.

RESULTS

A 51-year-old man presented to our clinic with sudden onset bilateral lower extremity weakness, inability to ambulate, and urinary retention. His past clinical history was remarkable only for hernia and left knee surgery but no spinal surgery. A year earlier, he had an infected draining abscess of the right axilla that was successfully managed medically. At presentation, his serum erythrocyte sedimentation rate and C-reactive protein were moderately elevated. Pan-spine magnetic resonance imaging was notable for a circumferential epidural mass from C5 to T6. He underwent emergent decompression; the mass was removed and sent for culture and pathologic evaluation. Cultures from all three specimens collected during surgery grew P. acnes, and the patient was successfully managed on intravenous ceftriaxone, while pathology revealed a chronic inflammatory reactive process.

CONCLUSIONS

This is the first reported case of a primary spinal mass with chronic inflammatory features caused by P. acnes. In cases of epidural mass of unknown origin, both pathologic specimens and cultures should be obtained as slow-growing organisms may mimic oncologic processes.

Evaluation and management of spinal epidural abscess

Spinal epidural abscess (SEA) is an uncommon and potentially catastrophic condition. SEA often presents a diagnostic challenge, as the "classic triad" of fever, spinal pain, and neurological deficit is evident in only a minority of patients. When diagnosis is delayed, irreversible neurological damage may ensue. To minimize morbidity, an appropriate level of suspicion and an understanding of the diagnostic evaluation are essential. Infection should be suspected in patients presenting with axial pain, fever, or elevated inflammatory markers. Although patients with no known risk factors can develop SEA, clinical concern should be heightened in the presence of diabetes, intravenous drug use, chronic renal failure, immunosuppressant therapy, or a recent invasive spine procedure. When the clinical profile is consistent with the diagnosis of SEA, gadolinium-enhanced magnetic resonance imaging of the spinal column should be obtained on an emergent basis to delineate the location and neural compressive effect of the abscess. Rapid diagnosis allows for efficient treatment, which optimizes the potential for a positive outcome.

Prevention of Paralytic Ileus Utilizing Alvimopan Following Spine Surgery

Postoperative ileus affects a substantial proportion of patients undergoing elective spine surgery, especially in cases of spinal deformity correction and where an anterior lumbar approach is utilized. Though the first line of treatment for postoperative ileus is conservative management, recent advances in pharmacology have yielded promising options for both treatment and prevention. We report a case of a patient who underwent a two-stage posterior spinal fusion. The patient suffered with a severe, prolonged ileus after her initial surgery. To prevent ileus following her second spinal surgery, alvimopan (a µ-opioid receptor antagonist) was administered and she had a rapid return of bowel function with no signs of ileus. Alvimopan, has been shown to reduce the rate of ileus in colorectal surgery patients, and may be useful for preventing ileus in high-risk orthopedic and spine surgery patients, although prospective studies will be needed to test this hypothesis.

Sexual and Reproductive Function in Spinal Cord Injury and Spinal Surgery Patients

Sexual and reproductive health is important quality of life outcomes, which can have a major impact on patient satisfaction. Spinal pathology arising from trauma, deformity, and degenerative disease processes may be detrimental to sexual and reproductive function. Furthermore, spine surgery may impact sexual and reproductive function due to post-surgical mechanical, neurologic, and psychological factors. The aim of this paper is to provide a concise evidence-based review on the impact that spine surgery and pathology can have on sexual and reproductive function. A review of published literature regarding sexual and reproductive function in spinal injury and spinal surgery patients was performed. We have found that sexual and reproductive dysfunction can occur due to numerous etiological factors associated with spinal pathology. Numerous treatment options are available for those patients, depending on the degree of dysfunction. Spine surgeons and non-operative healthcare providers should be aware of the issues surrounding sexual and reproductive function as related to spine pathology and spine surgery. It is important for spine surgeons to educate their patients on the operative risks that spine surgery encompasses with regard to sexual dysfunction, although current data examining these topics largely consists of level IV data.

Subtle anterior subtalar dislocation

Subtalar dislocations are uncommon injuries, and anterior subtalar dislocations are extremely rare. Only 7 cases have been reported in detail in the literature, but all were associated with substantial displacement immediately apparent on radiographs. We report a case of a subtle anterior subtalar dislocation that was missed on initial plain films but was subsequently treated successfully with closed reduction.

Adult Spinal Deformity: Contemporary Treatment and Patient Outcomes

The incidence of symptomatic adult spinal deformity (ASD) is increasing due to aging of the population, iatrogenic factors, and an increasingly active elderly population. Spinal deformity in the adult population can produce major functional disability. Patients with less severe forms of ASD can generally be managed without operative intervention. For those individuals with disabling pain, functional impairment, or progressive spinal malalignment, surgical treatment is available and effective. However, the surgery is complex and associated with a significant risk of perioperative complications. Efficacy and safety is optimal when operative intervention is performed by a surgical team (and hospital system) experienced in the management of complex spinal pathology. Quality of life for the ASD patient can be greatly improved with proper patient selection, technical execution, and perioperative care.

Complications associated with prone positioning in elective spinal surgery

Complications associated with prone surgical positioning during elective spine surgery have the potential to cause serious patient morbidity. Although many of these complications remain uncommon, the range of possible morbidities is wide and includes multiple organ systems. Perioperative visual loss (POVL) is a well described, but uncommon complication that may occur due to ischemia to the optic nerve, retina, or cerebral cortex. Closed-angle glaucoma and amaurosis have been reported as additional etiologies for vision loss following spinal surgery. Peripheral nerve injuries, such as those caused by prolonged traction to the brachial plexus, are more commonly encountered postoperative events. Myocutaneous complications including pressure ulcers and compartment syndrome may also occur after prone positioning, albeit rarely. Other uncommon positioning complications such as tongue swelling resulting in airway compromise, femoral artery ischemia, and avascular necrosis of the femoral head have also been reported. Many of these are well-understood and largely avoidable through thoughtful attention to detail. Other complications, such as POVL, remain incompletely understood and thus more difficult to predict or prevent. Here, the current literature on the complications of prone positioning for spine surgery is reviewed to increase awareness of the spectrum of potential complications and to inform spine surgeons of strategies to minimize the risk of prone patient morbidity.

The Current State of United States Spine Surgery Training: A Survey of Residency and Spine Fellowship Program Directors

STUDY DESIGN

Program director survey.

OBJECTIVES

To collect data on spine surgical experience during orthopedic and neurological surgery residency and assess the opinions of program directors (PDs) from orthopedic and neurological surgery residencies and spine surgery fellowships regarding current spine surgical training in the United States.

SUMMARY OF BACKGROUND DATA

Current training for spine surgeons in the United States consists of a residency in either orthopedic or neurological surgery followed by an optional spine surgery fellowship. Program director survey data may assist in efforts to improve contemporary spine training.

METHODS

An anonymous questionnaire was distributed to all PDs of orthopedic and neurological surgery residencies and spine fellowships in the United States (N = 382). A 5-point Likert scale was used to assess attitudinal questions. A 2-tailed independent-samples t test was used to compare responses to each question independently.

RESULTS

A total of 147 PDs completed the survey. Orthopedic PDs most commonly indicated that their residents participate in 76 to 150 spine cases during residency, whereas neurological surgery PDs most often reported more than 450 spine cases during residency (p < .0001). Over 88% of orthopedic surgery program directors and 0% of neurological surgery PDs recommended that their trainees complete a fellowship if they wish to perform community spine surgery (p < .001). In contrast, 98.1% of orthopedic PDs and 86.4% of neurological surgery PDs recommended that their trainees complete a fellowship if they wish to perform spinal deformity surgery (p = .038). Most PDs agreed that surgical simulation and competency-based training could improve spine surgery training (76% and 72%, respectively).

CONCLUSIONS

This study examined the opinions of orthopedic and neurological surgery residency and spine fellowship PDs regarding current spine surgery training in the United States. A large majority of PDs thought that both orthopedic and neurological surgical trainees should complete a fellowship if they plan to perform spinal deformity surgery. These results provide a background for further efforts to optimize contemporary spine surgical training.

Atraumatic avulsion of the distal iliopsoas tendon: an unusual cause of hip pain

While uncommon, isolated avulsion fractures of the lesser trochanter occur in children and adolescents prior to the fusion of this apophysis as a result of athletic activities. In the elderly, isolated fractures of the lesser trochanter are rare but can occur as a result of trauma. They have been identified in patients with primary or secondary bone malignancies, which were previously considered pathognomonic for metastatic disease. In the absence of trauma, weakening of the bone due to systemic disorders such as osteoporosis or osteomalacia chronica renal failure may also be responsible. Diagnosis may be difficult with physical examination and radiographs alone. This case report details this rare fracture in 2 patients suffering from debilitating chronic disease. Patient 1 was a 30-year-old woman with an 18-year history of type 1 diabetes mellitus, a 6-year history of end-stage renal disease, hypertension, hypothyroidism, peripheral vascular disease, and a 3-year history of systemic lupus erythematosus with antiphospholipid syndrome treated with warfarin. Patient 2 was a 66-year-old woman with a history of type 2 diabetes mellitus, peripheral neuropathy, obesity, chronic obstructive pulmonary disease, gout, hypertension, and chronic neck and low back pain. Both were assessed with magnetic resonance imaging following physical examination, which revealed atraumatic avulsion of the distal iliopsoas tendon from the lesser trochanter. Following retraction of the iliopsoas tendon, the patients were treated with conservative therapy and anti-inflammatory medication. These 2 cases broaden the range of patients for whom spontaneous avulsion of the distal iliopsoas tendon should be considered in the differential diagnosis.