Modified Clavien-Dindo-Sink Classification System for operative complications in adult spine surgery

OBJECTIVE

Currently there is no standardized mechanism to describe or compare complications in adult spine surgery. Thus, the purpose of the present study was to modify and validate the Clavien-Dindo-Sink complication classification system for applications in spine surgery.

METHODS

The Clavien-Dindo-Sink complication classification system was evaluated and modified for spine surgery by four fellowship-trained spine surgeons using a consensus process. A distinct group of three fellowship-trained spine surgeons completed a randomized electronic survey grading 71 real-life clinical case scenarios. The survey was repeated 2 weeks after its initial completion. Fleiss' and Cohen's kappa (κ) statistics were used to evaluate interrater and intrarater reliabilities, respectively.

RESULTS

Overall, interobserver reliability during the first and second rounds of grading was excellent with a κ of 0.847 (95% CI 0.785-0.908) and 0.852 (95% CI 0.791-0.913), respectively. In the first round, interrater reliability ranged from good to excellent with a κ of 0.778 for grade I (95% CI 0.644-0.912), 0.698 for grade II (95% CI 0.564-0.832), 0.861 for grade III (95% CI 0.727-0.996), 0.845 for grade IV-A (95% CI 0.711-0.979), 0.962 for grade IV-B (95% CI 0.828-1.097), and 0.960 for grade V (95% CI 0.826-1.094). Intraobserver reliability testing for all three independent observers was excellent with a κ of 0.971 (95% CI 0.944-0.999) for rater 1, 0.963 (95% CI 0.926-1.001) for rater 2, and 0.926 (95% CI 0.869-0.982) for rater 3.

CONCLUSIONS

The Modified Clavien-Dindo-Sink Classification System demonstrates excellent interrater and intrarater reliability in adult spine surgery cases. This system provides a useful framework to better communicate the severity of spine-related complications.

Can Artificial Intelligence Improve the Readability of Patient Education Materials?

BACKGROUND

The recommended readability of online health education materials is at or below the sixth- to eighth-grade level. Nevertheless, more than a decade of research has demonstrated that most online education materials pertaining to orthopaedic surgery do not meet these recommendations. The repeated evidence of this limited progress underscores that unaddressed barriers exist to improving readability, such as the added time and cost associated with writing easily readable materials that cover complex topics. Freely available artificial intelligence (AI) platforms might facilitate the conversion of patient-education materials at scale, but to our knowledge, this has not been evaluated in orthopaedic surgery.

QUESTIONS/PURPOSES

(1) Can a freely available AI dialogue platform rewrite orthopaedic patient education materials to reduce the required reading skill level from the high-school level to the sixth-grade level (which is approximately the median reading level in the United States)? (2) Were the converted materials accurate, and did they retain sufficient content detail to be informative as education materials for patients?

METHODS

Descriptions of lumbar disc herniation, scoliosis, and spinal stenosis, as well as TKA and THA, were identified from educational materials published online by orthopaedic surgery specialty organizations and leading orthopaedic institutions. The descriptions were entered into an AI dialogue platform with the prompt "translate to fifth-grade reading level" to convert each group of text at or below the sixth-grade reading level. The fifth-grade reading level was selected to account for potential variation in how readability is defined by the AI platform, given that there are several widely used preexisting methods for defining readability levels. The Flesch Reading Ease score and Flesch-Kincaid grade level were determined for each description before and after AI conversion. The time to convert was also recorded. Each education material and its respective conversion was reviewed for factual inaccuracies, and each conversion was reviewed for its retention of sufficient detail for intended use as a patient education document.

RESULTS

As presented to the public, the current descriptions of herniated lumbar disc, scoliosis, and stenosis had median (range) Flesch-Kincaid grade levels of 9.5 (9.1 to 10.5), 12.6 (10.8 to 15), and 10.9 (8 to 13.6), respectively. After conversion by the AI dialogue platform, the median Flesch-Kincaid grade level scores for herniated lumbar disc, scoliosis, and stenosis were 5.0 (3.3 to 8.2), 5.6 (4.1 to 7.3), and 6.9 (5 to 7.8), respectively. Similarly, descriptions of TKA and THA improved from 12.0 (11.2 to 13.5) to 6.3 (5.8 to 7.6) and from 11.6 (9.5 to 12.6) to 6.1 (5.4 to 7.1), respectively. The Flesch Reading Ease scores followed a similar trend. Seconds per sentence conversion was median 4.5 (3.3 to 4.9) and 4.5 (3.5 to 4.8) for spine conditions and arthroplasty, respectively. Evaluation of the materials that were converted for ease of reading still provided a sufficient level of nuance for patient education, and no factual errors or inaccuracies were identified.

CONCLUSION

We found that a freely available AI dialogue platform can improve the reading accessibility of orthopaedic surgery online patient education materials to recommended levels quickly and effectively. Professional organizations and practices should determine whether their patient education materials exceed current recommended reading levels by using widely available measurement tools, and then apply an AI dialogue platform to facilitate converting their materials to more accessible levels if needed. Additional research is needed to determine whether this technology can be applied to additional materials meant to inform patients, such as surgical consent documents or postoperative instructions, and whether the methods presented here are applicable to non-English language materials.

Reported Events Associated With Spine Robots: An Analysis of the Food and Drug Administration's Manufacturer and User Facility Device Experience Database

STUDY DESIGN

Cross-Sectional Analysis.

OBJECTIVES

To summarize medical device reports (MDRs) between August 1, 2017 and November 30, 2021 relating to robot-assisted spine systems within the Manufacturer and User Facility Device Experience (MAUDE) database maintained by The Food and Drug Administration (FDA).

METHODS

The MAUDE database was abstract for all MDRs relating to each FDA-approved robot-assisted spine system. Event descriptions were reviewed and characterized into specific event types. Outcome measures include specific robot-assisted spine systems and reported events as detailed by the MDRs. All data is de-identified and in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

RESULTS

There were 263 MDRs consisting of 265 reported events. Misplaced screws represented 61.5% (n = 163) of reported events. Of the 163 reported events, 57.1% (n = 93) described greater than 1 misplaced screw, 15.3% (n = 25) required return to the operating room, 8.6% (n = 14) resulted in neurologic injury, 4.3% (n = 7) resulted in dural tear, and 1.2% (n = 2) resulted in hemorrhage or bleeding. Reported events other than misplaced screws included system imprecision detected prior to screw placement (58/265, 21.9%), mechanical failure (23/265, 8.7%), and software failure (18/265, 6.8%).

CONCLUSIONS

As more robot-assisted spine systems gain FDA approval and the adoption of these systems continues to grow, documenting and understanding the range of reported events associated with each "tool" is imperative to balancing patient safety with surgical innovation. This study of the MAUDE database provides a unique summary of reported events associated with robot-assisted spine systems that is not directly linked to a research setting.

Does Publication History Predict Future Publication Output in Orthopaedics?

Background

The number of publications is widely used as a measure of academic productivity in the field of orthopaedics. How “productive” a physician is has a great influence on consideration for employment, compensation, and promotions. Predictors of potential high-output researchers would be of value to the orthopaedic department and university leadership for new faculty evaluation.

Methods

The study population included orthopaedic faculty from the top 10 orthopaedic institutions in the United States. Their names and the number of publications at each point in their training (medical school, residency, and fellowship) and early career (first five and 10 years following fellowship) along with a total number of publications to date were collected by using PubMed.

Results

Strong correlations were seen between publications during total training and publications output in the first five years following fellowship (r_s=0.717, P<0.0001). However, no significant correlations were found comparing publications during each stage of training and the first 10 years following fellowship. A moderate positive correlation was found when comparing publications during medical school and residency output (r_s=0.401, P<0.0001).

Conclusions

The data presented here may be utilized by department chairs during the evaluation of faculty and candidates to not interpret the number of publications during training and early career as a gauge of research interest and potential for future publications. Program directors may also use the only moderate correlation between publications in medical school and residency when evaluating applications as support of a more holistic review of applicants to determine research interest.

Quantifying Dysfunction of the Lumbar Multifidus Muscle After Radiofrequency Neurotomy and Fusion Surgery: A Preliminary Study

The multifidus is an important muscle for the active stabilization of the spine. Unfortunately, clinical procedures such as posterior lumbar fusion (PLF) and radio frequency neurotomy (RFN) cause injury to these muscles affecting their function. However, evaluating multifidus function using traditional biomechanical methods is challenging due to its unique anatomical features. The change in muscle shear modulus during contraction has been corrected to force generation for several skeletal muscles. Therefore, the change in shear modulus can be used to quantify muscle contraction. The objective of this study was to evaluate multifidus dysfunction by comparing changes in shear modulus during muscle contraction in healthy individuals and patients who received RFN and PLF in the lumbar spine. We used our recently developed protocol which consists of measuring changes of multifidus shear modulus at lying prone, sitting up, and sitting up with the arms lifted. In healthy individuals, the median multifidus shear modulus increased progressively from prone, sitting, and sitting with arms raised: 18.55 kPa, 27.14 kPa, and 38.45 kPa, respectively. A moderate increase in shear modulus for these body positions was observed in PLF patients: 9.81 kPa, 17.26 kPa, and 21.85 kPa. In RFN patients, the shear modulus remained relatively constant: 14.44 kPa, 16.57 kPa, and 17.26 kPa. Overall, RFN and PLF caused a reduction in the contraction of multifidus muscles. However, the contraction of multifidus muscle slightly increased during multifidus activation in PLF patients, while it did not change in RFN patients. These preliminary measurements suggest that the proposed protocol using SWE can provide important information about the function of individual spine muscles to guide the design and evaluation of postsurgical rehabilitation protocols.

Factors in Residency Decision Making for Female Neurosurgery Applicants

BACKGROUND

Neurosurgery remains a specialty with one of the largest gender gaps in the United States. Neurosurgery residency programs are highly motivated to attract the best female candidates in an effort to improve their program diversity, but no studies currently exist that examine the factors of highest importance to female applicants for neurosurgery residency selection. The purpose of this study was to determine factors that female neurosurgery residents used when selecting their residency.

METHODS

A 2-part survey was sent to female neurosurgical residents by e-mails collected from the American Association of Neurological Surgeons directory and residency program websites. The survey asked participants to score 17 characteristics of residency programs in terms of importance and then asked them to rank their top 5 most influential factors when selecting a neurosurgery residency.

RESULTS

The most important factors included variety/number of cases, camaraderie and happiness of current residents, early surgical/clinical experience, and academic reputation. The least important factors included gender diversity of faculty and residents, number of female residents, number of female faculty, and attitudes toward maternity leave.

CONCLUSIONS

Efforts to increase female applicants in neurosurgery residency programs should focus on highlighting some more universal, non-gender-related factors, such as happiness and camaraderie among residents and anticipated clinical experiences, as opposed to showcasing features that would seemingly appeal to female applicants, such as maternity leave and number of current female faculty or residents.

Surgical site infection in high-energy peri-articular tibia fractures with intra-wound vancomycin powder: a retrospective pilot study

BACKGROUND

Surgical site infections (SSI) continue to be a significant source of morbidity despite the introduction of perioperative intravenous antibiotics. Our objective was to assess the efficacy of local vancomycin powder on lowering deep SSI rates in high-energy tibial plateau and pilon fractures.

MATERIALS AND METHODS

A retrospective review of all tibial plateau and pilon fractures treated in 2012 at our level I trauma center identified 222 patients. Of these, 107 patients sustained high-energy injuries that required staged fixation, and 93 had minimum 6 month follow-up. Ten patients received 1 gram vancomycin powder directly into the surgical wound at the time of definitive fixation, and the remaining 83 patients served as controls. SSI was defined according to criteria from the Centers for Disease Control. Demographic data, patient comorbidities, injury and treatment details, and infection details were recorded. Descriptive and comparative statistics were performed.

RESULTS

Amongst the vancomycin powder group, 1 patient (10 %) developed a deep SSI; in the control group, 14 (16.7 %) developed deep SSI. The rate of deep SSI between the groups was not statistically significantly different (P = 1.0). The groups were statistically similar with regard to injuries, treatment, comorbidities, and infectious outcomes (P values range = 0.06-1.0).

CONCLUSIONS

The application of local vancomycin powder into surgical wounds of high-energy tibial plateau and pilon fractures did not reduce the rate of deep SSI in this retrospective review. There is a need to find effective, cheap, and widely available methods for prevention of SSI. Basic science and larger prospective clinical studies are needed to further delineate the role of local vancomycin powder as a modality to reduce deep SSI in extremity trauma.

Single and Dual-Incision Fasciotomy of the Lower Leg

Introduction

Compartment syndrome of the leg is an orthopaedic emergency and can be treated with single or dual-incision fasciotomy, allowing for necessary decompression of all four compartments.

Step 1 Single-Incision Technique Position the Patient

Place the patient supine with a bump underneath the ipsilateral buttock.

Step 2 Single-Incision Technique Make the Skin Incision

An incision centered over the posterolateral aspect of the leg provides access to all four compartments of the leg.

Step 3 Single-Incision Technique Decompress the Superficial Posterior Lateral and Anterior Compartments

Make longitudinal fascial incisions, approximately the length of the skin incision, in the superficial posterior, lateral, and then anterior compartments.

Step 4 Single-Incision Technique Decompress the Deep Posterior Compartment

Using the lateral intermuscular septum as a guide to reach the posterolateral aspect of the fibula, release the fascial attachment of the deep posterior compartment from the fibula.

Step 5 Single-Incision Technique Postoperative Protocol

After appropriate operative fixation and/or debridement of nonviable tissue, dress the wounds with a VAC device.

Step 1 Dual-Incision Technique Position the Patient

Position the patient, administer antibiotics, and prepare and drape the limb as described in Step 1 for the single-incision technique.

Step 2 Dual-Incision Technique Make the Anterolateral Skin Incision

Make an incision centered over the anterolateral aspect of the leg to provide access to the anterior and lateral compartments of the leg.

Step 3 Dual-Incision Technique Decompress the Anterior and Lateral Compartments

Make a longitudinal fascial incision in the anterior compartment anterior to the intermuscular septum and a separate longitudinal incision for decompression of the lateral compartment posterior to the intermuscular septum.

Step 4 Dual-Incision Technique Make the Posteromedial Skin Incision

Make an incision centered over the posteromedial aspect of the leg to provide access to the superficial and deep posterior compartments of the leg.

Step 5 Dual-Incision Technique Decompress the Superficial and Deep Posterior Compartments

Through the posteromedial skin incision, identify both the deep and the superficial posterior compartments and incise their fascia longitudinally for adequate decompression.

Step 6 Dual-Incision Technique Postoperative Protocol

Follow the same postoperative protocol as outlined in Step 5 for the single-incision technique.

Results

Both the single and the dual-incision techniques are effective for relieving elevated intracompartmental pressures to prevent myonecrosis.IndicationsContraindicationsPitfalls & Challenges.

Fibrinolysis is essential for fracture repair and prevention of heterotopic ossification

Bone formation during fracture repair inevitably initiates within or around extravascular deposits of a fibrin-rich matrix. In addition to a central role in hemostasis, fibrin is thought to enhance bone repair by supporting inflammatory and mesenchymal progenitor egress into the zone of injury. However, given that a failure of efficient fibrin clearance can impede normal wound repair, the precise contribution of fibrin to bone fracture repair, whether supportive or detrimental, is unknown. Here, we employed mice with genetically and pharmacologically imposed deficits in the fibrin precursor fibrinogen and fibrin-degrading plasminogen to explore the hypothesis that fibrin is vital to the initiation of fracture repair, but impaired fibrin clearance results in derangements in bone fracture repair. In contrast to our hypothesis, fibrin was entirely dispensable for long-bone fracture repair, as healing fractures in fibrinogen-deficient mice were indistinguishable from those in control animals. However, failure to clear fibrin from the fracture site in plasminogen-deficient mice severely impaired fracture vascularization, precluded bone union, and resulted in robust heterotopic ossification. Pharmacological fibrinogen depletion in plasminogen-deficient animals restored a normal pattern of fracture repair and substantially limited heterotopic ossification. Fibrin is therefore not essential for fracture repair, but inefficient fibrinolysis decreases endochondral angiogenesis and ossification, thereby inhibiting fracture repair.

How often are interfacility transfers of spine injury patients truly necessary?

BACKGROUND CONTEXT

Traumatic spine injuries are often transferred to regional tertiary trauma centers from outside hospitals (OSHs) and subsequently discharged from the trauma center's emergency department (ED) suggesting secondary overtriage of such injuries.

PURPOSE

The aim of the study was to investigate the definitive treatment and disposition of traumatic spine injuries transferred from OSH, particularly those without other trauma injuries or neurologic symptoms.

STUDY DESIGN

This was a retrospective study.

PATIENT SAMPLE

Adult patients presenting to a single Level 1 trauma center with spine injuries were included.

OUTCOME MEASURES

The outcome measures considered in the study were appropriateness of transfer, treatment, and cost.

METHODS

Four thousand five-hundred consecutive adult patients presenting to a single Level 1 trauma center with spine injuries (isolated or polytrauma) were reviewed. This consisted of 1,427 patients (32%) transferred from an OSH ED. All OSH, emergency medical services, and receiving institution (RI) patient records and imaging were reviewed.

RESULTS

Patients who were neurologically intact, nonpolytrauma, and without critical medical issues at the OSH (isolated intact spine transfers) comprised 29% of transfers. Helicopters transported 13% of these patients. The most frequent injuries were compression (26%), burst (17%), and transverse process (10%) fractures. Seventy-eight percent were discharged directly from the RI's ED. Similarly, 15% were not given any formal treatment, 13% had surgery, and 72% given orthosis treatment. The average cost for transportation and ED costs for those discharged from the RI ED were $1,863 and $12,895, respectively. Of the isolated intact spine transfers, 42% were considered to be inappropriate to warrant transfer. This was defined as those sent from an OSH with an orthopedic or neurosurgeon on staff and clearly stable injuries with minimal chance of progressing to instability. Isolated intact spine transfers whose OSH spine imaging was not considered unstable was 25% of transfers with a helicopter used to transport 14% of these patients. Eighty-seven percent were discharged from the ED, whereas only 3% went onto surgery.

CONCLUSIONS

This study is the first to investigate interfacility transfers with spine injuries and found high rate of secondary overtriage of neurologically intact patients with isolated spine injuries. Potential solutions include increasing spine coverage in community EDs, increasing direct communication between the OSH and the spine specialist at the tertiary center, and utilization of teleradiology.

Well-leg positioning on a fracture table: using a pillow sling

Although rare, acute compartment syndrome remains a well-reported complication of the lithotomy position. The avoidable nature of this potentially devastating complication has led many surgeons to forgo this well-leg setup when using the fracture table, and instead place the uninjured limb into a scissored position. In this report, we describe a safe and efficient technique for positioning the well leg in a scissored position on the fracture table using a pillow and a self-adherent compression bandage. With this positioning method for the uninjured limb, an optimal amount of relaxed hip and knee extension, and limb adduction to midline along the table's support bar, is reliably achieved to permit lateral fluoroscopic imaging of the injured limb without overlap of the well leg or interference with C-arm positioning.

Utility of Postoperative Radiographs for Pediatric Scoliosis: Association Between History and Physical Examination Findings and Radiographic Findings

BACKGROUND

Postoperative radiographs are routinely obtained following surgery for the correction of scoliosis in pediatric patients. The purpose of this study was to comprehensively evaluate the utility of obtaining routine postoperative radiographs in the management of these patients.

METHODS

A total of 1969 clinic notes and corresponding radiographs regarding 451 consecutive patients with scoliosis (age range, ten to eighteen years) who had surgical correction over a ten-year period at a single institution were retrospectively reviewed. Curve etiology, preoperative curve characteristics, and surgical procedures performed were recorded. All postoperative clinic notes and radiographs were reviewed for abnormalities and changes in treatment course. It was then determined whether clinical signs and symptoms and/or abnormal radiographic findings led to a change in treatment course, which was defined as a therapeutic intervention or further diagnostic testing.

RESULTS

Of the 451 patients in this study (average age [and standard deviation], 14.7 ± 2.4 years), 72.5% had adolescent idiopathic scoliosis, 23.3% had neuromuscular scoliosis, and 4.2% had other underlying causes of scoliosis. A change in treatment course occurred in the cases of forty-two patients, all of whom had symptomatic findings on postoperative history and physical examination and only fifteen of whom had supportive abnormal findings on postoperative radiographs. Curve etiology and surgical procedures performed had no impact on radiographic utility. A significant increase in utility was seen for radiographs obtained at visits one year or more following surgery compared with those obtained at visits less than one year following surgery (1.7% compared with 0.3%, p = 0.001). The overall sensitivity, specificity, positive predictive value, and negative predictive value of routine postoperative radiographs in guiding treatment course were 35.7%, 98.1%, 28.8%, and 98.6%, respectively.

CONCLUSIONS

Routine radiographs provide low utility in guiding the course of treatment for asymptomatic pediatric patients following surgery for scoliosis. The results of this study suggest that patient or caregiver complaints, comorbidities, and clinical suspicion should be considered before obtaining radiographs at postoperative visits in order to minimize radiation exposure in pediatric patients and reduce medical costs without compromising care.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bupivacaine for pain reduction after iliac crest bone graft harvest

Iliac crest bone graft remains the gold standard in achieving spinal arthrodesis, but chronic pain from graft harvest occurs in up to 39% of patients. Studies have shown that a single administration of local anesthetic reduces short-term pain, but they have not adequately investigated possible longer-term benefits. The goal of this study was to determine whether local administration of bupivacaine after iliac crest bone graft harvesting reduces pain and improves patient-reported outcomes. In this prospective, randomized, controlled, and blinded clinical study, 40 patients were identified who underwent posterior spine fusion with iliac crest bone graft and were randomized to receive either bupivacaine (treatment group, n=20) or saline (control group, n=20) at the iliac crest bone graft site. Pain at the harvest site was determined by a series of 12 visual and numeric pain scale assessments. Short Form-12 mental and physical component scores, EuroQol-5D, and Oswestry Disability Index assessments were made, along with determination of patient satisfaction and self-reported outcome of surgery. Baseline pain and outcome assessments were statistically similar (P>.05). Average pain scores were lower for all 12 assessments in the treatment group at mean follow-up of 5 weeks (significant differences in 6 assessments) and 20 weeks (significant differences in 2 assessments). No significant differences were found in Short Form-12 and EuroQol-5D scores. For patients who underwent lumbar fusion, the treatment group had significantly improved Oswestry Disability Index scores (mean±SD=10.8±7.1 vs 18.7±5.9, P=.012). Significantly more patients in the treatment group reported that surgery met all expectations (90% vs 50%, P=.016). This study is the 1st to show that a single administration of bupivacaine at the iliac crest bone graft harvest site during posterior spine fusion surgery can result in improved outcomes and reduced pain far beyond the anesthetic duration of activity.

Is it safe to place a tibial intramedullary nail through a traumatic knee arthrotomy?

We conducted a study to compare postoperative infection and nonunion rates in tibial intramedullary nails (IMNs) placed through either uninjured knees or traumatic knee arthrotomies (KAs). We reviewed all adult tibial diaphyseal fractures (n = 1378) treated with an IMN between 1998 and 2010. Fourteen of these nails were placed through a traumatic KA. Each patient in the study group was assigned 4 separate matched controls for comparison. Controls were matched on age, sex, diabetes, smoking, and fracture classification (closed or open with Gustilo-Anderson). There were no postoperative infections (knee or fracture site) in the traumatic KA group and 2 (3.5%) in the control group (P = .473). One nonunion (7.1%) was noted in the traumatic KA group, and 9 (16%) were noted in the control group (P = .6694). To our knowledge, this is the first study to report outcomes of placing tibial IMNs through traumatic KAs. In our sample, the practice presented no increased risk either for infection (at the knee or the fracture site) or for nonunion with appropriate surgical debridement.

Tibia-based referencing for standard proximal tibial radiographs during intramedullary nailing

Limited information exists to define standard tibial radiographs. The purpose of this study was to define new landmarks on the proximal tibia for standard anteroposterior and lateral radiographs. In 10 cadaveric knees, fibular head bisection was considered the anteroposterior image, and femoral condyle overlap the lateral image. In another 10 knees, a "twin peaks" anteroposterior view, showing the sharpest profile of the tibial spines, was used. The "flat plateau" lateral image was obtained by aligning the femoral condyles then applying a varus adjustment with overlap of the tibial plateaus. Medial peritendinous approaches were performed, and an entry reamer used to open the medullary canal. A priori analysis showed good to excellent intra-/inter-observer reliability with the new technique (intra-class correlation coefficient ICC 0.61-0.90). The "twin peaks" anteroposterior radiograph was externally rotated 2.7±2.1° compared to the standard radiograph with fibular head bisection. Portal position and incidence of damage to intra-articular structures did not significantly differ between groups (P>.05). The "twin peaks" anteroposterior view and "flat plateau" lateral view can safely be used for nail entry portal creation in the anatomic safe zone. Tibia-based radiographic referencing is useful for intramedullary nailing cases in which knee or proximal tibiofibular joint anatomy is altered.

One-year mortality after isolated pelvic fractures with posterior ring involvement in elderly patients

Previous 1-year mortality studies of pelvic fractures in elderly patients have focused on pubic rami fractures, in elderly patients with multiple injuries, or both. Baseline information on the 1-year mortality of isolated pelvic fractures in elderly patients is unavailable. The purpose of this study was to evaluate the 1-year mortality of elderly patients (aged 60 years or older) after isolated pelvic fractures with posterior ring involvement (Orthopaedic Trauma Association type 61-B and C). All patients aged 60 years or older treated for pelvic injuries at a single Level I trauma center over a 12-year period were retrospectively reviewed (N=1223). Exclusion criteria were associated injuries to other body systems (Abbreviated Injury Scale greater than 2), ballistic injuries, long bone fractures, concurrent acetabular fractures, and type 61-A fractures or isolated pubic rami fractures without posterior involvement. Mortality data were obtained from the Social Security Death Index. Seventy patients met the inclusion criteria. Patients treated nonoperatively were significantly older compared with those treated operatively. However, the Charlson Comorbidity Index did not significantly differ between treatment groups. A significantly higher percentage of type-B fractures (83.0%) were treated nonoperatively compared with type-C fractures, which were treated operatively 88.2% of the time. Mortality rates at 3 and 6 months and 1 year postoperatively were 7.1%, 11.4%, and 12.9%, respectively. These results suggest that the 1-year mortality rates of isolated pelvic fractures in elderly patients are lower than those reported previously for hip fractures and pelvic fractures with concurrent injuries. Although age was identified as a significant variable differing between patients treated operatively vs nonoperatively, comorbidities were not.

Implant contamination during spine surgery

BACKGROUND CONTEXT

Postoperative spine infections have been reported to occur in 1% to 15% of patients and subsequently lead to significant morbidity and cost, with an elevated risk for instrumented cases. Every effort should be made to minimize the risk of intraoperative wound contamination. Consequently, certain practices are followed in the operating room to prevent contamination, many of which are not evidence based. Conversely, certain objects believed to be sterile are frequently overlooked as potential sources of contamination.

PURPOSE

To assess to what degree contamination of spinal implants occurs during spine surgery and evaluate whether coverage of implants alters the rate of contamination.

STUDY DESIGN

Prospective study.

STUDY SAMPLE

This study included 105 consecutive noninfection surgical cases performed by a single spine surgeon that required the use of instrumentation.

OUTCOME MEASURE

Spinal implant contamination.

METHODS

Cases were randomized to have all implant trays either remain uncovered (n=54) or covered (n=51) with sterile surgical towels on opening until implants were required for the case. After the last implant was placed, a sterile culture swab was used to obtain a sample from all open implants that had been present at the start of the case. The paper outer wraps of the implant trays were sampled in each case as a positive control, and an additional 105 swabs were capped immediately after they were opened to obtain negative controls. Swab samples were assessed for bacterial growth on 5% sheep blood Columbia agar plates. Of note, only departmental funding was used and no applicable financial relationships exist with any author.

RESULTS

No growth was observed on any of the 105 negative controls, whereas 99.1% of positive controls demonstrated obvious contamination. Cultures from implant samples demonstrated a 9.5% overall rate of contamination with 2.0% (n=1) of covered implants versus 16.7% (n=9) of uncovered implants demonstrating contamination. Length of time implant trays were open before sample collection; implant type (plate, rods, vs. polyetheretherketone), number of scrubbed personnel, and number of implants used were all not found to be significantly associated with implant contamination (p>.05). However, coverage of implants was found to significantly reduce the implant contamination rate (p=.016).

CONCLUSIONS

The contamination of sterile implants during spine surgery was found to occur. However, this contamination was independent of the amount of time the implant trays remained open. Coverage of implants significantly reduces this contamination. Therefore, no matter the expected duration of a case, implant coverage is a simple modifiable way to reduce the risk of intraoperative wound contamination and potentially reduce postoperative infections.

Whole-body vibration: is there a causal relationship to specific imaging findings of the spine?

STUDY DESIGN

Systematic review.

OBJECTIVE

To perform a systematic review of the available literature for those studies that evaluated the role of whole-body vibration (WBV) on the spine, using imaging modalities as well as an estimation of WBV exposure.

SUMMARY OF BACKGROUND DATA

Numerous comparative studies have reported a possible association between the occurrence of spinal symptoms and exposure to WBV. These exposures have commonly been examined in the work environment largely through self-reported questionnaires only. From a scientific perspective, the majority of studies emphasize symptoms and lack objective medical evidence, such as spinal imaging, to help establish a specific spinal disorder. Because both neck and low back pain comprise symptoms that can arise from a host of factors including age, a casual link between spinal disorders and WBV cannot be affirmed.

METHODS

MEDLINE and EMBASE were searched for studies related to WBV and spinal symptoms, diagnosis, and/or disorders. Our searches were limited to studies published prior to August 2011. The resulting 700 citations (after excluding 354 duplicates) were then screened by 3 independent reviewers on the basis of the following predetermined inclusion and exclusion criteria: inclusion-clinical studies with imaging evaluation (radiographs, computed tomographic scans, and/or magnetic resonance images) and documented WBV exposure (occupation, amount of WBV, and/or duration); exclusion-reliance solely on self-reporting of symptoms (neck pain, low back pain, and/or sciatica), those articles based on a clinical diagnosis without use of imaging, and in vitro/animal/biomechanical studies.

RESULTS

Only 7 studies met the inclusion criteria for this systematic review. Included were 5 retrospective cohort and 2 cross-sectional studies. Although mixed results and conclusions were found, the majority of studies did not identify an association between WBV exposure and an abnormal spinal imaging finding indicating damage of the spine. We should also stress that each included study has limitations secondary to quantifying WBV exposure accurately, both as a single encounter and as a total exposure over years.

CONCLUSION

Based on our results from this systematic review, no causality can be shown between WBV and abnormal spinal imaging findings. With the conflicting data available in the literature, WBV has not been established as a cause for objective spinal pathological changes on a scientific basis.

Postoperative infections of the spine

The incidence of postoperative infections after spinal surgery ranges from less than 1% to 15%. This rate can vary based on several surgical- and patient-related risk factors, such as the type and duration of the procedure, nutritional status, immunosuppression, and comorbidities of the patient. Most surgeons routinely administer intravenous antibiotics prophylactically, and may employ other measures in an effort to prevent postoperative infection. Multiple diagnostic modalities, in conjunction with examination findings, should be utilized in the assessment of possible postoperative spinal infections. In particular, wound discharge or erythema, and an elevation in the erythrocyte sedimentation rate and C-reactive protein beyond expected postoperative values should raise a clinician's level of suspicion for an infection. The diagnosis of a postoperative spine infection can be difficult to confirm with diagnostic imaging, given findings are not all that different from normal postoperative changes. When suspected, the preferred treatment for a postoperative spinal infection is open irrigation and aggressive debridement of all necrotic tissue and bone, followed by antibiotic treatment based on culture sensitivity.

Oblique radiographs compared favorably with computed tomography images in assessing cervical foraminal area

Oblique radiographs are often ordered to evaluate the patency of cervical intervertebral foramina. Previous studies have shown that computed tomography (CT) provides accurate measurements of foraminal dimensions. Up until now, no study has directly compared the diagnostic utility of oblique radiographs and CT. We conducted a study to quantify the correlation between cervical foramina dimensions measured on oblique radiographs and on CT scans. Heights, widths, and cross-sectional areas were evaluated at every level from C2-C3 through C7-T1 using both oblique radiographs and oblique CT reconstructions. Both measurements were performed at a 50% oblique angle. Interreliability and intrareliability statistics for radiographs and CT were 0.91 and 0.99 for height, 0.90 and 0.97 for width, and 0.84 and 0.92 for area. Pearson correlation coefficients for height, width, and area were 0.439, 0.871, and 0.899, respectively. Oblique radiographs of the cervical spine provide accurate estimates of intervertebral foraminal dimensions--estimates similar to those generated from CT reconstructions. Thus, these radiographs may serve as an acceptable first-line imaging study for initial assessment of patients suspected of having nerve root compression that precludes the higher cost and radiation exposure associated with CT scans.

Augmented demineralized bone matrix: a potential alternative for posterolateral lumbar spinal fusion

Variable osteoinductive potential has been reported between and within production lots of different demineralized bone matrix (DBM) products. This study compared fusion rates of different manufactured lots and augmented formulations of DBM with a dose-response curve of recombinant human bone morphogenetic protein 2 (rhBMP-2) on inactivated DBM carrier in a posterolateral fusion rat model. Lumbar fusions were performed in 145 rats. In the control rats, we implanted autograft, graft alternative, including inactivated DBM, or nothing (ie, no graft). In the study rats, we implanted 1 of 2 BioSETR (RTI Biologics, Alachua, Florida) DBM lots, growth factor-enriched DBM, and inactivated DBM plus rhBMP-2 in different concentrations. Manual palpation revealed fusion rates of 25% (autograft), 0% (inactivated DBM), 17% (DBM donor A), and 36% (DBM donor B). The fusion rate of the most enhanced donor B graft (83%) was higher (P<.05) than that of autograft or unenhanced DBM. Inactivated DBM plus rhBMP-2 fused between 45% and 100%. There was no significant difference between DBM plus rhBPM-2 and the highest enrichment group of donor B. Differences between 2 DBM lots in an athymic rat ectopic bone formation model also were found in the spine fusion model. Enhanced DBM formulations were comparable with inactivated DBM plus rhBMP-2 with respect to performance and could represent a bone graft alternative in spine fusion.

Actual knee motion during continuous passive motion protocols is less than expected

Investigations of the usefulness of continuous passive motion (CPM) after TKA have yielded mixed results, with evidence suggesting its efficacy is contingent on the presence of larger motion arcs. Surprisingly, the range of motion (ROM) the knee actually experiences while in a CPM machine has not been elucidated. In this study, the ability of a CPM apparatus to bring about a desired knee ROM was assessed with an electrogoniometer. The knee experienced only 68% to 76% of the programmed CPM arc, with the higher percentages generated by elevating the head of the patient's bed. This disparity between true knee motion and CPM should be accounted for when designing CPM protocols for patients or investigations evaluating efficacy of CPM.

Radiation exposure from musculoskeletal computerized tomographic scans

BACKGROUND

Computerized tomographic scans are routinely obtained to evaluate a number of musculoskeletal conditions. However, since computerized tomographic scans expose patients to the greatest amounts of radiation of all imaging modalities, the physician must be cognizant of the effective doses of radiation that are administered. This investigation was performed to quantify the effective doses of computerized tomographic scans that are performed for various musculoskeletal applications.

METHODS

The digital imaging archive of a single institution was retrospectively reviewed to identify helical computerized tomographic scans that were completed to visualize the extremities or spine. Imaging parameters were recorded for each examination, and dosimetry calculator software was used to calculate the effective dose values according to a modified protocol derived from publication SR250 of the National Radiological Protection Board of the United Kingdom. Computerized tomographic scans of the chest, abdomen, and pelvis were also collected, and the effective doses were compared with those reported by prior groups in order to validate the results of the current study.

RESULTS

The mean effective doses for computerized tomographic scans of the chest, abdomen, and pelvis (5.27, 4.95, and 4.85 mSv, respectively) were consistent with those of previous investigations. The highest mean effective doses were recorded for studies evaluating the spine (4.36, 17.99, and 19.15 mSv for the cervical, thoracic, and lumbar spines, respectively). In the upper extremity, the effective dose of a computerized tomographic scan of the shoulder (2.06 mSv) was higher than those of the elbow (0.14 mSv) and wrist (0.03 mSv). Similarly, the effective dose of a hip scan (3.09 mSv) was significantly higher than those observed with knee (0.16 mSv) and ankle (0.07 mSv) scans.

CONCLUSIONS

Computerized tomographic scans of the axial and appendicular skeleton are associated with substantially elevated radiation exposures, but the effective dose declines substantially for anatomic structures that are further away from the torso.

Survey of spine surgeons on attitudes regarding osteoporosis and osteomalacia screening and treatment for fractures, fusion surgery, and pseudoarthrosis

BACKGROUND CONTEXT

Osteoporosis and osteomalacia are significant risk factors for fracture and spine instrumentation failure. Low-energy fractures are becoming increasingly more common because of an increase in life expectancy and age of the population. Decreased bone density is an independent risk factor for instrumentation failure in spinal fusion operations.

PURPOSE

To assess the awareness and practice patterns of spine surgeons regarding metabolic bone disorders and osteoporosis with emphasis on fracture care and arthrodesis.

STUDY DESIGN/SETTING

Questionnaire study.

PATIENT SAMPLE

Spine surgeons attending the "Disorders of the Spine" conference (January 2007, Whistler, British Columbia, Canada).

OUTCOME MEASURES

Respondent reported frequencies of diagnostics, screening, and treatment methods for patients with low-energy spine fractures, pseudoarthrosis, and those undergoing spinal arthrodesis.

METHODS

A ten-question survey was administered to orthopedic surgeons and neurosurgeons who treated spine fractures and degenerative spine conditions in their practice. The survey was given to those who were attending a continuing medical education spinal disorders conference. The survey asked about treatment patterns with respect to osteoporosis and osteomalacia workup and treatment for patients with low-energy spine fractures, pseudoarthrosis, and those undergoing spinal arthrodesis.

RESULTS

Of the 133 surgeons to whom the questionnaire was distributed at this meeting, 114 questionnaires were returned that corresponds to a response rate of 86%. Twenty-one surveys were excluded because of incomplete biographical information, resulting in a total of 93 completed questionnaires that were available for analysis. When treating patients with low-energy spine fractures, 60% checked dual-energy X-ray absorptiometry (DEXA) and 39% checked metabolic laboratories (of those who did not order laboratories and DEXA about 63% refer for treatment). Before instrumented fusion, 44% of those queried checked DEXA and 12% checked metabolic laboratories (vitamin D, parathyroid hormone [PTH], and calcium [Ca]). Before noninstrumented fusion, 22% checked DEXA and 11% checked metabolic laboratories. Before addressing pseudoarthrosis, 19% checked DEXA and 20% checked metabolic laboratories.

CONCLUSIONS

Despite of the large number of elderly patients undergoing spine care and the high incidence of osteoporosis and/or osteomalacia in this population, a large portion of the spine surgeons who responded to the survey reported that they do not perform routine osteoporosis/osteomalacia workups. Of those who do perform workups, some commented that it will change their surgical plan or preoperative treatment. It appears that there is a need for increased awareness among spine specialists regarding osteoporosis screening and treatment. Osteoporosis practice patterns may also be affected with newly evolving government quality reporting regulations.

Postoperative bracing after spine surgery for degenerative conditions: a questionnaire study

BACKGROUND CONTEXT

A variety of orthoses are routinely applied after spinal procedures but there are limited data regarding their efficacy, especially with the increasing use of internal fixation. At this time, the proper indications for postoperative bracing are not well established.

PURPOSE

To assess the postoperative bracing patterns of spine surgeons.

STUDY DESIGN/SETTING

Questionnaire study.

PATIENT SAMPLE

Spine surgeons attending the "Disorders of the Spine" conference (January 2008, Whistler, Canada).

OUTCOME MEASURES

Frequencies of bracing after specific surgical procedures.

METHODS

A single-page questionnaire was distributed to all spine surgeons attending the "Disorders of the Spine" conference (January 2008). The questionnaire focused on whether surgeons typically immobilize patients after specific spinal procedures, the type of orthosis used, the duration of treatment, and the rationale for bracing.

RESULTS

Ninety-eight of 118 surgeons completed the survey (response rate: 83%). The frequency of bracing was similar between academic and private as well as orthopedic and neurosurgical practices. The difference in the bracing tendencies of fellowship and non-fellowship trained surgeons was found to be statistically significant (61% vs. 46%, p<.0001). The duration of clinical experience did not appear to influence the propensity of surgeons to use orthoses. Bracing was employed more regularly after cervical spine procedures than surgeries involving the lumbar spine (63% vs. 49%, p<.0001). In the anterior cervical spine, orthoses were used more often as the complexity of the procedure increased from single to multilevel constructs (55% vs. 76%, p<.0001). The frequencies of bracing were not significantly different between noninstrumented and instrumented lumbar fusions. In most cases, bracing was continued for a total of 3-8 weeks and the restriction of patient activity was the most common reason cited by surgeons who use orthoses.

CONCLUSIONS

Although most of the respondents brace their patients postoperatively, there is an obvious lack of consensus regarding the most appropriate type, duration, and indications for immobilization. Further prospective, clinical studies may play a helpful role in evaluating the efficacy of postoperative bracing protocols.

Which regions of the operating gown should be considered most sterile?

Various guidelines have been proposed regarding which portions of a surgical gown may be considered sterile. Unfortunately, the validity of these recommendations has not been definitively established. We therefore evaluated gown sterility after major spinal surgery to assess the legitimacy of these guidelines. We used sterile culture swabs to obtain samples of gown fronts at 6-inch increments and at the elbow creases of 50 gowns at the end of 29 spinal operations. Another 50 gowns were swabbed immediately after they were applied to serve as negative controls. Bacterial growth was assessed using semiquantitative plating techniques on a nonselective, broad-spectrum media. Contamination was observed at all locations of the gown with rates ranging from 6% to 48%. Compared with the negative controls, the contamination rates were greater at levels 24 inches or less and 48 inches or more relative to the ground and at the elbow creases. The section between the chest and operative field had the lowest contamination rates. Based on these results, we consider the region between the chest and operative field to be the most sterile and any contact with the gown outside this area, including the elbow creases, should be avoided to reduce the risk of infection.

Sterility of C-arm fluoroscopy during spinal surgery

STUDY DESIGN

Prospective study evaluating the sterility of 25 C-arm drapes after their use during spine surgery.

OBJECTIVE

To use swab samples to evaluate the sterility of draped C-arms at the end of spine surgical cases and assess the integrity of the sterile technique.

SUMMARY OF BACKGROUND DATA

Intraoperative fluoroscopy is used routinely in the operating room for a variety of spinal applications. Although the C-arm may help the surgeon assess spinal alignment and facilitate the placement of instrumentation, there are concerns that the C-arm may represent a potential source of contamination and increase the risk of developing a postoperative infection. METHODS.: This study included 25 surgical cases requiring a standard fluoroscopic C-arm that were performed by 2 spine surgeons. Sterile culture swabs were used to obtain samples from 5 defined locations on the C-arm drape after its use during the operation. The undraped technician's console was sampled in each case as a positive control and an additional 25 C-arm drapes were swabbed immediately after they were applied to the C-arm unit in order to obtain negative controls. Swab samples were assessed for bacterial growth on 5% sheep blood Columbia agar plates using a semiquantitative technique.

RESULTS

Contamination was noted on only 1 of 25 negative control drapes at a single location (4%). One hundred percent and 96% of the positive control swabs that were obtained from the negative controls and postoperative drapes exhibited growth, respectively. Although at least some degree of contamination was observed at all locations of the C-arm drape after surgery, the upper 2 sample sites demonstrated the greatest degree of contamination; the incidences of postoperative contamination were significantly greater for the top (56%, P < 0.000001) and upper front of the receiver (28%, P = 0.010) compared to the negative controls. In contrast, the lower front, receiver plate, and midportion of the C-arm were associated with lower rates of contamination (12%-20%).

CONCLUSION

The upper portions of the C-arm clearly exhibited the greatest rates of contamination during spinal operations. This contamination most likely occurs when the undraped portions of the C-arm are rotated to acquire lateral images. As a result, we no longer consider the top portion of the C-arm drape to be sterile in these situations and we believe that avoiding contact with these areas may decrease the risks of intraoperative contamination and possibly postoperative infection as well.

Role of exertion or emotion as inciting events for acute aortic dissection

It is well known that hypertension, aortic dilatation, and collagen disorders predispose to acute aortic dissection (AAD). The inciting events that precede the instant of AAD are incompletely understood. One hundred seventy-five consecutive patients having AAD, treated at our institution during a 10-year period, were reviewed; 65 were women and 110 were men (mean age 61 years). The ascending aorta was affected in 110 patients, and the descending in 65. Information was collected using patients' charts supplemented with direct telephone interviews. Ninety patients were contacted; 65 (24 women, 41 men, mean age 61 years, average aortic size 5.56 cm) could recall specific inciting events for their dissection. In 34 patients, the ascending aorta was involved and in 31 the descending. Eighteen patients (28%) had a positive family history of aortic disease, defined as having > or =1 first-degree relative with aortic disease (aneurysm or dissection). In 24 of the 90 patients contacted (27%), strenuous activity was identified as a clear precipitating factor before the acute onset of thoracic pain; in 36 of 90 (40%) severe emotional stress preceded the onset of dissection pain. Three dissections were iatrogenic. Two additional patients reported a severe exacerbation of chronic obstructive pulmonary disease before their acute onset of chest pain. In conclusion, severe physical and emotional stress may precipitate AAD, presumably on the basis of a transient, severe hypertensive reaction.