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BACKGROUND: Cervical disc arthroplasty (CDA) was originally approved by the US Food and Drug Administration (FDA) in 2007 as a motion-sparing procedure to treat cervical degenerative disc disease. Since then, promising results from randomized control trials have led to increasing popularity. However, data discussing monetary trends are limited. The aim of this study was to determine how utilization, hospital charges, and Medicare physician reimbursement for CDA have changed over time. METHODS: In this retrospective cohort study, International Classification of Diseases procedure codes were used to identify all patients who underwent CDA from 2007 to 2017 in the National Inpatient Sample database. The Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services was queried for primary CDA using current procedural terminology codes to determine Medicare physician reimbursement from 2009 to 2021. Nominal monetary values were adjusted for inflation using the Consumer Price Index and inflation-adjusted data reported in 2021 US dollars. RESULTS: A total of 33,079 weighted patients who underwent CDA were included for analysis. CDA utilization increased by 183% from 2007 to 2017, with Medicare beneficiary utilization increasing 149%. Inflation-adjusted total hospital charges for CDA increased by 22.4%. However, inflation-adjusted Medicare physician reimbursement fell by 1.20% per year, demonstrating a total decrease of 12.9%, starting at $1928 in 2009 and declining to $1679 in 2021. CONCLUSIONS: While utilization and total hospital charges for CDA continue to rise, Medicare physician reimbursement has not shown the same trend. In fact, inflation-adjusted reimbursement has seen a steady decline since FDA approval in 2007. If this trend persists, it may become unsustainable for physicians to continue offering CDA to Medicare patients. As disproportionate increases in hospital charges incentivize a transition to outpatient CDA, stricter patient selection criteria associated with outpatient procedures may create health care disparities for Medicare patients and those with higher comorbidity burden. CLINICAL RELEVANCE: This study shows the decreasing reimbursement trends for CDA, which may disproportionately affect Medicare patients and those with increased comorbidities. LEVEL OF EVIDENCE: 3.

BACKGROUND: The purpose of this review is to provide a brief history of previous attempts at developing patient screening tools and to further examine the definitions of these psychological concepts, relevance to clinical outcomes, and implications for spine surgeons during preoperative patient assessments. METHODS: A literature review was performed by 2 independent researchers to identify original manuscripts related to spine surgery and novel psychological concepts. The history of presurgical psychology screening was also studied, and definitions of frequently utilized metrics were detailed. RESULTS: Seven manuscripts were identified that utilized psychological metrics for preoperative risk assessments and correlated outcomes with these scores. The metrics most frequently used in the literature included resilience, patient activation, grit, and self-efficacy. DISCUSSION: Current literature favors resilience and patient activation as important metrics for preoperative patient screening. Available studies demonstrate significant associations between these character traits and patient outcomes. Further research is warranted to investigate the roles of preoperative psychological screening to optimize patient selection in spine surgery. CLINICAL RELEVANCE: The purpose of this review is to provide clinicians with a reference for available psychosocial screening tools and their relevance to patient selection. This review also serves to guide future research directions given the importance of this topic. LEVEL OF EVIDENCE: 4.

Objective: To review the evidence for the use of electromyography (EMG), motor-evoked potentials (MEPs), and somatosensory-evoked potentials (SSEPs) intraoperative neuromonitoring (IONM) strategies during lateral lumbar interbody fusion (LLIF), as well as discuss the limitations associated with each technique.Methods: A comprehensive review of the literature and compilation of findings relating to clinical studies investigating the efficacy of EMG, MEP, SSEP, or combined IONM strategies during LLIF.Results: The evidence for the use of EMG is mixed with some studies demonstrating the efficacy of EMG in preventing postoperative neurologic injuries and other studies demonstrating a high rate of postoperative neurologic deficits with EMG monitoring. Multimodal IONM strategies utilizing MEPs or saphenous SSEPs to monitor the lumbar plexus may be promising strategies based on results from a limited number of studies.Conclusion: The use of traditional EMG during LLIF remains without consensus. There is a growing body of evidence utilizing multimodal IONM with MEPs or saphenous SSEPs demonstrating a possible decrease in postoperative neurologic injuries after LLIF. Future prospective studies, with clear definitions of neurologic injury, that evaluate different multimodal IONM strategies are needed to better assess the efficacy of IONM during LLIF.

Study Design: Review. Objective: Venothromboembolic (VTE) complications, composed of deep vein thrombosis and pulmonary embolism are commonly observed in the perioperative setting. There are approximately 500 000 postoperative VTE cases annually in the United States and orthopedic procedures contribute significantly to this incidence. Data on the use of VTE prophylaxis in elective spinal surgery is sparse. This review aims to provide an updated consensus within the literature defining the risk factors, diagnosis, and the safety profile of routine use of pharmacological prophylaxis for VTE in elective spine surgery patients. Methods: A comprehensive review of the literature and compilation of findings relating to current identified risk factors for VTE, diagnostic methods, and prophylactic intervention and safety in elective spine surgery. Results: VTE prophylaxis use is still widely contested in elective spine surgery patients. The outlined benefits of mechanical prophylaxis compared with chemical prophylaxis varies among practitioners. Conclusion: The benefits of any form of VTE prophylaxis continues to remain a controversial topic in the elective spine surgery setting. A specific set of guidelines for implementing prophylaxis is yet to be determined. As more risk factors for thromboembolic events are identified, the complexity surrounding intervention selection increases. The benefits of prophylaxis must also continue to be balanced against the increased risk of bleeding events and neurologic injury.

Minimally invasive spine surgery (MISS) continues to evolve, and the advent of robotic spine technology may play a role in further facilitating MISS techniques, increasing safety, and improving patient outcomes. In this chapter we review early limitations of spinal robotic systems and go over currently available spinal robotic systems. We then summarize the evidence-based advantages of robotic spine surgery, with an emphasis on pedicle screw placement. Additionally, we review some common and expanded clinical applications of robotic spine technology to facilitate MISS. The chapter concludes with a discussion regarding the current limitations and future directions of this relatively novel technology as it applies to MISS.

AIM To explore the current evidence surrounding the administration of prophylactic antibiotics for arthroscopic knee surgery. METHODS Databases were searched from inception through May of 2018 for studies examining prophylactic antibiotic use and efficacy in knee arthroscopy. Studies with patient data were further assessed for types of arthroscopic procedures performed, number of patients in the study, use of antibiotics, and outcomes with the intention of performing a pooled analysis. Data pertaining to “deep tissue infection” or “septic arthritis” were included in our analysis. Reported data on superficial infection were not included in our data analysis. For the pooled analysis, a relative risk ratio was calculated and χ2 tests were used to assess for statistical significance between rates of infection amongst the various patient groups. Post hoc power analyses were performed to compute the statistical power obtained from our sample sizes. Number needed to treat analyses were performed for statistically significant differences by dividing 1 by the difference between the infection rates of the antibiotic and no antibiotic groups. An alpha value of 0.05 was used for our analysis. Study heterogeneity was assessed by Cochrane’s Q test as well as calculation of the I2 value. RESULTS A total of 49682 patients who underwent knee arthroscopy for a diverse set of procedures across 19 studies met inclusion critera for pooled analysis. For those not undergoing graft procedures, there were 27 cases of post-operative septic arthritis in 34487 patients (0.08%) who received prophylactic antibiotics and 16 cases in 10911 (0.15%) who received none [risk ratio (RR) = 0.53, 95% confidence interval (CI): 0.29-0.99, P = 0.05]. A sub-group analysis in which bony procedures were excluded was performed which found no significant difference in infection rates between patients that received prophylactic antibiotics and patients that did not (P > 0.05). All anterior cruciate ligament reconstruction studies used prophylactic antibiotics, but two studies investigating the effect of soaking the graft in vancomycin in addition to standard intravenous (IV) prophylaxis were combined for analysis. There were 19 cases in 1095 patients (1.74%) who received IV antibioitics alone and no infections in 2034 patients who received IV antibiotics and had a vancomycin soaked graft (RR = 0.01, 95%CI: 0.001-0.229, P < 0.01). CONCLUSION Prophylactic antibiotics are effective in preventing septic arthritis following simple knee arthroscopy. In procedures involving graft implantation, graft soaking reduces the rate of infection.

Traditionally, ex vivo gene therapy involves a two-step approach, with culture expansion of cells prior to transduction and implantation. We have tried to simplify this strategy and eliminate the time and cost associated with culture expansion, by introducing “next-day” regional gene therapy using human bone marrow cells. The purpose of this study was to determine whether a lentiviral vector (LV) carrying the cDNA for BMP-2 can transduce freshly isolated human BM cells, leading to abundant BMP production and bone formation in vivo, and evaluate the in vivo osteoinductive potential of “next-day” gene therapy and the standard “two-step” tissue culture expansion approach. To this end, human bone marrow cells (HBMC) from patients undergoing total hip arthroplasty were harvested, transduced with a BMP-2-expressing LV either overnight (“next day” gene therapy; ND) or after culture expansion (cultured “two-step” approach; C) and then implanted into a rat critical-sized femoral defect. The animals were randomly assigned to one of the following groups: I; ND-HBMC transduced with LV-TSTA BMP-2, II; ND-HBMC transduced with LV-TSTA GFP, III; non-transduced ND-HBMC; IV; C-HBMC transduced with LV-TSTA BMP-2, V; C-HBMC transduced with LV-TSTA-GFP, VI; non-transduced C-HBMC. Treatment with either “next-day” or cultured HBMC demonstrated a significant increase in new bone formation compared with all negative control groups as seen in plain radiographs, microCT and histologic/histomorphometric analysis. At 12 weeks post-op, complete defect union on plain X-rays occurred in 7/14 animals in the ND-HBMC/BMP-2 group and 12/14 in the C-HBMC/BMP-2 treated rats. The two-step approach was associated with more consistent results, a higher union rate, and superiority with regards to all of the studied bone healing parameters. In this study we demonstrate proof of concept that BMP-2-transduced human bone marrow cells can be used to enhance bone healing in segmental bone defects, and that regional gene therapy using lentiviral transduction has the osteoinductive potential to heal large bone defects in clinical settings.

Background Arteriovenous malformations (AVMs) are commonly treated using endovascular techniques. Previous nerve palsies after embolization have been reported as isolated case reports, none of which affected the forearm. Case Description A case of acute, transient neuropathy of the radial nerve following embolization of a forearm AVM is described. The patient, an otherwise healthy 27-year-old man, began having symptoms of superficial radial nerve (SRN) and posterior interosseous nerve (PIN) palsies immediately following endovascular embolization. He underwent decompression of the radial nerve within 5 days and was found to have direct compression of the PIN and SRN. The patient recovered completely at the time of his 7-month follow-up. Literature Review Few cases of nerve palsy after endovascular embolization have been reported in the literature. Many are intracranial, but rare instances of peripheral nerve palsy have been reported, including two sciatic nerve and four digital nerve palsies after endovascular embolization. No cases of peripheral nerve palsy in the forearm have been reported. Clinical Relevance We recommend careful consideration of surrounding neural elements at risk for palsy prior to endovascular embolization and detailed discussion with the patient during the informed consent process.

Background: Fifth metacarpal fractures are often treated nonoperatively with serial radiographs; however, the utility of these radiographs in altering clinical management has not been investigated. We hypothesize that follow-up plain films will not alter clinical management and are therefore unnecessary for most patients. Methods: Between 2007 and 2014, patients with a fifth metacarpal fracture at our level I trauma center were retrospectively reviewed. Patients with inadequate documentation or imaging, ipsilateral upper extremity injuries, or who underwent initial surgical fixation were excluded. Initial and postreduction radiographs were reviewed by 4 board-certified attending hand surgeons and 2 hand fellows who indicated their preferred management. At a later date, blinded to their initial management, the reviewers assessed follow-up films taken at least 2 weeks later and indicated their preferred management. Results: In total, 60 patients met inclusion criteria, and of those, 30 were randomly selected. There were 9 base, 7 shaft, and 14 neck fractures. Initially, reviewers opted for nonoperative management in 72.2% of base, 71.4% of shaft, and 91.7% of neck fractures. After reviewing follow-up films, reviewers changed from nonoperative to operative management in 0.0% of base, 9.5% of shaft, and 1.2% of neck fractures. Conclusions: Follow-up radiographs may not be indicated for most fifth metacarpal base and neck fractures. Follow-up radiographs may change management in select fifth metacarpal shaft fractures as these fractures may displace. Follow-up radiographs should be performed at the discretion of the treating surgeon on an as-needed basis for fractures at risk for displacement.

Background: The purpose of this study is to examine the incidence of nerve injury, clinical variables associated with nerve palsy, and predictive factors of nerve laceration after gunshot wounds to the upper extremity. Methods: Forty-one patients from a level I trauma center with gunshot wounds to the upper extremity who underwent surgical exploration between 2007 and 2014 were identified retrospectively. Patients with proximal ipsilateral injuries, inadequate documentation, imaging, or with a pre-existing neurologic deficit were excluded. Patient demographics, clinical sensory and motor examination, the presence of retained bullet fragments, fracture, vascular injury, and compartment syndrome were recorded. Univariate analysis was performed to determine significant predictors of intraoperative nerve laceration. Significance was set at P < .05. Results: Fifty-nine nerves were explored in 41 patients. There were higher frequencies of fractures, retained fragments, vascular injury, and compartment syndrome in patients with nerve palsies, although none were associated with nerve laceration. Patients with palsies on presentation were significantly more likely to have a nerve laceration found intraoperatively. Conclusions: Gunshot wounds to the upper extremity with focal nerve deficits remain a difficult problem for orthopedic surgeons. The present study provides evidence that may help guide operative decision making in treatment of these injuries.

Recent changes in healthcare and advances in technology have increased the use of large-volume national databases in surgical research. These databases have been used to develop perioperative risk stratification tools, assess postoperative complications, calculate costs, and investigate numerous other topics across multiple surgical specialties. The results of these studies contain variable information but are subject to unique limitations. The use of large-volume national databases is increasing in popularity, and thorough understanding of these databases will allow for a more sophisticated and better educated interpretation of studies that utilize such databases. This review will highlight the composition, strengths, and weaknesses of commonly used national databases in surgical research.

Background The management of extra-articular distal radius fractures is highly variable, with no clear consensus regarding their optimal management. Purpose To assess comparatively the biomechanical stability of Kirschner wire (K-wire) fixation, volar plating, and intramedullary nailing for unstable, extra-articular distal radius fractures with both (1) constant and (2) cyclical axial compression, simulating forces experienced during early postoperative rehabilitation. Methods Twenty-six volar locking plate, intramedullary nail, and K-wire bone-implant constructs were biomechanically assessed using an unstable extra-articular distal radius bone model. Bone implant models were created for each type of construct. Three samples from each construct underwent compressive axial loading until fixation failure. The remaining samples from each construct underwent fatigue testing with a 50-N force for 2,000 cycles followed by repeat compressive axial loading until fixation failure. Results Axial loading revealed the volar plate was significantly stiffer than the intramedullary nail and K-wire constructs. Both the volar plate and intramedullary nail required greater than 300 N of force for fixation failure, while the K-wire construct failed at less than 150 N. Both the volar plate and intramedullary nail demonstrated less than 1 mm of displacement during cyclic loading, while the K-wire construct displaced greater than 3 mm. Postfatigue testing demonstrated the volar plate was stiffer than the intramedullary nail and K-wire constructs, and both the volar plate and intramedullary nail required greater than 300 N of force for fixation failure while the K-wire construct failed at less than 150 N. Conclusions Volar plating of unstable extra-articular distal radius fractures is biomechanically stiffer than K-wire and intramedullary fixation. Both the volar plate and intramedullary nail demonstrated the necessary stability and stiffness to maintain anatomic reduction during the postoperative rehabilitation period. Clinical Relevance Both the volar plate and intramedullary nail demonstrated the necessary biomechanical stability to maintain postoperative reduction in extra-articular distal radius fractures, warranting further clinical comparison.