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OBJECTIVE De novo infections of the spine are an increasing healthcare problem. The decision for nonsurgical or surgical treatment is often made case by case on the basis of physician experience, specialty, or practice affiliation rather than evidence-based medicine. To create a more systematic foundation for surgical assessments of de novo spinal infections, the authors applied a formal validation process toward developing a spinal infection scoring system using principles gained from other spine severity scoring systems like the Spine Instability Neoplastic Score, Thoracolumbar Injury Classification and Severity Score, and AO Spine classification of thoracolumbar injuries. They utilized an expert panel and literature reviews to develop a severity scale called the "Spinal Infection Treatment Evaluation Score" (SITE Score). METHODS The authors conducted an evidence-based process of combining literature reviews, extracting key elements from previous scoring systems, and obtaining iterative expert panel input while following a formal Delphi process. The resulting basic SITE scoring system was tested on selected de novo spinal infection cases and serially refined by an international multidisciplinary expert panel. Intra- and interobserver reliabilities were calculated using the intraclass correlation coefficient (ICC) and Fleiss’ and Cohen’s kappa, respectively. A receiver operating characteristic analysis was performed for cutoff value analysis. The predictive validity was assessed through cross-tabulation analysis. RESULTS The conceptual SITE scoring system combines the key variables of neurological symptoms, infection location, radiological variables for instability and impingement of neural elements, pain, and patient comorbidities. Ten patients formed the first cohort of de novo spinal infections, which was used to validate the conceptual scoring system. A second cohort of 30 patients with de novo spinal infections, including the 10 patients from the first cohort, was utilized to validate the SITE Score. Mean scores of 6.73 ± 1.5 and 6.90 ± 3.61 were found in the first and second cohorts, respectively. The ICCs for the total score were 0.989 (95% CI 0.975–0.997, p < 0.01) in the first round of scoring system validation, 0.992 (95% CI 0.981–0.998, p < 0.01) in the second round, and 0.961 (95% CI 0.929–0.980, p < 0.01) in the third round. The mean intraobserver reliability was 0.851 ± 0.089 in the third validation round. The SITE Score yielded a sensitivity of 97.77% ± 3.87% and a specificity of 95.53% ± 3.87% in the last validation round for the panel treatment decision. CONCLUSIONS The SITE scoring concept showed statistically meaningful reliability parameters. Hopefully, this effort will provide a foundation for a future evidence-based decision aid for treating de novo spinal infections. The SITE Score showed promising inter- and intraobserver reliability. It could serve as a helpful tool to guide physicians’ therapeutic decisions in managing de novo spinal infections and help in comparison studies to better understand disease severity and outcomes.

Expansion of the anterior column and compression of the posterior column restores lordosis and sagittal imbalance. Anterior longitudinal ligament (ALL) release has been described from lateral and anterior approaches as a technique to improve lumbar lordosis; however, posterior approach to release the ALL has not been adequately assessed.We demonstrate a case series of ALL release using a posterior approach performed in conjunction with posterior column osteotomy (PCO), with or without transforaminal lumbar interbody fusion (TLIF) for spinal deformity. Eleven cases were identified from billing records between 2010 and 2019. Retrospective review was conducted for perioperative complications and revision surgery. Overall and segmental lumbar lordosis (LL) correction was measured from pre- and postoperative imaging.Eleven patients underwent ALL release with a PCO. Kyphosis, scoliosis, and flat back syndrome were the most common spinal deformities. On average, patients had 9 ± 3 levels fused and a single level ALL release. ALL release was most commonly performed at L1-L2 and L2-L3 levels. An overall LL correction of 28.6° ± 19.8ALL release as an adjunct to PCO and TLIF is a viable technique for providing increased deformity correction without subjecting the patient to a more invasive three-column osteotomy. While this approach may not be appropriate for all patients, it represents a useful option in spinal deformity correction while limiting blood loss and additional anterior surgery.IV.

Objectives Primary objectives were outcomes comparison of instrumented surgery used for de-novo spinal infections in terms of infection recurrence, reoperations, primary failure, mortality, and length of stay relative to non-instrumented surgery. Secondary objectives were outcomes for surgical and non-surgical treatment of de-novo spinal infections regarding recurrence of infection, mortality, quality of life, and length-of-stay. Methods A systematic literature review was performed using the PubMed database. Studies comparing outcome variables of patients with de-novo spinal infections (DNSI) treated with and without instrumentation and surgical versus non-surgical treatment were included. Studies primarily focusing on epidural abscesses or non-de-novo infections were excluded. A meta-analysis was performed for infection recurrence, reoperation, primary treatment failure, mortality, and quality-of-life parameters. Results A total of 17 retrospective studies with 2.069 patients met the inclusion criteria. 1.378 patients received surgical treatment with or without instrumentation; 676 patients were treated non-surgically. For the comparison of instrumented to non-instrumented surgery Odds-Ratios were .98 (P = .95) for infection recurrence, .83 (P = .92) for primary failure, .53 (P = .02) for mortality and .32 (P = .05) for reoperation. For the comparison of non-surgical to surgical treatment, Odds-Ratios were .98 (P = .95) for infection recurrence, and 1.05 (P = .89) for mortality. Conclusion Available data support that instrumented surgery can be performed safely without higher rates of infection recurrence or primary failure and lower reoperation and mortality rates compared to nonsurgical treatment for DNSI. Furthermore, spine surgical treatment may generally be performed without higher risk of infection recurrence and mortality and better quality-of-life outcomes compared to generic non-surgical treatment.

Background Intraoperative manipulation of the craniocervical junction with the Cervical Management Base Unit (CMBU) has been used as an adjunct for achieving optimal anatomic alignment during instrumented fusion procedures in a variety of disease settings. Here, we present our experience using the CMBU as a supplement to achieving a successful reduction and fixation of a reducible craniocervical subluxation with associated basilar impression/medullary compression in the setting of Grisel syndrome. Case Description Under fluoroscopy and neuromonitoring guidance, the elevator and axial translation mechanisms of the CMBU safely allowed for presurgical assessment of reducibility and facilitated complete reduction of the deformity with restitution of a normal atlantodental interval, spinolaminar line, and clivoaxial angle. Magnetic resonance imaging acquired 1 month after surgery and antibiotic therapy showed resolution of a large epidural abscess in the region of the dens and no evidence of residual neural impingement. Upright plain films at 9 months showed maintenance of the desired craniocervical alignment. Conclusions Intraoperative manipulation of the craniocervical junction using the CMBU, when implemented under fluoroscopy and neuromonitoring, can safely facilitate an enduring anatomic correction of craniocervical deformity in the setting of Grisel syndrome. The dynamic utility of the CMBU for translation of the head and neck obviated the need to apply forces directly to hardware-bone interfaces, and its utility may extend to craniocervical disorders of other etiologies, especially those of a reducible nature and in the setting of poor bone quality and joint laxity.

In cervical traumatic spinal cord injury (TSCI), the therapeutic effect of timing of surgery on neurological recovery remains uncertain. Additionally, the relationship between extent of decompression, imaging biomarker evidence of injury severity, and outcome is incompletely understood. We investigated the effect of timing of decompression on long-term neurological outcome in patients with complete spinal cord decompression confirmed on postoperative magnetic resonance imaging (MRI). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients 6 months after confirmed decompression. Thirty-two patients underwent decompressive surgery ultra-early (< 12 h), 25 underwent decompressive surgery early (12–24 h), and 15 underwent decompressive surgery late (> 24–138.5 h) after injury. Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission ASIA motor score, and surgical technique were not statistically different among groups. Motor complete patients (p = 0.009) and those with fracture dislocations (p = 0.01) tended to be operated on earlier. Improvement of one grade or more was present in 55.6% of AIS grade A, 60.9% of AIS grade B, and 86.4% of AIS grade C patients. Admission AIS motor score (p = 0.0004) and pre-operative IMLL (p = 0.00001) were the strongest predictors of neurological outcome. AIS grade improvement occurred in 65.6%, 60%, and 80% of patients who underwent decompression ultra-early, early, and late, respectively (p = 0.424). Multiple regression analysis revealed that IMLL was the only significant variable predictive of AIS grade conversion to a better grade (odds ratio, 0.908; confidence interval [CI], 0.862–0.957; p

Background Pedicle subtraction osteotomy (PSO) can improve sagittal alignment but carries risks, including iatrogenic spinal cord and nerve root injury. Critically, during the reduction phase of the technique, medullary kinking or neural element compression can lead to neurologic deficits. Methods We describe 3 cases of thoracic PSO and evaluate the feasibility, findings, and utility of intraoperative ultrasound in this setting. Results Intraoperative ultrasound can provide a visual assessment of spinal cord morphology before and after PSO reduction and influences surgical decision making with regard to the final amount of sagittal plane correction. This modality is particularly useful for confirming ventral decompression of disc–osteophyte complex before reduction and also after reduction maneuvers when there is kinking of the thecal sac but uncertainty about the underlying status of the spinal cord. Intraoperative ultrasound is a reliable modality that fits well into the technical sequence of PSO, adds a minimal amount of operative time, and has few limitations. Conclusions We propose that intraoperative ultrasound is a useful supplement to standard neuromonitoring modalities for ensuring safe PSO reduction and decompression of neural elements.

Objective Hemorrhagic contusion in cervical spinal cord injury (CSCI) is poorly understood. We investigated hemorrhagic expansion in patients with CSCI with an assigned elevated mean arterial pressure (MAP) goal of >85 mm Hg. The change in hemorrhagic area and long-term follow-up data ≥6 months after injury was studied. Methods A retrospective review was performed from 2005 to 2016 to identify patients with motor complete CSCI with 2 cervical magnetic resonance imaging (MRI) scans within 7 days of injury showing evidence of hemorrhagic contusion and assigned a MAP goal of >85 mm Hg for 7 days. T2-weighted MRI was used to calculate the hemorrhagic surface area in the sagittal plane. A calculated MAP was recorded for each blood pressure measure between the initial and follow-up MRI scans. The American Spinal Injury Association impairment scale (AIS) and American Spinal Injury Association motor scores were recorded at the final follow-up examination at ≥6 months. Results A total of 193 patients were identified. The mean change in the hemorrhagic area was 24.0 mm2. Of the 193 patients, the AIS grade was A for 114 and B for 79 patients. Multiple logistic regression analysis demonstrated that the MAP and systolic blood pressure were nonsignificant predictors of hemorrhagic contusion expansion. An increased hemorrhagic contusion area on the follow-up MRI scan was associated with a reduced odds of AIS improvement of ≥1 and ≥2 points (odds ratio, 0.97; 95% confidence interval, 0.87–0.97; P = 0.028; and odds ratio, 0.92; 95% confidence interval, 0.99–1.13; P = 0.008, respectively) at the final ≥6-month follow-up examination. Conclusion The present study investigated the clinical safety of elevated MAP goals for patients with CSCI and hemorrhagic contusion. Elevated MAPs did not significantly increase the risk of hemorrhagic expansion in those with CSCI. We have also reported the use of hemorrhagic contusion size as a potential radiographic biomarker for neurological outcomes.

Although decompressive surgery following traumatic spinal cord injury (TSCI) is recommended, adequate surgical decompression is rarely verified via imaging. We utilized magnetic resonance imaging (MRI) to analyze the rate of spinal cord decompression after surgery. Pre-operative (within 8 h of injury) and post-operative (within 48 h of injury) MRI images of 184 motor complete patients (American Spinal Injury Association Impairment Scale [AIS] grade A = 119, AIS grade B = 65) were reviewed to verify spinal cord decompression. Decompression was defined as the presence of a patent subarachnoid space around a swollen spinal cord. Of the 184 patients, 100 (54.3%) underwent anterior cervical discectomy and fusion (ACDF), and 53 of them also underwent laminectomy. Of the 184 patients, 55 (29.9%) underwent anterior cervical corpectomy and fusion (ACCF), with (26 patients) or without (29 patients) laminectomy. Twenty-nine patients (16%) underwent stand-alone laminectomy. Decompression was verified in 121 patients (66%). The rates of decompression in patients who underwent ACDF and ACCF without laminectomy were 46.8% and 58.6%, respectively. Among these patients, performing a laminectomy increased the rate of decompression (72% and 73.1% of patients, respectively). Twenty-five of 29 (86.2%) patients who underwent a stand-alone laminectomy were found to be successfully decompressed. The rates of decompression among patients who underwent laminectomy at one, two, three, four, or five levels were 58.3%, 68%, 78%, 80%, and 100%, respectively (p

OBJECTIVES: Proactive Health is a comprehensive study on consumer perception of added functionality in food and beverages, and ingredient preferences linked with specific perceived functional benefits. We wanted to more deeply understand consumer acceptance, knowledge and expectation from added functionality and functional ingredients. In particular, we asked questions to understand preference for certain ingredients and how these vary across different functional benefits. This study aligns sought on uncover rational for why consumers add nutrition functionality and proactive health. Our research focused on how consumer perceptions can inform the food and beverage industry and influence future innovation in food and beverages. METHODS: The study is based on 965 US consumers, conducted in 2019 with the goal to understand and determine consumer expectation and importance of functional benefits derived from food and beverages. The study included consumers across gender, age groups, and ethnicities, uncovering specific preferences of functional benefits, and corresponding functional ingredients. The research was conducted across health conscious consumers in the US, who always pay attention to on pack details and claims, read the ingredient deck, as well as the nutritional panel. A quantitative online research study was conducted to estimate specific consumer preferences of 85 different ingredients across various functional benefits were surveyed in addition to specifics on various food and beverages category insights as it pertains to added functionality. All differences across age, gender, ethnicities and life stages highlighted in the research are at a 95% significant difference level. RESULTS: In this study we found that 67% of Americans are proactive with their health and 57% are trying to manage their diet via a healthy diet. Gen Z and Older Millennials are the most proactive with their Health (76% and 72%, respectively). Sleep stress and energy are the most common types of health priorities for proactive health consumers (51%, 50%, and 40%, respectively). However, proactive consumers priorities change toward cardiovascular health while eating out. Dietary supplements and medication are used extensively to help consumers meet their goals, but supplements are much more likely used for weight control (65%). Foods commonly used for proactive health were nutritional beverages (55%), yogurts (52%) and proteins powders (50%). CONCLUSIONS: The past decade has witnessed a dramatic increase in consumer proactivity with regards to their health. Consumer management of personal health is no longer limited to periodic medical checkups, prescription medication, or dietary supplements alone. The results of this study can better help us identify which methods consumers use to proactively improve health, and allow nutrition practitioners to formulate solutions that match consumer demand. FUNDING SOURCES: Kerry, Inc. SUPPORTING TABLES, IMAGES AND/OR GRAPHS

OBJECTIVE Optimal strategies for fixation in the osteoporotic lumbar spine remain a clinical issue. Classic transpedicular fixation in the osteoporotic spine is frequently plagued with construct instability, often due to inadequate cortical screw–bone purchase. A cortical bone trajectory maximizes bony purchase and has been reported to provide increased screw pullout strength. The aim of the current investigation was to evaluate the biomechanical efficacy of cortical spinal fixation as a surgical alternative to transpedicular fixation in the osteoporotic lumbar spine under physiological loading. METHODS Eight fresh-frozen human spinopelvic specimens with low mean bone mineral densities (T score less than or equal to –2.5) underwent initial destabilization, consisting of laminectomy and bilateral facetectomies (L2–3 and L4–5), followed by pedicle or cortical reconstructions randomized between levels. The surgical constructs then underwent fatigue testing followed by tensile load to failure pullout testing to quantify screw pullout force. RESULTS When stratifying the pullout data with fixation technique and operative vertebral level, cortical screw fixation exhibited a marked increase in mean load at failure in the lower vertebral segments (p = 0.188, 625.6 ± 233.4 N vs 450.7 ± 204.3 N at L-4 and p = 0.219, 640.9 ± 207.4 N vs 519.3 ± 132.1 N at L-5) while transpedicular screw fixation demonstrated higher failure loads in the superior vertebral elements (p = 0.024, 783.0 ± 516.1 N vs 338.4 ± 168.2 N at L-2 and p = 0.220, 723.0 ± 492.9 N vs 469.8 ± 252.0 N at L-3). Although smaller in diameter and length, cortical fixation resulted in failures that were not significantly different from larger pedicle screws (p > 0.05, 449.4 ± 265.3 N and 541.2 ± 135.1 N vs 616.0 ± 384.5 N and 484.0 ± 137.1 N, respectively). CONCLUSIONS Cortical screw fixation exhibits a marked increase in mean load at failure in the lower vertebral segments and may offer a viable alternative to traditional pedicle screw fixation, particularly for stabilization of lower lumbar vertebral elements with definitive osteoporosis.