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Introduction: Previous studies have shown that T1 tilt is positively correlated with post-operative shoulder balance (SB). The aim of this study was to explore the role of intra-operative T1 tilt, among other shoulder parameters as a potential parameter to predict post-operative SB in adolescent idiopathic scoliosis (AIS) patients., Methods: A retrospective review of AIS patients with structural thoracic curves with minimum 2 year follow up was conducted from a single tertiary center. Standing pre-operative, 1st erect, 1 year and 2-year follow-up; and intra-operative final prone radiographs were reviewed along with clinical data. Patients were stratified into 2 cohorts: Group A-Final intra-operative T1 tilt ≤5° and Group B-Final intra-operative T1 tilt >5°. These groups were compared for post-operative SB as a whole and separately for patients with baseline right or left shoulder high and if UIV was T2 or T3/T4. Patients with optimal SB (Radiographic shoulder height (RSH) <2 cm) at 2 years were compared to sub-optimal SB (RSH ≥ 2 cm) with respect to multiple SB variables., Results: 55 patients (mean age 15.1 years-old, 43 F, mean BMI 22, mean thoracic Cobb-49.8°) were included. Based on Lenke curve types, there were 13 patients with type 1A, 10 patients with 1B, 12 patients with 1C, 7 patients with 2A, 4 patients with 2B and 9 patients with type 3C. T1 tilt was significantly correlated with RSH, Clavicle angle difference (CAD), First Rib Angle (FRA), and UIV tilt at first erect, 1-year, and 2-year post-op radiographs (p < 0.05 for all). When comparing groups, A and B, Group A patients showed significantly better restoration of their 2-year SB parameters; RSH (6.8 vs 11.8 mm, p = 0.01), CAD (3.9 vs 9.1 p < 0.001) and T1 tilt (4.7 vs 7.8° p = 0.01). Similar results were found for patients with baseline right shoulder high; RSH (p = 0.04), CAD (p < 0.001) and T1 tilt (p < 0.001) and whether UIV was T2 or T3/T4. Eight patients with sub-optimal SB had worse intra-operative T1 tilt (p = 0.03) compared to 47 patients with optimal SB despite no difference in MT Cobb correction (83.1 vs 79.8%, p = 0.57)., Conclusion: Post-operative T1 tilt correlates with lateral shoulder parameters at first erect, 1 year, and 2-year radiographs. Therefore, T1 tilt can potentially be used as a surrogate to predict post-operative SB. Leveling intra-operative T1 tilt ≤5° is associated with better 2-year post-operative shoulder balance parameters irrespective of whether the UIV was T2 or T3/T4. Patients with sub-optimal SB at 2 years had worse final intra-operative T1 tilt despite similar percent correction of main thoracic curve for all patients., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Introduction: There remains variability in the acquisition of whole-spine MRI prior to surgical correction in patients with adolescent idiopathic scoliosis (AIS). In this study, we take a retrospective look at the clinical impact of uniformly obtaining spinal MRI on all patients with a diagnosis of AIS., Methods: Three hundred thirty four patients with presumed AIS who underwent surgery between 2017 and 2022 were identified; 283 of these patients who were asymptomatic and had a preoperative MRI in the database were included. We investigated radiographic, demographic, and clinical risk factors for the presence of neural axis anomalies. Radiologists' reports were reviewed to determine the level of the conus medullaris and the presence of any intra-spinal dysraphisms. The utility of known risk factors for neural axis anomalies and the utility of MRI identifying anomalies on clinical decision-making, intra-operative neuromonitoring (IONM) alerts, and postoperative neurologic insult in asymptomatic AIS patients were investigated., Results: There were 283 patients with a mean age of 14.1 years, 67 males (22.6%) and 26 (9.2%) left-sided thoracic curves. MRI identified nine patients with central cord dilations, four patients with low cerebellar tonsils, four patients with Chiari Malformations, five patients with low-lying conus, one patient with a tethered cord, and five patients with arachnoid cysts. Six (2.1%) of the 283 patients underwent a neurosurgical intervention and 3 (50%) of the 6 went on to have IONM alerts. Eighteen (6.4%) of the 283 patients had IONM alerts and 5 (28%) of the 18 had neural axis anomalies. None of the patients with IONM alerts had a permanent neurologic deficit post-operatively., Conclusion: In asymptomatic patients presumed to have AIS, 9.9% had a neuro-axis anomaly, 2.1% needed a neurosurgical intervention, and 6.4% of the patients had an IONM alert. We did not find known risk factors for identifying neural axis anomalies to have statistically significant application in asymptomatic AIS patients. Presence of neuroaxis anomalies increased the chance of having IONM alerts, however, we were unable to demonstrate if neurosurgical interventions in these patients with anomalies were preventative for IONM alerts or have statistically significant protection against clinical complications., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Study Design: Retrospective case control study., Objectives: To determine the role of TXA when used as topical soaked sponges (tTXA) on peri-operative blood loss and changes in hemoglobin following posterior spinal fusion (PSF) for neuromuscular and syndromic scoliosis (NMS)., Methods: A single center review of NMS patients who underwent PSF was conducted. The initial set of patients where no tTXA (control) was used were compared to consecutive NMS patients in whom tTXA was used. In the tTXA group, sponges soaked in 1g TXA in 500 mL normal saline were packed in the wound instead of dry sponges. Estimated blood loss (EBL) was calculated intraoperatively using a standard way. Pre-operative, intra-operative and immediate post-operative variables were collected and compared between the 2 groups., Results: 33 patients were included (mean age- 13.5 yrs., BMI- 21, 17 patients in tTXA and 16 patients in control group). Pre-op demographic and radiographic variables were similar between the 2 groups. EBL, EBL per level, EBVL, operative time and number of levels fused were similar in both groups. tTXA group received less intra-operative pRBC transfusion as compared to the control group (150 ± 214 vs 363 ± 186 cc, P = .004). No difference was noted in post-op blood transfusion and drain output for 3 days in both the groups. tTXA group had lesser hospital (5.1 vs 8.9 days) and ICU length of stay (2 vs 4.2 days) and fewer immediate post-operative complications (23.5 vs 52.9%) compared to the control group but not statistically significant ( P > .05)., Conclusion: Administration of tTXA-soaked sponges is an effective and safe method to reduce intraoperative blood transfusion requirements in the correction of spinal deformity in patients with NMS., Competing Interests: Declaration of conflicting interestsDr. Thomas J. Errico is a speaker and consultant to Stryker. He also has royalties from Stryker and Altus Spine. Dr. Subaraman Ramchandran, Dr. Sassan Keshavarzi, Dr. Ergin Coskun, Andrew Pierce, Osvaldo Conde and Dr. Stephen George declare they have no financial or non-financial interests to disclose.

Introduction: AIS type 1 Curves are sub-classified based on the tilt of L4 as 1AR and 1AL. These curves are different w.r.t their curve behavior, progression and level selection. Presently there is no known anatomic etiology for the different behavior. Facet tropism (FT) is defined as the asymmetry between the facet angle of the left and right facet joints. The purpose of this study was to evaluate the correlation between facet tropism in the lumbar segments and occurrence of type 1AR and 1AL curves in AIS patients., Methods: AIS patients with diagnosis of type 1 AR and 1AL right thoracic AIS curves who underwent posterior instrumented fusion were queried from a single institutions' database. Patients needed to have an MRI of their entire spine to be included. L2-3, L3-4 and L4-5 Facet angles (FA, angle made by the facet line with the mid-sagittal line at respected vertebral level) were calculated. FT was classified as follows: ≤ 5° (minimal), 6- 10° (mild) and ≥ 11° (severe). 1AR and 1AL curves were compared for FA, FT and FT grade at each lumbar segmental levels., Results: One hundred nineteen patients were included (77 females, mean age-13.85 years, mean BMI- 21.63, 73 1AL and 46 1AR). The mean thoracic Cobb was 52.5 ± 9.8°, thoracic kyphosis was 28.12 ± 12° and lumbar lordosis was 53.48 ± 12.6°. L3-4 FA on the right side was more coronally oriented in 1AR curves compared to 1AL curves (37° vs. 31°, p = 0.04). On comparing FT at each level, 1AR curves had a higher FT at L3-4 (1.5° vs. - 2.3°, p = 0.01) and L4-5 levels (5.8° vs. - 0.28°, p < 0.001) compared to 1AL patients. Similarly, 1AR patients had significantly more patients with severe FT at L3-4 (34.8% vs. 13.7%, p = 0.02) and at L4-5 (17.3% vs. 6.8%, p = 0.01) compared to 1ALcurves., Conclusion: L3-4 joints are more coronally oriented in 1AR curves compared to 1AL curves. 1AR patients displayed higher FT at L3-4 and L4-5 compared to 1AL patients. 1AR curves also reveal a higher percentage of severe FT at L3-4 and L4-5 levels. This may influence the curve behavior and progression in these two curve types., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: Utility of pre-operative MRI for patients undergoing scoliosis correction has expanded to include an MRI classification for identifying patients at increased risk of experiencing intra-operative neuromonitoring (IONM) alerts based on the shape of the spinal cord and circumferential presence of CSF at the apex of the thoracic curve. In the present study, the authors explore the utility of this new MRI classification and multiple X-ray radiographic parameters in identifying the AIS sub-population at high risk of IONM alerts., Methods: AIS patients < 18 years old who underwent posterior spinal fusion between 2018 and 2022 at a single institution. Imaging reviewed to determine main thoracic (MT) and thoraco-lumbar (TL) Cobb angles, major thoracic Apical Vertebral Translation (AVT) and lumbar/thoraco-lumbar AVT (TL AVT), thoracic kyphosis (TK), coronal main thoracic Deformity Angular Ratio (cDAR), sagittal DAR (sDAR), and MRI to determine the spinal cord type (1, 2, or 3)., Results: A total of 155 AIS patients who met the inclusion criteria between 2018 and 2022 were included. There was a trend to have an increased incidence of Type 3 spinal cord shape both with increase in the MT Cobb angle and MT AVT. There was also a shift toward more IONM alerts in patients with Type 3 (19.5%) spinal cords, AVT ≥ 5 cm (18.9%), and Cobb angle ≥ 65 0 (28.2%)., Conclusion: Higher magnitude of thoracic Cobb angle and AVT are associated with higher likelihood of type 3 spinal cord at the apex in MRI. Patients with Type 3 spinal cord, Cobb angle ≥ 65 0 , AVT > 5 cm, and cDAR > 10 have higher likelihood to have IONM alerts. Patient with a Type 3 spinal cord and a Cobb angle ≥ 65 0 (50.0%), cDAR > 10 (43.7%), and AVT > 5 cm (35.2%) have the highest risk of having IONM alerts., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Study Design: Retrospective cohort study., Objectives: The purpose of the study is to evaluate the role of supine radiographs in determining flexibility of thoracic and thoracolumbar curves., Methods: Ninety operative AIS patients with 2-year follow-up from a single institution were queried and classified into MT structural and TL structural groups. Equations were derived using linear regression to compute cut-off values for MT and TL curves. Thresholds were externally validated in a separate database of 60 AIS patients, and positive and negative predictive values were determined for each curve., Results: MT supine values were highly predictive of MT side-bending values (TL group: 0.63, P < 0.001; MT group: 0.66, P = 0.006). Similarly, TL supine values were highly predictive of TL side-bending values (TL group: 0.56, P = 0.001 MT group: 0.68, P = 0.001). From our derived equations, MT and TL curves were considered structural on supine films if they were ≥ 30° and 35°, respectively. Contingency table analysis of external validity sample showed that supine films were highly predictive of structurality of MT curve (Sensitivity = 0.91, PPV = 0.95, NPV = 0.81) and TL curve (Sensitivity = 0.77, PPV = 0.81, NPV = 0.94). ROC analysis revealed that the area under curve for MT structurality from supine films was 0.931 (SEM: 0.03, CI: 0.86-0.99, P < 0.001) and TL structurality from supine films was 0.922 (SEM: 0.03, CI- 0.84-0.98, P < 0.001)., Conclusions: A single preoperative supine radiograph is highly predictive of side-bending radiographs to assess curve flexibility in AIS. A cut-off of ≥ 30° for MT and ≥ 35° for TL curves in supine radiographs can determine curve structurality.

Introduction: Health professions are heavily engaged facing the current threat of SARS-CoV-2 (COVID-19). Although there are many diagnostic tools, an accurate and rapid laboratory procedure for diagnosing COVID-19 is recommended. We focused on platelet parameters as the additional biomarkers for clinical diagnosis in patients presenting to the emergency department (ED)., Materials and Methods: Five hundred and sixty-one patients from February to April 2020 have been recruited. Patients were divided into three groups: (N = 50) COVID-19 positive and (N = 21) COVID-19 negative with molecular testing, (N = 490) as reference population without molecular testing. A Multiplex rRT-PCR from samples collected by nasopharyngeal swabs was performed and the hematological data collected., Results: We detected a mild anemia in COVID-19 group and lymphopenia against reference population: hemoglobin (g/dL) 13.0 (11.5-14.8) versus 13.9 (12.8-15.0) (P = .0135); lymphocytes (10 9 /L) 1.24 (0.94-1.73) versus 1.99 (1.49-2.64) (P < .0001). In addition, abnormal platelet parameters as follows (COVID group vs reference population): PLT (×10 9 /L) 209 (160-258) vs 236 (193-279) (P = .0239). IPF (%) 4.05 (2.5-5.9) versus 3.4 (2.2-4.9) (P = .0576); H-IPF (%) 1.25 (0.8-2.2) versus 0.95 (0.6-1.5) (P = .0171) were identified. In particular, COVID positive group had a high H-IPF/IPF Ratio compared to reference population [0.32 (0.29-0.36) versus 0.29 (0.26-0.32), respectively, (P = .0003)]. Finally, a PLT difference of nearly 50 × 10 9 /L between pre/postCOVID-19 sampling for each patient was found (N = 42) (P = .0194)., Conclusions: COVID-19 group results highlighted higher IPF and H-IPF values, with increased H-IPF/IPF Ratio, associated to PLT count reduction. These findings shall be adopted for a timely diagnosis of patients upon hospital admission., (© 2021 John Wiley & Sons Ltd.)

Purpose: To evaluate the effectiveness of the use of topical tranexamic acid (tTXA) in spinal deformity correction in AIS patients METHODS: Sixty consecutive operative AIS patients were reviewed from a single institution and divided into two groups with similar demographics. Standardized peri-operative blood salvage techniques were utilized in all 60 patients. In the latter 30 patients, tTXA soaked sponges (1 g mixed in 500 ml Normal Saline) was utilised for wound packing during the entire surgical procedure compared to dry sponges as used in the former 30 patients. Both the groups were compared for the magnitude of deformity corrected, EBL per level fused, total EBL, blood transfused, drain output and peri-operative events., Results: Sixty AIS patients (mean age 14.4 yrs, 43 females, mean BMI 21.5, mean levels 10.7) were included. Both groups achieved similar change in Coronal Cobb correction. The EBVL (Estimated blood volume loss) % lost in the topical TXA group was 38% less than the control group (11.2 vs. 18.3%, p = 0.006). Similarly, the EBL/level was significantly lower in the topical TXA group (41 ± 30 ml vs. 57 ± 26 ml, p = 0.03). Three of 30 patients in the control group required at least 1 unit of blood transfusion, whereas only 1 patient in the topical TXA group required transfusion (10 vs. 3.3%, p = 0.001). No differences were noted in post-operative drain output, change in hemoglobin levels, and peri-operative complication rates., Conclusion: When used as an adjunct to the conventional blood salvage techniques in spinal deformity correction procedures, the use of tTXA resulted in reduced operative blood loss, and blood transfusion requirements., (© 2021. Scoliosis Research Society.)

Objective: To quantify muscle characteristics (volumes and fat infiltration) and identify their relationship to sagittal malalignment and compensatory mechanism recruitment., Methods: Female adult spinal deformity patients underwent T1-weighted MRI with a 2-point Dixon protocol from the proximal tibia up to the T12 vertebra. 3D reconstructions of 17 muscles, including extensors and flexors of spine, hip and knee, were obtained. Muscle volume standardized by bone volume and percentage of fat infiltration (Pfat) were calculated. Correlations and regressions were performed., Results: A total of 22 patients were included. Significant correlations were observed between sagittal alignment and muscle parameters. Fat infiltration of the hip and knee flexors and extensors correlated with larger C7-S1 SVA. Smaller spinal flexor/extensor volumes correlated with greater PI-LL mismatch (r =  - 0.45 and - 0.51). Linear regression identified volume of biceps femoris as only predictor for PT (R 2  = 0.34, p = 0.005) and Pfat of gluteus minimus as only predictor for SVA (R 2  = 0.45, p = 0.001). Sagittally malaligned patients with larger PT (26.8° vs. 17.2°) had significantly smaller volume and larger Pfat of gluteus medius, gluteus minimus and biceps femoris, but similar values for gluteus maximus, the hip extensor., Conclusion: This study is the first to quantify the relationship between degeneration of spino-femoral muscles and sagittal malalignment. This pathoanatomical study identifies the close relationship between gluteal, hamstring muscles and PT, SVA, which deepens our understanding of the underlying etiology that contributes to adult spinal deformity.

Study Design: This study is a single-center retrospective radiographic review., Objectives: The objective of this study is to evaluate a novel measurement parameter, mandibular slope (MS), as a measure of horizontal gaze., Introduction: Assessment of sagittal spinal alignment is essential in the evaluation of spinal deformity patients. Ability to achieve a horizontal gaze, a parameter of sagittal alignment, is needed for the performance of daily activities. Standard measures of horizontal gaze, including the gold-standard chin-brow to vertical angle (CBVA) and the surrogate measures McGregor's line (McGS) and Chamberlain's line (CS), require high-quality imaging, precise head positioning, and reliance on difficult to view visual landmarks. A novel measurement parameter, MS, utilizing the caudal margin of the mandible on standard lateral spine radiographs is proposed., Methods: 90 radiographs from spine deformity patients with or without spinal implants from a single center were evaluated. Three spine surgery fellows independently measured CBVA, McGS, CS, and MS at two timepoints at least one week apart to assess accuracy and reliability. MS was measured as the angle created by the inferior edge of the mandibular body and the horizontal. Formulas for calculating CBVA based on the above parameters were derived and compared to the actual CBVA., Results: Mean age was 49.7 years, 76 females and 14 males. CBVA correlated with CS, McGS, and MS, r = 0.85, 0.81, and 0.80, respectively (p < 0.001). Standard error between real CBVA and calculated CBVA using CS (0.4 ± 4.79) and McGS (0.4 ± 3.9) was higher than that calculated using MS (- 0.2 ± 4.3). ICC demonstrated the highest inter-observer reliability with MS (0.999). MS had the highest intra-observer reliabilities 0.975, 0.981, and 0.988 (p < 0.001); CS and McGS also demonstrated high intra-observer reliability., Conclusions: MS is a promising measure of horizontal gaze that correlates highly with CBVA, has excellent intra- and inter-observer reliability with CBVA, and is easily measured using standard lateral spine radiographs.

Introduction: Students seek gap years to enhance knowledge and improve chances of professional success. Although many institutions offer research opportunities, no studies have examined outcomes after these experiences. This study evaluates a dedicated year of orthopaedic research on a cohort's ultimate orthopaedic surgery match rate., Methods: From 2001 to 2018, 129 learners spent a year with our Department of Orthopedic Surgery at a major academic medical center. The students were either completing a gap year after college, during or after medical school, or after an unsuccessful match. Participants were asked to respond to a survey, which included demographics, educational information, and metrics related to the program. For the subcohort of students who ranked orthopaedic surgery, the match rate was compared with the mean for the US orthopaedic surgery match rates from 2006 to 2018 using a chi-square analysis. In addition, a Mann-Whitney U test was used to compare the number of publications before and after the year., Results: One hundred three students (80%) returned completed questionnaires. Of all learners who applied to and ranked orthopaedic surgery, 91% matched into an orthopaedic surgery residency program. These results compared favorably with the US orthopaedic match from 2006 to 2018 (67.9%; P < 0.001), despite a 4-point lower United States Medical Licensing Examination (USMLE) Step 1 score for the research cohort. Finally, the research cohort had a greater percentage of women (23%) and minorities (40%) than the proportion of woman and minority practicing orthopaedic surgeons., Conclusion: Students who completed a gap year in research matched into orthopaedics at a higher rate than the national average, despite a lower Step score. Mentors may also target traditionally underrepresented groups to help increase the pool of diverse applicants.

Introduction: Balance and fall risk before and after lumbar surgery was assessed to determine whether balance at baseline predicts long-term postsurgical outcomes., Methods: Forty-three patients in the United States and Israel performed the single-leg stance (SLS) test, four square step test (FSST), and 8-foot up-and-go (8FUG) test before and 2 to 4 months after lumbar spine surgery. They completed the Oswestry Disability Index (ODI) and pain rating before and 12 months after lumbar surgery., Results: From baseline to follow-up, the SLS time was 3.74 seconds longer (P = 0.01), the FSST time was 1.94 seconds faster (P < 0.001), and the 8FUG time was 1.55 seconds faster (P = 0.02). Before surgery, 26% of the patients were considered high fall risk according to the FSST and 51% according to the 8FUG. Postsurgery, all patients could complete the physical tests, but 26% remained at high fall risk according to the 8FUG and 7.5% according to the FSST. The three physical measures together explained 30% of the variance in postsurgical ODI scores (P = 0.02). Age was not correlated with performance., Discussion: Risk of falling is higher than surgeons suspect. Balance tests (ie, SLS, FSST, and 8FUG) are quick and easy to administer. The findings support the importance of screening for balance and fall risk in adults undergoing lumbar spine surgery.

Background: Hospital-acquired venous thromboembolisms (HA-VTE) are a significant source of morbidity and mortality in spine surgery patients. The purpose of this study was to review HA-VTE rates at our institution and evaluate the prevalence of known risk factors in patients who developed HA-VTE among both neurosurgical and orthopedic spine surgeries., Methods: Retrospective chart reviews were conducted of all spine surgery patients from January 1, 2013, to July 31, 2017, to evaluate rates of HA-VTE and prevalence of known HA-VTE risk factors among these patients. Univariate and multivariate logistic regression analysis for categorical variables and independent Student t test for continuous variables were utilized with significance set at P  < .05., Results: The overall HA-VTE rate was 0.94% (0.61% orthopedic, 1.87% neurosurgery). Patients with VTEs had higher rates of thoracic procedure ( P  = .002), posterior approach ( P  = .001), diagnosis of fracture ( P  = .013) or flatback syndrome ( P  = .028), neurosurgery division ( P  < .001), and diagnosis-related group (DRG) of noncervical malignancy ( P  = .001). Patients with VTEs had lower rates of cervical procedure ( P  < .001), diagnosis of herniated nucleus pulposus ( P  = .006) and degenerative disc disease ( P  = .001), and DRG of cervical spine fusion ( P  < .001). In the patients who sustained VTE, the neurosurgical patients had higher rates of active cancer (22.86% vs 0%, P  = .004) and age >60 (80% vs 50%, P  < .001), and orthopedic patients had higher estimated blood loss (EBL) (2436 ml vs 1176 mL, P  = .006) and rates of anterior-posterior surgery (22.58% vs 0%, P  = .003). Neurosurgery department, diagnosis of fracture, and DRG of noncervical malignancy were found to be significant independent risks for developing HA-VTE. Cervical procedures were independently associated with significantly lower risk. Postoperative anticoagulation initiated sooner in neurosurgery patients (postoperative day 1.26 vs 3.19, P  < .001)., Conclusions: The overall HA-VTE rate at our institution was 0.94% (0.61% orthopedic, 1.87% neurosurgery). In patients who sustained VTE, neurosurgical patients had higher rates of active cancer and age >60 years, and orthopedic patients had higher EBL and rates of anterior-posterior surgery. This highlights the different patient populations between the 2 departments and the need for individualized thromboprophylaxis regimens., Level of Evidence: 4., Competing Interests: Disclosures and COI: Each institution obtained approval from its local institutional review board to enroll patients in the prospective database, and informed consent was obtained from each patient., (©International Society for the Advancement of Spine Surgery 2020.)

Study Design: Retrospective review from a single institution., Objective: To investigate the effect of hip osteoarthritis (OA) on spinopelvic compensatory mechanisms as a result of reduced hip range of motion (ROM) between sitting and standing., Summary of Background Data: Hip OA results in reduced hip ROM and contracture, causing pain during postural changes. Hip flexion contracture is known to reduce the ability to compensate for spinal deformity while standing; however, the effects of postural spinal alignment change between sitting and standing is not well understood., Methods: Sit-stand radiographs of patients without prior spinal fusion or hip prosthesis were evaluated. Hip OA was graded by Kellgren-Lawrence grades and divided into low-grade (LOA; grade 0-2) and severe (SOA; grade 3 or 4) groups. Radiographic parameters evaluated were pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), PI-LL, thoracic kyphosis (TK), SVA, T1-pelvic angle (TPA), T10-L2, proximal femoral shaft angle (PFSA), and hip flexion (PT change-PFSA change). Changes in sit-stand parameters were compared between LOA and SOA groups., Results: 548 patients were included (LOA = 311; SOA = 237). After propensity score matching for age, body mass index, and PI, 183 LOA and 183 SOA patients were analyzed. Standing analysis demonstrated that SOA had higher SVA (31.1 vs. 21.7), lower TK (-36.2 vs. -41.1), and larger PFSA (9.1 vs. 7.4) (all p < .05). Sitting analysis demonstrated that SOA had higher PT (29.7 vs. 23.3), higher PI-LL (21.6 vs. 12.4), less LL (31.7 vs. 41.6), less TK (-33.2 vs. -38.6), and greater TPA (27.9 vs. 22.5) (all p < .05). SOA had less hip ROM from standing to sitting versus LOA (71.5 vs. 81.6) (p < .05). Therefore, SOA had more change in PT (15.2 vs. 7.3), PI-LL (20.6 vs. 13.7), LL (-21.4 vs. -13.1), and T10-L2 (-4.9 vs. -1.1) (all p < .001), allowing the femurs to change position despite reduced hip ROM. SOA had greater TPA reduction (15.1 vs. 9.6) and less PFSA change (86.7 vs. 88.8) compared with LOA (both p < .001)., Conclusions: Spinopelvic compensatory mechanisms are adapted for reduced hip joint motion associated with hip OA in standing and sitting., Level of Evidence: Level III., (Copyright © 2019 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background: Congenital scoliosis (CS) is associated with more rigid, complex deformities relative to adolescent idiopathic scoliosis (AIS) which theoretically increases surgical complications. Despite extensive literature studying AIS patients, few studies have been performed on CS patients. The purpose of this study was to evaluate complications associated with spinal fusions for CS and AIS., Methods: A retrospective review of the Kid's Inpatient Database (KID) years 2000 to 2009 was performed. Inclusion: patients under 20 years with ICD-9 diagnosis codes for idiopathic scoliosis (IS-without concomitant congenital anomalies) and CS, undergoing spinal fusion from the KID years 2000 to 2009. Two analyses were performed according to age below 10 years and 10 years and above. Univariate analysis described differences in demographics, comorbidities, intraoperative complications, and clinical values between groups. Binary logistic regression controlling for age, sex, race, and invasiveness predicted complications risk in CS (odds ratios; 95% confidence interval)., Results: In total, 25,131 patients included (IS, n=22443; CS, n=2688). For patients under age 10, CS patients underwent 1 level shorter fusions (P<0.001), had fewer comorbidities (P<0.001), and sustained similar complication incidence. In the 10 and over age analysis, CS patients similarly had shorter fusions, but greater comorbidities, and significantly more complications (odds ratio, 1.6; confidence interval, 1.4-1.8)., Conclusions: CS patients have higher in-hospital complication rates. With more comorbidities, these patients have increased risk of sustaining procedure-related complications such as shock, infection, and Adult Respiratory Distress Syndrome. These data help to counsel patients and their families before spinal fusion., Level of Evidence: Level III-retrospective review of a prospectively collected database.

Background: A variety of techniques have been utilized to improve the accuracy of pedicle screw instrumentation. Recently, a novel handheld computerized drill system, IntelliSense Drill Technology, has been used in orthopedic trauma to improve drilling accuracy and reduce radiation and iatrogenic injury. The specialized drill technology detects changes in cortical density to prevent inadvertent cortical violation. The aim of this study is to assess the ability of this system to identify pedicle trajectories in the thoracic and lumbar spine compared to a standard freehand technique., Methods: Two spine surgeons, including 1 senior-level and 1 junior-level attending drilled pedicle screw tracts using a freehand technique and computerized drill technology in 4 cadaveric spines from T2 to S1. A total of 134 pedicle screws were placed, including 70 by the senior surgeon and 64 by the junior surgeon. Cortical violations were assessed using computed tomography after instrumenting each pedicle tract, and procedure time for insertion of pedicle screws was recorded., Results: A total of 15 (22.4%) and 12 (18.2%) pedicle violations were noted using the freehand and computerized drill technique, respectively ( P  = .767). Perforations using the computerized drill decreased from 31.1% in the first attempt to 5.9% in the second attempt (P  = .027). Mean drill time per pedicle using the freehand and computerized drill techniques were comparable (12.2 ± 8.4 versus 12.1 ± 13.2, P  = .871), and both surgeons had an improvement in procedure time using the computerized drill (surgeon 1: 12.3 ± 13.7-5.7 ± 3.8 [SD], P  = .059; surgeon 2: 20.3 ± 20.0-10.4 ± 5.6 [SD], P  = .063)., Conclusions: We demonstrate the use of a novel drill technology for placement of pedicle screws in the thoracic and lumbar spine. After an initial learning curve, this technology is comparable to use of a freehand technique by both a senior-level and a junior-level attending surgeon in a cadaveric model. Further investigation is needed to identify the clinical role of this technology in spine surgery., Competing Interests: Disclosures and COI: TE (personal fees from Fastenetix and K2M; other from International Spine Study Group Foundation [ISSG], Medtronic, Paradigm Spine, and Pfizer, outside the submitted work). MR (other from McGinley Orthopedics and GammaCore, outside the submitted work). For the remaining authors none declared. Funding for the cadavers was provided by a grant from K2M. The funding body played no role in the study design, collection analysis, interpretation of data, or manuscript writing.

Study Design: Retrospective cohort study., Objective: To evaluate the ability of patient reported outcome measurement information system (PROMIS) assessments to capture disability related to cervical sagittal alignment and secondarily to compare these findings to legacy outcome measures., Summary of Background Data: PROMIS is a validated patient-reported outcome metric that is increasing in popularity due to its speed of administration relative to legacy metrics. The ability of PROMIS to capture disability from sagittal alignment and baseline health status in patients with neck pain has not been investigated., Methods: Patients presenting with a chief complaint of neck pain from December 2016 to July 2017 were included. Demographics and comorbidities were retrospectively collected. All patients prospectively completed the neck disability index (NDI), EQ-5D, visual analog scale (VAS) neck, VAS arm, PROMIS physical function, PROMIS pain intensity, and PROMIS pain interference metrics. Cervical sagittal alignment parameters were measured on standing X-rays. The correlations between outcome measures, health status indexes, psychiatric diagnoses, and sagittal alignment were analyzed., Results: Two hundred twenty-six patients were included. The sample was 58.4% female with a mean age of 55.1 years. In patients with neck pain, PROMIS physical function correlated strongly with the NDI (r = -0.763, P < 0.01), EQ-5D (r = 0.616, P < 0.01), VAS neck pain (-0.466, P < 0.01), and VAS arm pain (r = -0.388, P < 0.01). One hundred seventy-seven patients (69.96%) were included in the radiographic analysis. 20.3% of the radiographic cohort had cervical deformity and in this group, less cervical lordosis correlated with PROMIS pain intensity and EQ-5D but not NDI. In patients without cervical deformity, no outcome metric was found to correlate significantly with cervical alignment parameters., Conclusion: PROMIS domains correlated strongly with legacy outcome metrics. For the whole cohort, sagittal alignment was not correlated with outcomes. In patients with sagittal cervical deformity, worsening alignment correlated with PROMIS pain intensity and EQ-5D but not NDI., Level of Evidence: 3.

Background: Given the paucity of literature regarding compensatory mechanisms used by obese patients with sagittal malalignment, it is necessary to gain a better understanding of the effects of obesity on compensation after comparing the degree of malalignment to age-adjusted ideals. This study aims to compare baseline alignment of obese and nonobese patients using age-adjusted spino-pelvic alignment parameters, describing associated spinal changes., Methods: Patients ≥ 18 years with full-body stereoradiographs were propensity-score matched for sex, baseline pelvic incidence (PI), and categorized as nonobese (body mass index < 30kg/m 2 ) or obese (body mass index ≥ 30). Age-adjusted ideals were calculated for sagittal vertical axis, spino-pelvic mismatch (PI-LL), pelvic tilt, and T1 pelvic angle using established formulas. Patients were stratified as meeting alignment ideals, being above ideal, or being below. Spinal alignment parameters included C0-C2, C2-C7, C2-T3, cervical thoracic pelvic angle, cervical sagittal vertical axis SVA, thoracic kyphosis, T1 pelvic angle, T1 slope, sagittal vertical axis, lumbar lordosis (LL), PI, PI-LL, pelvic tilt. Lower-extremity parameters included sacrofemoral angle, knee flexion (KA), ankle flexion (AA), pelvic shift (PS), and global sagittal angle (GSA). Independent t tests compared parameters between cohorts., Results: Included: 800 obese, 800 nonobese patients. Both groups recruited lower-extremity compensation: sacrofemoral angle ( P  = .004), KA, AA, PS, GSA (all P  < .001). Obese patients meeting age-adjusted PI-LL had greater lower-extremity compensation than nonobese patients: lower sacrofemoral angle ( P  = .002), higher KA ( P  = .008), PS ( P  = .002), and GSA ( P  = .02). Obese patients with PI-LL mismatch higher than age-adjusted ideal recruited greater lower-extremity compensation than nonobese patients: higher KA, AA, PS, GSA (all P  < .001). Obese patients showed compensation through the cervical spine: increased C0-C2, C2-C7, C2-T3, and cervical sagittal vertical axis (all P  < .001), high T1 pelvic angle ( P  < .001), cervical thoracic pelvic angle ( P  = .03), and T1 slope ( P  < .001), with increased thoracic kyphosis ( P  = .015) and decreased LL ( P  < .001) compared to nonobese patients with PI-LL larger than age-adjusted ideal., Conclusions: Regardless of malalignment severity, obese patients recruited lower-limb compensation more than nonobese patients. Obese patients with PI-LL mismatch larger than age-adjusted ideal also develop upper-cervical and cervicothoracic compensation for malalignment., Level of Evidence: III., Clinical Relevance: Clinical evaluation should extend to the cervical spine in obese patients not meeting age-adjusted sagittal alignment ideals., Competing Interests: Disclosures and COI: The authors report no conflicts of interest concerning the materials or methods used in this study or the findings specified in this paper. Ethics Review Committee Statement: Institutional Review Board approval was obtained for this study, prior to patient enrollment.

Study Design: Retrospective analysis of Medicare claims and procedure details from a single institution participation in the Bundled Payments for Care Improvement (BPCI) program., Objective: To analyze the effects of the BPCI program on patient outcome metrics and cost data., Summary of Background Data: The BPCI program was designed to improve the value of care provided to patients, but the financial consequences of this system remain largely unknown. We present 2 years of data from participation in the lumbar spine fusion bundle at a large, urban, academic institution., Methods: In 2013 and 2014, all Medicare patients undergoing lumbar spine fusions for DGR 459 (spinal fusion except cervical with major complication or comorbidity [MCC]) and 460 (without MCC) at our institution were enrolled in the BPCI program. We compared the BPCI cohort to a baseline cohort of patients under the same diagnosis related groups (DRGs) from 2009 to 2012 from which the target price was established., Results: Three hundred fifty patients were enrolled into the BPCI program, while the baseline group contained 518 patients. When compared with the baseline cohort, length of stay decreased (4.58 ± 2.51 vs. 5.13 ± 3.75; P = 0.009), readmission rate was unchanged, and discharges with home health aid increased. Nonetheless, we were unable to effect an episode-based cost savings ($52,655 ± 27,028 vs. $48,913 ± 24,764). In the larger DRG 460 group, total payments increased in the BPCI group ($51,105 ± 26,347 vs. $45,934 ± 19,638, P = 0.001). Operative data demonstrated a more complex patient mix in the BPCI cohort. The use of interbody fusions increased from 2% to 16% (P < 0.001), and the percentage of complex spines increased from 23% to 45% (P < 0.001)., Conclusion: Increased case complexity was responsible for increasing costs relative to the negotiated baseline target price. This payment system may discourage advancement in spine surgery due to the financial penalty associated with novel techniques and technologies., Level of Evidence: 3.

Study Design: A retrospective analysis of a patient-reported outcomes database from a single institution from December 2016 to April 2017., Objective: To validate the association of Patient Reported Outcome Measurement Information System (PROMIS) with Neck Disability Index (NDI) in patients with neck pain and examine each instruments ability to capture concomitant arm pain and concomitant back pain., Summary of Background Data: PROMIS has been increasingly utilized and its computer adapted testing methodology improves assessment of pain and disability. However, literature is lacking regarding how these instruments perform in neck pain patients with concomitant arm pain or back pain., Methods: Inclusion criteria were age >18 years and a primary complaint of neck pain. The NDI; Visual Analog Scale (VAS) back, neck, arm, and leg; and PROMIS physical function, pain intensity, and pain interference questionnaires were administered. Propensity score matching was performed to compare patients with high and low back and arm pain by controlling for neck pain. Bivariate correlations and independent samples t tests were performed to assess linear relationships and compare back and arm pain groups with PROMIS., Results: Approximately, 130 patients were included. NDI correlated strongly to PROMIS physical function (r = -0.771, P < 0.001), pain intensity (r = 0.605, P < 0.001), and pain interference (r = 0.786, P < 0.001). VAS neck and arm pain also correlated to the PROMIS pain intensity instrument (VAS neck: r = 0.642, P < 0.001; VAS arm: r = 0.376, P < 0.001).After matching for neck pain, the high and low back pain groups each included 32 patients. There were significant differences in PROMIS physical function when high and low back pain groups were compared (39.07 vs. 43.68, P = 0.031). No significant difference was found for any outcome metric for high and low arm pain groups., Conclusion: PROMIS instruments are capable of characterizing pain and disability in patients with neck pain and are sensitive to disability in regions adjacent to the neck., Level of Evidence: 3.

Objective: The Patient-Reported Outcomes Measurement Information System (PROMIS) has become increasingly popular due to computer adaptive testing methodology. This study aims to validate the association between PROMIS and legacy outcome metrics and compare PROMIS to legacy metrics in terms of ceiling and floor effects and questionnaire burden., Methods: A retrospective review of an outcomes database was performed at a single institution from December 2016 to April 2017. Inclusion criteria were age > 18 years and a chief complaint of back pain or neck pain. The PROMIS computer adaptive testing Pain Interference, Physical Function (PF), and Pain Intensity domains; Oswestry Disability Index (ODI); Neck Disability Index (NDI); and visual analog scale (VAS) back, VAS leg, VAS neck, and VAS arm were completed in random order. PROMIS was compared to legacy metrics in terms of the average number of questions needed to complete each questionnaire and the score distributions in the lower and higher bounds of scores., Results: A total of 494 patients with back pain and 130 patients with neck pain were included. For back pain, ODI showed a strong correlation with PROMIS-PF (R = -0.749, p < 0.001), Pain Intensity (R = 0.709, p < 0.001), and Pain Interference (R = 0.790, p < 0.001) domains. Additionally, the PROMIS Pain Intensity domain correlated to both VAS back and neck pain (R = 0.642, p < 0.001 for both). PROMIS-PF took significantly fewer questions to complete compared to the ODI (4.123 vs 9.906, p < 0.001). When assessing for instrument sensitivity, neither survey presented a significant ceiling and floor effect in the back pain population (ODI: 0.40% and 2.63%; PROMIS-PF: 0.60% and 1.41%). In the neck pain cohort, NDI showed a strong correlation with PROMIS-PF (R = 0.771, p < 0.001). Additionally, PROMIS Pain Intensity correlated to VAS neck (R = 0.642, p < 0.001). The mean number of questions required to complete the questionnaire was much lower for PROMIS-PF compared to NDI (4.417 vs 10, p < 0.001). There were no significant differences found in terms of ceiling and floor effects for neck complaints (NDI: 2.3% and 6.92%; PROMIS-PF: 0.00% and 5.38%) or back complaints (ODI: 0.40% and 2.63%; PROMIS-PF: 1.41% and 0.60%)., Conclusions: PROMIS correlates strongly with traditional disability measures in patients with back pain and neck pain. For both back and neck pain, the PROMIS-PF required patients to answer significantly fewer questions to achieve similar granularity. There were no significant differences in ceiling and floor effects for NDI or ODI when compared with the PROMIS-PF instrument.

Background: The impact of obesity on global spinopelvic alignment is poorly understood. This study investigated the effect of body mass index on achieving alignment targets and compensation mechanisms after corrective surgery for adult spinal deformity (ASD)., Methods: Retrospective review of a single-center database. Inclusion: patients ≥18 years with full-body stereographic images (baseline and 1 year) and who met ASD criteria (sagittal vertical axis [SVA] >5 cm, pelvic incidence minus lumbar lordosis [PI-LL] >10°, coronal curvature >20° or pelvic tilt >20°). Patients were stratified by age (<40, 40-65, and ≥65 years) and body mass index (<25, 25-30, and >30). Postoperative alignment was compared with age-adjusted ideal values. Prevalence of patients who matched ideals and unmatched (undercorrected/overcorrected) was assessed. Health-related quality of life (HRQL) scores, alignment, and compensatory mechanisms were compared across cohorts using analysis of variance and temporally with paired t tests., Results: A total of 116 patients were included (average age, 62 years; 66% female). After corrective surgery, obese and overweight patients had more residual malalignment (worse PI-LL, T1 pelvic angle, pelvic tilt, and SVA) compared with normal patients (P < 0.05). In addition, obese and overweight patients recruited more pelvic shift (obese, 62.36; overweight, 49.80; normal, 31.50) and had a higher global sagittal angle (obese, 6.51; overweight, 6.35; normal, 3.40) (P < 0.05). Obese and overweight patients showed lower overcorrection rates and higher undercorrection rates (P < 0.05). Obese patients showed worse postoperative HRQL scores (Scoliosis Research Society 22 Questionnaire, Oswestry Disability Index, visual analog scale-leg) than did overweight and normal patients (P < 0.05). Obese and overweight patients who matched age-adjusted alignment targets for SVA or PI-LL showed no HRQL improvements (P > 0.05)., Conclusions: After surgery, obese patients were undercorrected, showed more residual malalignment, recruited more pelvic shift, and had a greater global sagittal angle and worse HRQL scores. The benefits from age-adjusted alignment targets seem to be less substantial for obese and overweight patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Study Design: A retrospective review was conducted of 57 consecutive patients (26 female; mean age: 16.6 years) who underwent posterior or combined anterior-posterior spinal fusion for neuromuscular scoliosis (NMS) from 2006 and 2007., Objectives: We aimed to assess which patient and surgical factors are predictive of increased blood loss and transfusion requirements during spinal fusion for NMS., Background: Spinal fusion surgery in patients with NMS has been associated with significant intraoperative blood loss and transfusion requirements. Specific factors predictive of greater blood loss have not been delineated; recognizing these factors will assist predicting the need for blood products and antifibrinolytics., Methods: Data gathered included demographic, operative (operative time, levels fused, estimated blood loss, cell saver transfused, IV fluids transfused, and units transfused), and laboratory parameters (hemoglobin, hematocrit, platelet count, prothrombin time, partial prothrombin time, and international normalized ratio). Multivariate linear regression was used to identify parameters associated with greater intraoperative blood loss and transfusion requirements., Results: Eighty-three percent of patients underwent primary surgery with mean levels fused of 13.5. Regression analysis showed a statistically significant increase in blood loss with age (p = 0.00), operative time (p = 0.00), and postoperative platelets (p = 0.016). Each year of increasing age corresponded with an increase of 50 cc of estimated blood loss (EBL). Each additional hour of operative time was associated with an additional EBL of 147.7 cc. Each additional unit of postoperative platelets was associated with an EBL decrease of 2.8 cc. Units transfused increased with age (p = 0.00): each year of increasing age corresponded with an increase of 0.04 units of blood transfused., Conclusions: Patients with NMS remain a challenging group of patients to treat. We find that age, operative time, and postoperative platelets are predictive of increased blood loss while only age was related to greater transfused units. Our findings may predict the need for blood products and antifibrinolytic agents preoperatively in this heterogeneous population, especially as patients age.

Study Design: Consensus-building using the Delphi and nominal group technique., Objective: To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery., Summary of Background Data: Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed., Methods: The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting., Results: Participants had a mean of 13.4 years of practice (range: 2-32 years) and 103.1 (range: 50-250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants., Conclusion: We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery., Level of Evidence: Level V., (Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background: Hospital length of stay (LOS), 30-day readmission rate, and other metrics are increasingly being used to evaluate quality of surgical care. The factors most relevant to cervical spondylotic myelopathy (CSM) are not yet established., Objective: To identify perioperative factors associated with extended LOS and 30-day readmission following elective surgery for CSM., Methods: Surgical CSM patients at institutions represented by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) during 2010-2012 were included. Patients with fracture, 9 or more levels fused, or cancer were excluded. Extended LOS was defined as 75th percentile of the cohort. Univariate analysis and multivariate logistic regression identified predictors for extended LOS, 30-day readmission, and reoperation. Linear regression modeling was used to evaluate variables., Results: Three thousand fifty-seven surgical CSM cases were isolated. Age (odds ratio [OR], 1.496), diabetes (OR, 1.691), American Society of Anesthesiologists (ASA) class (OR, 2.081), posterior surgical approach (OR, 2.695), and operative time (OR, 1.008) were all positive predictors (P < 0.05) for extended LOS (≥4 days). Thirty-two percent of the cohort (976 patients) had 30-day readmission data. Among these, 915 patients were not readmitted (93.8%), while 61 (6.2%) were readmitted. Diabetes (OR, 1.460) and ASA class (OR, 2.539) were significant positive predictors for hospital readmission. Age (OR, 0.918) was a negative predictor of re-operation in readmitted patients, and pulmonary comorbidities (OR, 4.584) were a positive predictor (P < 0.05)., Conclusions: Patients with diabetes and higher ASA class were at increased risk for extended LOS and readmission within 30-days. Patients with increased operative time have greater risk for extended LOS. Preoperative pulmonary comorbidities increased reoperation risk, whereas increased age reduced the risk. Attention to these factors may benefit CSM patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: While there is a consensus that pelvic incidence (PI) remains constant after skeletal maturity, recent reports argue that PI increases after 60 years. This study aims to investigate whether PI increases with age and to determine potential associated factors., Methods: 1510 patients with various spinal degenerative and deformity pathologies were enrolled, along with an additional 115 asymptomatic volunteers. Subjects were divided into six age subgroups with 10-year intervals., Results: PI averaged 54.1° in all patients. PI was significantly higher in the 45-54-year age group than 35-44-year age group (55.8° vs. 49.7°). There were significant PI differences between genders after age 45. Linear regression revealed age, gender and malalignment as associated factors for increased PI with R 2 of 0.22 (p < 0.001)., Conclusions: PI is higher in female patients and in older patients, especially those over 45 years old. Spinal malalignment also may have a role in increased PI due to increased L5-S1 bending moment.

Purpose: A comprehensive understanding of normative sagittal profile is necessary for adult spinal deformity. Roussouly described four sagittal alignment types based on sacral slope, lumbar lordosis, and location of lumbar apex. However, the lower limb, a newly described component of spinal malalignment compensation, is missing from this classification. This study aims to propose a full-body sagittal profile classification in an asymptomatic population based on full-body imaging., Methods: This is a retrospective analysis of a prospective single-center study of 116 asymptomatic volunteers. Cluster analysis including all sagittal parameters was first performed, and then ANOVA was performed between sub-clusters to eliminate the non-significantly different parameters. This loop was repeated until all parameters were significantly different between each sub-cluster., Results: Three types of full-body sagittal profiles were finalized according to cluster analysis with ten radiographic parameters: hyperlordosis type (77 subjects), neutral type (28 subjects), and compensated type (11 subjects). Radiographic parameters included knee angle, pelvic shift, pelvic angle, PT, PI-LL, C7-S1 SVA, TPA, T1 slope, C2-C7 angle, and C2-C7 SVA. Age was significantly different across compensation types, while BMI and gender were comparable. Age-matched subjects were randomly selected with 11 subjects in each type. ANOVA analysis revealed that all parameters but PT and C2-C7 angle remained significantly different., Conclusions: The current three compensation types of full-body sagittal profiles in asymptomatic adults included significant changes from cervical region to knee, indicating that subjects should be evaluated with full-length imaging. All three types exist regardless of age, but the distribution may vary.

Pelvic tilt is an essential parameter in spinal deformity surgery and in acetabular positioning for total hip arthroplasty. However, the measurement of tilt varies between the hip and spine literature. Hip surgeons measure the anterior pelvic plane tilt, whereas spine surgeons measure the spinopelvic tilt. This study uses stereoradiography (EOS imaging SA, Paris, France) to assess the relationship and the inter-observer and intra-observer reliability of measuring these two common references for pelvic tilt. Retrospective analysis of full-body, standing stereoradiographic studies of 100 patients with varying degrees of spinal deformity was performed at a single institution. Assessment of anterior pelvic plane and spinopelvic tilt were undertaken by two orthopaedic surgeons and two orthopaedic residents using validated software. The pelvic incidence and sacral slope were also measured. The mean difference between anterior pelvic plane and spinopelvic tilt was 13.98° ± 7.04°, and the values were linearly inversely related. Both measures of tilt were strongly correlated with each other. Spinopelvic tilt has greater inter- and intra-user reliability and was a more precise measurement than anterior pelvic plane. Spinopelvic tilt is a more precise and reliable measurement than the anterior pelvic plane tilt; however, both measurements are strongly correlated. The clinical implications of this are not completely understood; however, it may be important for hip surgeons when placing acetabular components with precision. Further investigation is needed to assess which is a more accurate reference for the placement of acetabular components in hip arthroplasty.

Study Design: Retrospective study., Objective: The aim of this study was to propose radiographic characteristics of patients with cervical disability and to investigate the relevant parameters when assessing cervical alignment., Summary of Background Data: Although cervical kyphosis is traditionally recognized as presentation of cervical deformity, an increasing number of studies demonstrated that cervical kyphosis may not equal cervical deformity. Therefore, several other differentiating criteria for cervical deformity should be investigated and supported with quality of life scores., Methods: A database of full-body radiographs was retrospectively reviewed. Patients without previous cervical surgery, with a well-aligned thoracolumbar profile (defined as T1 pelvis angle <15°), and with an available Neck Disability Index (NDI) score were reviewed in this study. Subjects were stratified into an asymptomatic (64 subjects with NDI ≤15, Visual Analogue Scale [VAS] neck ≤3, and VAS arm ≤3) and a symptomatic group (107 subjects with NDI >15, VAS neck >3, or VAS arm >3). Independent t tests were performed to investigate differences between two groups. Logistic regressions and principal component analyses were then performed., Results: NDI averaged 5.43 in asymptomatic group, significantly smaller than symptomatic group (5.43 vs. 41.25). t Test revealed that C2-C7 sagittal vertical axis (SVA), McGregor slope, and the slope of line of sight (SLS) were significantly different while C2-C7 angle (cervical curvature, CC) did not show statistical difference (P = 0.09). Logistic regressions were performed using the significantly different parameters as well as CC. Results identified C2-C7 SVA and SLS as independent risk factors for low health-related quality of life. The principal component analysis leads to a new factor (0.55 × C2C7SVA + 0.34 × COC2 + 0.77 × CC) with strong correlations with NDI, VAS, and EQ5D measurements., Conclusion: The traditional concept of cervical kyphosis should not be regarded as a standalone criterion of cervical deformity. The most clinically relevant components of cervical analysis are the C2-C7 SVA, C0C2 angle, and C2C7 angle. In addition, the three components should be assessed together in harmony and not individually., Level of Evidence: 4.

Background Context: Adult spinal deformity (ASD) represents a constellation of complex malalignments affecting the spinal column. Corrective surgical procedures aimed at improving ASD can be equally challenging, and commonly require multiple index procedures and potential revisions before definitive management. There is a paucity of data comparing the outcomes of same-day(simultaneous [SIM]) and 2-day (staged [STA]) procedures for long spinal fusions for ASD. Using a large patient cohort with surgeon- and patient-reported outcomes will be particularly useful in determining the utility and effect of staging long spinal fusions for ASD., Purpose: This study aimed to compare intraoperative, perioperative, and 2-year outcomes of STA and SIM procedures correcting ASD., Study Design: This is a retrospective analysis of a prospective multicenter database., Patient Sample: A total of 142 patients (71 STA, 71 SIM) were included., Outcome Measures: Primary outcome measures were intra- and perioperative (6 weeks) complication rates. Secondary outcome measures were 2-year thoracolumbar and spinopelvic radiographic parameters, 2-year health-related quality of life (HRQoL) changes (Oswestry Disability Index [ODI] and Short Form-36 [SF-36]), and 2-year complication rates., Methods: Inclusion criteria included patients with ASD ≥18 years with 6-week and 2-year follow-up. Propensity score matching identified similar patients undergoing STA or SIM long spinal fusions based on surgical invasiveness, pelvic tilt, and sagittal vertical axis (SVA). Complications, HRQoL scores (Scoliosis Research Society-22 Patient Questionnaire [SRS-22r], SF-36, ODI), and patient characteristics were compared across and within treatment groups at follow-up with analysis of variance (ANOVA) and paired t tests at three surgical stages: intraoperatively, perioperatively (6 weeks), and postoperatively (>6 weeks)., Results: A total of 142 patients were included (71 STA, 71 SIM). Matching STA and SIM groups based on degree of deformity and surgical invasiveness created two groups similar in overall correction of the surgery. Patients undergoing STA underwent more anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) procedures, whereas patients undergoing SIM had longer fusions. Charlson comorbidity index and revision status were similar between groups (p>.05). Staging procedures had significantly more complications causing reoperation (STA: 47% vs. SIM: 8%, p=.021), and had a greater number of perioperative complications requiring a return to the operating room (OR) (STA: 9.9% vs. SIM: 1.4%, p=.029). There was no difference in intraoperative complications, mortality, or perioperative infection or wound complications (p>.05) between the two procedures. At 2-year follow-up, incidence of revision surgery was higher in STA (STA: 21.1% vs. SIM: 8.5%, p=.033)., Conclusion: Staged spinal fusions, which add ALIFs and LLIFs to the procedure, compared with similar-correction SIM procedures, result in similar intraoperative complication incidence, but significantly higher rates of peri- and postoperative complications leading to revision. Functional outcomes, radiographic parameters, and mortality were similar. This will aid surgeons in their determination of the optimal treatment for such complex procedures., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Design: Retrospective review of prospectively collected data., Objective: Assess outcomes of adult spinal deformity (ASD) surgery performed by one versus two attending surgeons., Summary of Background Data: ASD centers have developed two attending teams to improve efficiency; their effects on complications and outcomes have not been reported., Methods: Patients with ASD with five or more levels fused and more than 2-year follow-up were included. Estimated blood loss (EBL), length of stay (LOS), operating room (OR) time, complications, quality of life (Health Related Quality of Life), and x-rays were analyzed. Outcomes were compared between one-surgeon (1S) and two-surgeon (2S) centers. A deformity-matched cohort was analyzed., Results: A total of 188 patients in 1S and 77 in 2S group were included. 2S group patients were older and had worse deformity based on the Scoliosis Research Society-Schwab classification (P < 0.05). There were no significant differences in levels fused (P = 0.57), LOS (8.7 vs 8.9 days), OR time (445.9 vs 453.2 min), or EBL (2008 vs 1898 cm; P > 0.05). 2S patients had more three-column osteotomies (3CO; P < 0.001) and used less bone morphogenetic protein 2 (BMP-2; 79.9% vs 15.6%; P < 0.001). The 2S group had fewer intraoperative complications (1.3% vs 11.1%; P = 0.006). Postoperative (6 wk to 2 yr) complications were more frequent in the 2S group (4.8% vs 15.6%; P < 0.002). After matching for deformity, there were no differences in (9.1 vs 10.1 days), OR time (467.8 vs 508.4 min), or EBL (3045 vs 2247 cm; P = 0.217). 2S group used less BMP-2 (20.6% vs 84.8%; P < 0.001), had fewer intraoperative complications (P = 0.015) but postoperative complications due to instrumentation failure/pseudarthrosis were more frequent (P < 0.01)., Conclusion: No significant differences were found in LOS, OR time, or EBL between the 1S and 2S groups, even when matching for severity of deformity. 2S group had less BMP-2 use, fewer intraoperative complications but more postoperative complications., Level of Evidence: 2.

Study Design: A comparative effectiveness database study., Objective: The aim of this study was to describe variation in use of adjuvant therapies for managing postoperative pain in in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and determine association between use of these therapies and patient outcomes., Summary of Background Data: Variation in postoperative pain management for children undergoing PSF for AIS likely impacts outcomes. Minimal evidence exists to support strategies that most effectively minimize prolonged intravenous (IV) opioids and hospitalizations., Methods: We included patients aged 10 to 18 years discharged from one of 38 freestanding children's hospitals participating in a national database from December 1, 2012, to January 5, 2015, with ICD9 codes indicating scoliosis and PSF procedure. Use of ketorolac, gamma aminobutyric acid (GABA) analogues (GABAa), and benzodiazepines was compared across hospitals. Hierarchical logistic regression adjusting for confounders and accounting for clustering of patients within hospitals was used to estimate association between these therapies and odds of prolonged duration of IV opioids, prolonged length of stay (LOS), and early readmissions., Results: Across hospitals, use of ketorolac and GABAa was highly variable and increased over time among 7349 subjects. Use of ketorolac was independently associated with significantly lower odds of prolonged LOS [odds ratio (OR) 0.75, 95% confidence interval (95% CI) 0.64-0.89] and prolonged duration of IV opioid (OR 0.84, 95% CI 0.73-0.98). GABAa use was significantly associated with decreased odds of prolonged IV opioid use (OR 0.63, 95% CI 0.53-0.75). Readmission rate at 30 days was 1.6% and most strongly associated with prolonged LOS., Conclusion: In this national cohort of children with AIS undergoing PSF, patients who received postoperative ketorolac or GABAa were less likely to have prolonged IV opioid exposure. Given the rapid increase in use of adjuvant therapies without strong evidence, resources should be devoted to multicenter trials in order to optimize effectiveness and outcomes., Level of Evidence: 3.

Study Objective: Perioperative thrombotic complications after orthopedic surgery are associated with significant morbidity and mortality. The use of aspirin to reduce perioperative cardiovascular complications in certain high-risk cohorts remains controversial. Few studies have addressed aspirin use, bleeding, and cardiovascular outcomes among high-risk patients undergoing joint and spine surgery., Design/setting/patients: We performed a retrospective comparison of adults undergoing knee, hip, or spine surgery at a tertiary care center during 2 periods between November 2008 and December 2009 (reference period) and between April 2013 and December 2013 (contemporary period)., Measurements: Patient demographics, comorbidities, management, and outcomes were ascertained using hospital datasets., Main Results: A total of 5690 participants underwent 3075 joint and spine surgeries in the reference period and 2791 surgeries in the contemporary period. Mean age was 61±13 years, and 59% were female. In the overall population, incidence of myocardial injury (3.1% vs 5.8%, P<.0001), hemorrhage (0.2% vs 0.8%, P=.0009), and red blood cell transfusion (17.2% vs 24.8%, P<.001) were lower in the contemporary period. Among 614 participants with a preoperative diagnosis of coronary artery disease (CAD), in-hospital aspirin use was significantly higher in the contemporary period (66% vs 30.7%, P<.0001); numerically, fewer participants developed myocardial injury (13.5% vs 19.3%, P=.05), had hemorrhage (0.3% vs 2.1%, P=.0009), and had red blood cell transfusion (37.2% vs 44.2%, P<.001) in the contemporary vs reference period., Conclusions: In a large tertiary care center, the incidence of perioperative bleeding and cardiovascular events decreased over time. In participants with CAD, perioperative aspirin use increased and appears to be safe., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Pre-donation of autologous blood prior to spine fusion for adolescent idiopathic scoliosis (AIS) has been used in deformity surgery. The effect of pre-donation on pre-operative hematocrit (Hct) remains debated. Multiple factors may influence pre-operative Hct including intravascular volume status, patient factors, and timing of pre-operative blood donation. The purpose of this study was to determine if pre-donation significantly lowers pre-incision Hct in AIS patients., Methods: A retrospective cohort study of a Level-1 prospective randomized trial was conducted. 125 patients from the homogeneous population were included. AIS patients undergoing a posterior only spinal fusion for AIS were separated into two groups based on their pre-operative blood donation history. Demographic variables, pre-incision Hct, and transfusion rates were compared between the two groups using the Student's T-test., Results: Pre-donation and non pre-donation groups had 28 and 97 patients, respectively. Pre-donation group was 75% female (21F, 7M) and non pre-donation group was 78% female (76F, 21M). There was no difference between pre-donation and non pre-donation groups in mean age (15.6 ± 2.2 vs 14.8 ± 2.2, p = 0.081), BMI (23.1 ± 4.2 vs 21.7 ± 5.3, p = 0.219), and pre-incision Hct (32.8 ± 3.4 vs 33.8 ± 3.1, p = 0.628). The overall transfusion rates were equivalent (32.1± 48.0% vs 25.8 ± 44.0%, p = 0.509), however, the rate of allogenic transfusion for the pre-donation group was significantly lower (3.6 ± 18.9% vs 25.8 ± 44.0%, p = 0.011)., Conclusions: This study supports the use of pre-donation for AIS, without a significant drop in pre-incision Hct. Patients that donate are also much less likely to be exposed to allogenic blood. There may be a surgeon bias to recommend pre-donation in patients with a larger BMI and older age. Future studies are needed from a larger population of patients including those with non-AIS pathology., Level of Evidence: Level III.

Background: High-quality studies that compare operative and nonoperative treatment for adult spinal deformity (ASD) are needed., Objective: To compare outcomes of operative and nonoperative treatment for ASD., Methods: This is a multicenter, prospective analysis of consecutive ASD patients opting for operative or nonoperative care. Inclusion criteria were age >18 years and ASD. Operative and nonoperative patients were propensity matched with the baseline Oswestry Disability Index, Scoliosis Research Society-22r, thoracolumbar/lumbar Cobb angle, pelvic incidence-to-lumbar lordosis mismatch (PI-LL), and leg pain score. Analyses were confined to patients with a minimum of 2 years of follow-up., Results: Two hundred eighty-six operative and 403 nonoperative patients met the criteria, with mean ages of 53 and 55 years, 2-year follow-up rates of 86% and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At baseline, operative patients had significantly worse health-related quality of life (HRQOL) based on all measures assessed (P < .001) and had worse deformity based on pelvic tilt, pelvic incidence-to-lumbar lordosis mismatch, and sagittal vertical axis (P ≤ .002). At the minimum 2-year follow-up, all HRQOL measures assessed significantly improved for operative patients (P < .001), but none improved significantly for nonoperative patients except for modest improvements in the Scoliosis Research Society-22r pain (P = .04) and satisfaction (P < .001) domains. On the basis of matched operative-nonoperative cohorts (97 in each group), operative patients had significantly better HRQOL at follow-up for all measures assessed (P < .001), except Short Form-36 mental component score (P = .06). At the minimum 2-year follow-up, 71.5% of operative patients had ≥1 complications., Conclusion: Operative treatment for ASD can provide significant improvement of HRQOL at a minimum 2-year follow-up. In contrast, nonoperative treatment on average maintains presenting levels of pain and disability., Abbreviations: ASD, adult spinal deformityHRQOL, health-related quality of lifeLL, lumbar lordosisMCID, minimal clinically important differenceNRS, numeric rating scaleODI, Oswestry Disability IndexPI, pelvic incidenceSF-36, Short Form-36SRS-22r, Scoliosis Research Society-22rSVA, sagittal vertical axis.

Background: Preoperative anemia is a well-established risk factor for short-term mortality in patients undergoing noncardiac surgery, but appropriate thresholds for transfusion remain uncertain. The objective of this study was to determine long-term outcomes associated with anemia, hemorrhage, and red blood cell transfusion in patients undergoing noncardiac surgery., Methods: We performed a long-term follow-up study of consecutive subjects undergoing hip, knee, and spine surgery between November 1, 2008 and December 31, 2009. Clinical data were obtained from administrative and laboratory databases, and retrospective record review. Preoperative anemia was defined as baseline hemoglobin < 13 g/dL for men and < 12 g/dL for women. Hemorrhage was defined by International Classification of Diseases, Ninth Revision coding. Data on long-term survival were collected from the Social Security Death Index database. Logistic regression models were used to identify factors associated with long-term mortality., Results: There were 3050 subjects who underwent orthopedic surgery. Preoperative anemia was present in 17.6% (537) of subjects, hemorrhage occurred in 33 (1%), and 766 (25%) received at least one red blood cell transfusion. Over 9015 patient-years of follow-up, 111 deaths occurred. Anemia (hazard ratio [HR] 3.91; confidence interval [CI], 2.49-6.15) and hemorrhage (HR 5.28; 95% CI, 2.20-12.67) were independently associated with long-term mortality after multivariable adjustment. Red blood cell transfusion during the surgical hospitalization was associated with long-term mortality (HR 3.96; 95% CI, 2.47-6.34), which was attenuated by severity of anemia (no anemia [HR 4.39], mild anemia [HR 2.27], and moderate/severe anemia [HR 0.81]; P for trend .0015)., Conclusions: Preoperative anemia, perioperative bleeding, and red blood cell transfusion are associated with increased mortality at long-term follow-up after noncardiac surgery. Strategies to minimize anemia and bleeding should be considered for all patients, and restrictive transfusion strategies may be advisable. Further investigation into mechanisms of these adverse events is warranted., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Adult spinal deformity (ASD) is a complex disease comprised of different deformity types that often involve the entire spine. Accurate assessment of ASD requires a thorough radiographic evaluation of both the spine and pelvis, including concomitant assessment of the cervical, thoracic, and lumbar spine, as well as the femoral heads and pelvis. Radiographic measurements should include assessment of regional alignment (including lumbar lordosis, thoracic kyphosis, C2-C7 lordosis), global alignment (including C7 SVA, C2-C7 SVA, and T1 pelvic angle), and measures of pelvic compensation and morphology (pelvic tilt, pelvic incidence, T1 slope, and C2-pelvic tilt). Together these radiographic parameters provide important information regarding how the ASD patient maintains upright posture and correlate with the patient's pain and disability. ASD surgical planning must integrate regional, global, and pelvic compensatory/morphologic parameters to adequately correct deformity and thereby provide pain relief and improve function. Radiographic classifications for cervical and thoracolumbar deformities have been developed that utilize the regional and global measures of spinal deformity that are most predictive of patient-reported pain and function. These classifications are aimed to standardize the assessment of ASD to aid in clinical management and to facilitate future research on the evaluation and treatment of ASD.

Study Design: Retrospective., Objective: This study assessed the feasibility of combining Oswestry and Neck Disability Index (ODI and NDI) into 1 shorter "Total Disability Index" (TDI) from which reconstructed scores could be computed., Summary of Background Data: ODI and NDI are not pure assessments of disability related to back and neck, respectively. Because of similarities/redundancies of questions, ODI scores may be elevated in neck-pain patients and the converse is true for NDI in back-pain patients., Methods: Spine patients completed ODI and NDI, and complaints were recorded as back pain (BP), neck pain (NP), or both (BNP). Questionnaire scores were compared across cohorts via descriptives and Spearman (ρ) correlations. In exploring the feasibility of merging ODI/NDI, TDI was constructed from 9 ODI and 5 NDI items. Extracting questions from TDI, reconstructed 9-item rODI and 10-item rNDI indices were formed and compared with true ODI/NDI., Results: There were a total of 1207 patients: 741 BP, 134 NP, and 268 BNP. Mean ODI was 37 ± 21 and mean NDI was 32 ± 21. Patients with concurrent BP and NP had significantly more disability. Seventy-eight patients of 134 (58%) patients with NP only had at least "moderate disability" by ODI and 297 of 741 (40%) patients with back pain only, had at least "moderate disability" by NDI. ODI versus NDI correlation was ρ = 0.755; ODI versus reconstructed rODI correlated at ρ = 0.985, and NDI versus reconstructed rNDI correlated at ρ = 0.967 (P < 0.01)., Conclusion: Elevated ODI/NDI scores in patients with isolated complaints show that disability in 1 region affects scores on both surveys. This study constructed a 14-item TDI that represents every domain of ODI/NDI with exception of ODI "Sex Life." From this TDI, reconstructed scores correlated near perfectly with true scores. TDI provides a more global assessment of spinal disability and is a questionnaire that reduces the time burden to patients. The TDI allows for simultaneous assessment of back, neck, and global spinal disability.

Study Design: A multicenter, prospective review of surgical patients with adult spine deformity., Objective: Assessment of the incidence, risk factor, and impact of radiographical and implant-related complications (RIC) on health-related quality of life measures., Summary of Background Data: This study provides assessment of the incidence of RIC in adult spinal deformity surgery and impact of these complications on need for reoperation. Risk factors for development of RIC are also assessed, as well as the impact of these complications on health-related quality of life (HRQOL) outcomes measures., Methods: A multicenter, prospective database of surgical patients with adult spinal deformity was reviewed. All patients with complete 2-year follow-up were included. HRQOL was measured using the Oswestry Disability Index, General Health Survey (36-Item Short Form Health Survey [SF-36]), and Scoliosis Research Society-22 (SRS-22r) at baseline, 6 weeks, 1 year, and 2 years postoperatively. Univariate testing was performed as appropriate. Multivariate logistic regression modeling was used to determine independent predictors of RIC. Multivariate repeated-measures mixed models were used to examine HRQOL, accounting for confounders., Results: A total of 245 patients met inclusion criteria. The incidence of RIC was 31.7% and 52.6% of those patients required reoperation. Rod breakage accounted for 47% of the implant-related complications, and proximal junctional kyphosis accounted for 54.5% of radiographical complications. Univariate analysis identified the following potential risk factors for RIC: weight, American Society of Anesthesiologists score, revision, stopping the fusion in the lower thoracic spine, worse SRS-Schwab classification modifiers (pelvic tilt++, pelvic incidence minus lumbar lordosis++, sagittal vertical axis++), higher T1 spinopelvic inclination, and higher T1 slope. Independent predictors of RIC as identified on multivariate logistic regression included American Society of Anesthesiologists (odds ratio: 1.75, P = 0.029) and sagittal vertical axis modifier ++ (odds ratio 3.43, P = 0.0001). The RIC and no RIC groups each experienced significant improvement over time, as measured on the Oswestry Disability Index (P = 0.0001), SF-36 (P = 0.0001), and SRS-22r (P = 0.0001). However, the rate of improvement over time was less for patients with RIC (SRS-22r P = 0.043, SF-36 P = 0.0001)., Conclusion: This study identified that nearly one-third of patients undergoing adult spinal deformity surgery experienced a radiographical or implant-related complication, and that just more than one-half of these patients experiencing complication required a reoperation within 2 years of surgery. These complications significantly affected HRQOL measures. Baseline patient characteristics and parameters of the SRS-Schwab classification can be used to help identify those patients at greater risk., Level of Evidence: 3.

Background: Wound drains that are left in place for a prolonged period of time have a higher rate of bacterial contamination. Following spinal surgery, a drain is often left in place for a longer period of time if it maintains a high output. Given the major consequences of an infection following spinal surgery and the lack of data with regard to the use of antibiotics and drains, we performed a study of patients with a drain following spinal surgery to compare infection rates between those who were treated with antibiotics for twenty-four hours and those who received antibiotics for the duration for which the drain was in place., Methods: We performed a prospective randomized trial of 314 patients who underwent multilevel thoracolumbar spinal surgery followed by use of a postoperative drain. The patients were randomized into two groups, one of which received perioperative antibiotics for twenty-four hours (twenty-four-hour group) and the other of which received antibiotics for the duration that the drain was in place (drain-duration group). Data collected included demographic characteristics, medical comorbidities, type of spinal surgery, and surgical site infection., Results: Twenty-one (12.4%) of the 170 patients in the twenty-four-hour group and nineteen (13.2%) of the 144 in the drain-duration group developed a surgical site infection (p = 0.48). There were no significant differences between the twenty-four-hour and drain-duration groups with respect to demographic characteristics (except for the American Society of Anesthesiologists [ASA] classification), operative time, type of surgery, drain output, or length of hospital stay., Conclusions: Continuing perioperative administration of antibiotics for the entire duration that a drain is in place after spinal surgery did not decrease the rate of surgical site infections., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Myocardial necrosis in the perioperative period of noncardiac surgery is associated with short-term mortality, but long-term outcomes have not been characterized. We investigated the association between perioperative troponin elevation and long-term mortality in a retrospective study of consecutive subjects who underwent hip, knee, and spine surgery. Perioperative myocardial necrosis and International Classification of Disease, Ninth Revision-coded myocardial infarction (MI) were recorded. Long-term survival was assessed using the Social Security Death Index database. Logistic regression models were used to identify independent predictors of long-term mortality. A total of 3,050 subjects underwent surgery. Mean age was 60.8 years, and 59% were women. Postoperative troponin was measured in 1,055 subjects (34.6%). Myocardial necrosis occurred in 179 cases (5.9%), and MI was coded in 20 (0.7%). Over 9,015 patient-years of follow-up, 111 deaths (3.6%) occurred. Long-term mortality was 16.8% in subjects with myocardial necrosis and 5.8% with a troponin in the normal range. Perioperative troponin elevation (hazard ratio 2.33, 95% confidence interval 1.33 to 4.10) and coded postoperative MI (adjusted hazard ratio 3.51, 95% confidence interval 1.44 to 8.53) were significantly associated with long-term mortality after multivariable adjustment. After excluding patients with coronary artery disease and renal dysfunction, myocardial necrosis remained associated with long-term mortality. In conclusion, postoperative myocardial necrosis is common after orthopedic surgery. Myocardial necrosis is independently associated with long-term mortality at 3 years and may be used to identify patients at higher risk for events who may benefit from aggressive management of cardiovascular risk factors., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Study Design: This is a prospective, randomized, double-blinded comparison of tranexamic acid (TXA), epsilon aminocaproic acid (EACA), and placebo used intraoperatively in patients with adult spinal deformity., Objective: The purpose of this study was to provide high-quality evidence regarding the comparative efficacies of TXA, EACA, and placebo in reducing blood loss and transfusion requirements in patients undergoing posterior spinal fusion surgery., Summary of Background Data: Spine deformity surgery usually involves substantial blood loss. The antifibrinolytics TXA and EACA have been shown to improve hemostasis in large blood loss surgical procedures., Methods: Fifty-one patients undergoing posterior spinal fusion of at least 5 levels for correction of adult spinal deformity were randomized to 1 of 3 treatment groups. Primary outcome measures included intraoperative estimated blood loss, total loss, (estimated blood loss + postoperative blood loss), and transfusion rates., Results: Patients received TXA (n = 19), EACA (n = 19), or placebo (n = 13) in the operating room (mean ages: 60, 47, and 43 yr, respectively); TXA patients were significantly older and had larger estimated blood volumes than both other groups. Total losses were significantly reduced for EACA versus control, and there was a demonstrable but nonsignificant trend toward reduced intraoperative blood loss in both antifibrinolytic arms versus control. EACA had significant reductions in postoperative blood transfusions versus TXA., Conclusion: The findings in this study support the use of antifibrinolytics to reduce blood loss in posterior adult spinal deformity surgery., Level of Evidence: 1.