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Mandy MJ Li,1,2 Don Daniel Ocay,2,3 Alisson R Teles,2,4 Pablo M Ingelmo,5,6 Jean A Ouellet,1–2,7 M Gabrielle Pagé,8,9 Catherine E Ferland2,4–6,101Faculty of Medicine, McGill University, Montreal, Quebec, Canada; 2Department of Clinical Research, Shriners Hospitals for Children-Canada, Montreal, Quebec, Canada; 3Department of Experimental Surgery, McGill University, Montreal, Quebec, Canada; 4Integrated Program in Neurosciences, McGill University, Montreal, Quebec, Canada; 5Chronic Pain Services, Montreal Children’s Hospital, Montreal, Quebec, Canada; 6Department of Anesthesia, McGill University, Montreal, Quebec, Canada; 7Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada; 8Département d’anesthésiologie, Université de Montréal, Montreal, Quebec, Canada; 9Carrefour de l’innovation et de l’évaluation en santé, Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada; 10Child Health and Human Development Research Axis, Research Institute-McGill University Health Centre, Montreal, Quebec, CanadaBackground: The days following surgery are a critical period where the use of opioids predicts long-term outcomes in adults. It is currently unknown as to whether opioid consumption throughout the acute postoperative period is associated with long-term outcomes in pediatric patients. The aims of this study were to characterize opioid consumption trajectories in the acute postoperative period, identify predictors of trajectory membership and determine associations between opioid consumption trajectories and long-term patient outcomes.Materials and methods: Medication use, pain and mental health status were assessed at baseline in adolescents with idiopathic scoliosis who were scheduled for spinal fusion surgery. Cumulative 6-hr opioid consumption was recorded for up to 5 days after spinal surgery. At 6 months after surgery, medication use, pain and functional activity were evaluated. Growth mixture modeling was used to identify opioid trajectories.Results: One hundred and six patients were included in the study. Mean cumulative 6-hr opioid consumption in the acute postoperative period was 13.23±5.20 mg/kg. The model with the best fit contained 5 acute postoperative trajectories and a quadratic term (AIC =6703.26, BIC =6767.19). Two types of patient behaviors were identified: high opioid consumers (trajectories 4 and 5) and low opioid consumers (trajectories 1, 2 and 3). Intraoperative intrathecal morphine dose was a predictor of trajectory membership (p=0.0498). Opioid consumption during the acute postoperative period was not significantly associated with pain, functional activity or pain medication use at 6 months after surgery.Conclusion: In pediatric patients, intraoperative intrathecal morphine dose predicts opioid consumption in the acute postoperative period. Importantly, opioid consumption during this period does not affect long-term outcomes in pediatric patients after a spine surgery.Keywords: opioids, pediatrics, postsurgical pain, trajectories, adolescent idiopathic scoliosis, spinal fusion surgery

Some studies have demonstrated that physiotherapists have a high prevalence of low back pain (LBP). The association between physiotherapy students, who are potentially exposed to the same LBP occupational risks as graduates, and LBP has never been demonstrated. The objective of the study is to evaluate the association between undergraduate physiotherapy study and LBP. The study design includes a cross-sectional study. A questionnaire-based study was carried out with physiotherapy and medical students. LBP was measured as lifetime, 1-year and point prevalence. Bivariate and multivariate analyses were performed to find the factors associated with LBP. Bivariate analyses were also performed to assess differences between LBP characteristics in the two courses. 77.9% of the students had LBP at some point in their lives, 66.8% in the last year and 14.4% of them reported they were suffering from LBP at the moment of answering the questionnaire. Physiotherapy students reported a higher prevalence of LBP when compared with the medical students in all measures. In the logistic regression model, physiotherapy students (A-OR 2.51; 95% CI 1.35-4.67; p = 0.003), and being exposed to the undergraduate study for more than four semesters (A-OR 2.55; 95% CI 1.43-4.55; p = 0.001) were independently associated with LBP. There were no differences between the courses concerning pain intensity and disability. As it was a cross-sectional study, we were not able to observe accurately if there is an increasing incidence of LBP during the course. Also, we did not intend to identify which activities in the course were associated with the development of LBP. This study clearly demonstrated an association between undergraduate physiotherapy study and LBP. The length of course exposure is also associated with LBP. [ABSTRACT FROM AUTHOR]

Myxoma is a neoplasm of mesenchymal origin composed of undifferentiated stellate cells in a myxoid stroma. This tumor can develop in a variety of locations. Myxomas that arise from skeletal muscles are called intramuscular myxomas. They usually occur in large skeletal muscles. Only ten cases of these benign tumors involving the neck muscles were reported in literature. Of them, only three were located at the paraspinal muscles. A 64-year-old woman presented with occipital and neck pain over 5 years noted an expansive painful lesion located at posterior cervical region with progressive volume increase in the last 12 months. Image exams revealed a large mass located in the left posterior region of the neck in contact with the C2, C3 and C4 laminae with no invasion of the vertebrae. Tumor total removal was performed through normal muscle margins and the vertebral periosteum was scraped. The tumor was encapsulated, lobulated with a gray-white appearance. The histological examination yielded the diagnosis of intramuscular myxoma. Follow-up at 1 year showed complete resolution of preoperative symptoms and no evidence of local recurrence. In conclusion, although rare, intramuscular myxoma should be included in differential diagnosis of cervical paraspinal tumors. We reported the fourth case of intramuscular myxoma in the paraspinal musculature of the neck. Despite its benign characteristics, local recurrence was reported after subtotal resection. Tumor total removal should be the goal of surgery. [ABSTRACT FROM AUTHOR]

Introduction: Dental injuries during anesthesia, especially when advanced airway management is required, represent a legal problem. Factors such as poor dental condition and excessive pressure during intubation contribute to dental damage. The maxillary central incisors are commonly affected., Objective: The objective of this review is to know the incidence of dental injuries in adults undergoing anesthesia that requires airway management., Materials and Methods: The search was performed in MEDLINE (through Pubmed), ClinicalTrials.gov, Scopus, LILACS (through the Virtual Health Library Regional Portal), and SciELO for all available literature on the subject up to December 2022. Inclusion criteria involved articles that studied patients aged 18 years or older who underwent general anesthesia requiring airway management with tracheal intubation or insertion of a laryngeal mask airway., Results: Of all the articles, nine report dental injury associated with the type of airway management. Only one article does not have dental injury., Discussion: This study addresses dental injuries related to tracheal intubation during general anesthesia. Although techniques are used to prevent them, these injuries still occur. Laryngoscopy, especially with support on the upper central incisors, can cause damage to the teeth., Conclusions: It is important that the anesthesiologist is aware of dental trauma and that orotracheal intubation or the placement of the laryngeal mask airway is performed systematically and rigorously, always considering the patient's dentition to choose the best approach in each specific situation.

Bisphosphonates represent an established treatment against bone resorption and osseous loss. Local application could help increase bone mineral density while minimizing their systemic use side-effects. Bone cement, used on a large scale in orthopedic surgery and a historically successful drug carrier, could represent an effective scaffold. The aim of this review was to investigate the alterations produced on the cement's structure and properties by this mixture, as well as its antiosteoporotic and antitumor effect. After a thorough research of articles, title screening and duplicate removal we retained 51 papers. Two independent authors performed abstract and full-text reading, finally leaving 35 articles included in this review. In the current literature, acrylic and calcium phosphate bone cement have been used as carriers. A combination with nitrogen-containing bisphosphonates, e.g., zoledronic acid, provokes modifications in terms of setting time prolongation and mechanical strength decline within acceptable levels, on the condition that the drug's quantity stays beneath a certain plateau. Bisphosphonates in bone cement seem to have a powerful anti-osteoclastic and osteogenic local impact as well as a direct cytotoxic effect against several neoplastic lesions. Further investigation on the subject is required, with specifically designed studies focusing on this method's advantages and potential clinical applications., Competing Interests: The authors have no conflict of interest.

Study Design: Cross-sectional., Objectives: To evaluate current practice of Latin American spine surgeons regarding surgical timing in patients with traumatic spinal cord injury (tSCI) and to identify potential barriers for early surgery., Setting: Web-based., Methods: A web-based questionnaire was sent to members of AOSpine Latin America. Questions involved demographic features, familiarity with management of tSCI, and timing of surgery in various tSCI scenarios. The participants were also asked if they would like to operate earlier on patients with tSCI, indicating potential obstacles to early surgery., Results: A total of 307 surgeons answered the questionnaire. Early surgery (<24 h) is performed by 66.8% for ASIA A, 76.9% for ASIA B, and 76.9% for ASIA C/D injuries. For traumatic cauda equina syndrome (tCES), 85.2% performed surgery within 24 h. For traumatic central cord syndrome (tCCS) without osteoligamentous instability, only 31.5% performed surgery within 24 h and 41.2% follow-up on these patients, indicating surgery if no symptom improvement. Early surgery was performed always or in most cases by 50.4% and 41.8% of surgeons for incomplete and complete tSCI, respectively. The majority (85.4%) would like to operate earlier on patients with tSCI than they actually do. The most frequently perceived barriers to early surgery were difficulty of access to surgical implants (70.9%) and delay in patient transport to reference hospital for surgery (57.8%)., Conclusion: Latin American spine surgeons tend to operate earlier on patients with tCES and incomplete tSCI, then on those with complete tSCI and tCCS. The most reported obstacles for early surgery involved healthcare resources., (© 2022. The Author(s), under exclusive licence to International Spinal Cord Society.)

Management by the environment is complex, which means a much higher percentage of difficult airways than in a regulated environment such as the operating room. Failure or prolonged attempt to tracheal intubation is associated with unfavorable outcomes and serious complications. Acute epiglottitis is a life-threatening disorder, classified as a medical emergency within the diseases of the upper respiratory airway and characterized by its sudden and deadly evolution if rapid intubation is not achieved to allow oxygenation of the patient. We describe a 36-year-old male patient with stridor, dyspnea e hypoxemia due to total obstruction of airway, caused by an acute epiglottitis. We aim to highlight this unusual injury and its management from the prehospital until discharge illustrating the severity of the clinical presentation, current treatment and outcome., (Copyright © 2021 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Study Design: Cohort study., Objective: Our goal was to verify the validity of the global alignment and proportion (GAP) score, SRS-Schwab, and Roussouly theoretical apex of lordosis in predicting mechanical complications in adult spinal deformity (ASD)., Summary of Background Data: Achieving adequate sagittal alignment is critical to obtain favorable outcomes in ASD surgery. It has been proposed that mechanical complications are largely secondary to postoperative spinal alignment., Methods: Retrospective review of consecutive primary ASD cases that underwent deformity correction in the same institution over a 5-year period. Association between the 6-week postoperative spinal alignment classification and occurrence of mechanical complications on the last follow-up was assessed using logistic regressions. The discriminant capacity was assessed using the receiver operating characteristic (ROC) curve analysis., Results: 58.3% (N = 49/84) of patients presented with mechanical complications and 32.1% (N = 27/84) underwent revision surgery. GAP score did not show discriminant ability to predict complications (AUC = 0.53, 95% confidence interval [CI] = 0.40-0.66, P = 0.58). Conversely, the SRS-Schwab sagittal modifier score demonstrated a statistically significant (although modest) predictive value for mechanical complications (AUC = 0.67, 95% CI = 0.54-0.79, P = 0.008). There was a significant association between pelvic tilt (PT) (P = 0.03) and sagittal vertical axis (SVA) (P = 0.01) at 6 weeks postoperatively and the occurrence of later mechanical complications. There was no significant association between matched Roussouly theoretical apex of lordosis and final outcome (P = 0.47)., Conclusion: The results point to the complexity of mechanical failure and the high likelihood that causative factors are multifactorial and not limited to alignment measures. GAP score should be used with caution as it may not explain or predict mechanical failure based on alignment in all populations as originally expected. Future studies should focus on etiology, surgical technique, and patient factors in order to generate a more universal score that can be applied to all populations.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Cross-sectional survey study., Objective: To evaluate the prevalence of burnout, assess the personal and professional characteristics associated with burnout in spine surgeons and determine their quality of life., Summary of Background Data: Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment that leads to decreased effectiveness at work. To date, there has been a lack of information on the prevalence of burnout among spine surgeons worldwide and the risk factors associated with this condition., Methods: An electronic survey with members of AO Spine was performed in May 2018. The survey evaluated demographic variables, practice characteristics, burnout, and quality of life. Maslach Burnout Inventory (MBI) and EuroQol 5-dimensions (EQ5D) were used to evaluate burnout and quality of life, respectively., Results: A total of 818 surgeons from 86 countries completed the survey. The prevalence of burnout was 30.6%. In the multiple linear model, emotional fatigue was independently associated with younger age (B = -0.17, CI95% = -0.26 to -0.07, P < 0.0001), and longer working hours per week (B = -2.71, CI95% = -4.34 to -1.07, P = 0.001); depersonalization was independently associated with younger age (B = -0.13, CI95% = -0.19 to -0.07, P < 0.0001), practicing outside Latin America (LA) (B = 0.71, CI95% = 0.41-1.01, P < 0.0001) and currently being a fellow (B = 0.54, CI95% = 0.06-1.02, P = 0.02); and higher scores of personal fulfilment was associated with practicing in LA (B = -1.27, CI95% = -1.69 to -0.85, P < 0.0001)., Conclusion: Burnout is a common condition among spine surgeons worldwide. There is a significant association between burnout scores and decreased general quality of life. These results highlight the need to develop interventional programs to better identify, prevent, and manage this condition among practicing spine surgeons.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Management by the environment is complex, which means a much higher percentage of difficult airways than in a regulated environment such as the operating room. Failure or prolonged attempt to tracheal intubation is associated with unfavorable outcomes and serious complications. Acute epiglottitis is a life-threatening disorder, classified as a medical emergency within the diseases of the upper respiratory airway and characterized by its sudden and deadly evolution if rapid intubation is not achieved to allow oxygenation of the patient. We describe a 36-year-old male patient with stridor, dyspnea e hypoxemia due to total obstruction of airway, caused by an acute epiglottitis. We aim to highlight this unusual injury and its management from the prehospital until discharge illustrating the severity of the clinical presentation, current treatment and outcome., (Publicado por Elsevier España, S.L.U.)

Lumbar disc herniation (LDH) is a relatively common pathology usually presenting with unilateral radiculopathy ipsilateral to the disc herniation. Some patients can present with contralateral radicular symptoms. The objective of this article is to review the current literature on lumbar disc herniations with contralateral radiculopathy regarding its pathophysiology and surgical strategies. A systematic review of the literature on LDH with contralateral radiculopathy was performed using MEDLINE (via PubMed) using MeSH terms. This review was done following recommendations of PRISMA statement and PICOT strategy of search. Initial electronic search identified 126 papers. Finally, 18 articles were reviewed. None of the included papers was described as comparative. Pathophysiological processes underlying contralateral pain may include prominent spondylotic changes and the accompanying stenosis; hypertrophic yellow ligament; dural attachments along the posterior longitudinal ligament; nerve root traction forces; and friction radiculitis, migrated epidural fat, nerve root anomaly, and venous congestion inside the vertebral canal. In our pooled analysis, 11 patients reported were treated by bilateral approach with 100% of clinical success and no complications. Eight patients were treated by unilateral approach ipsilateral to pain with 100% of clinical success and no complications. Forty-eight patients were treated by unilateral approach ipsilateral to herniation with 100% of clinical success and no complications. Pathophysiology underlying contralateral pain in LDH is probably multifactorial. There is not enough scientific evidence to define the best surgical approach for patients with LDH and contralateral pain.

Background: The treatment of unilateral CFD in patients without neurologic deficits remains controversial, especially in the choice of the best surgical approach. Our objective is to determine the way spine surgeons from Latin America manage this condition., Methods: A survey regarding management and surgical strategies was conducted by the AO Spine Latin American Trauma Study Group considering the treatment of unilateral CFD., Results: All AO Spine Latin American Trauma Study Group members were sent a link to the survey, among whom 285 replied, with 197 respondents answering all the questions. Nonsurgical management was considered by 25% of the surgeons. The majority stated that magnetic resonance imaging is necessary (65%) to treat this type of patient. A posterior approach was preferred by 44%, an anterior approach by 29%, and a combined approach by 25%, while 2.2% did not answer. Traction was not used by the majority of respondents (62%). In the setting of an anterior disk herniation, the majority of surgeons preferred to employ an anterior (45%) or combined (44%) approach versus an isolated posterior approach (only 0.5%). Comparing early versus late cervical trauma, fewer surgeons adopted an isolated anterior approach with the latter (29% vs. 15%)., Conclusions: Wide variations exist in the management of unilateral CFD by Latin American surgeons, with early injuries generally treated using either an anterior or posterior approach and treated early but after an MRI, while a combined approach is used more commonly with late injuries. Either an anterior or combined approach is used when disk herniation is present., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to determine the publication rate of abstracts presented at the annual meetings of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves (Spine Summit)., Methods: The authors used a search algorithm in PubMed to determine the publication rate of abstracts presented at the Spine Summit from 2007 to 2012. The variables assessed were presentation modality, topic, meeting year, publication year, destiny journal and its 5-year impact factor (IF), country, and citation count (retrieved from the Scopus database)., Results: One thousand four hundred thirty-six abstracts were analyzed; 502 were oral presentations and 934 were digital poster presentations. The publication rate was 53.97% (775/1436). The mean time from presentation to publication was 1.35 ± 1.97 years (95% CI 1.21-1.49 years). The mean citation count of published articles was 40.55 ± 55.21 (95% CI 36.66-44.44). Oral presentations had a higher publication rate (71.51%, 359/502) than digital posters (44.54%, 416/934; OR 3.13, 95% CI 2.48-3.95, p < 0.001). Oral presentations had a higher number of citations (55.51 ± 69.00, 95% CI 48.35-62.67) than digital posters (27.64 ± 34.88, 95% CI 24.28-31.00, p < 0.001). The mean IF of published articles was 3.48 ± 2.91 (95% CI 3.27-3.70). JNS: Spine (191/775, 24.64%), Spine (103/775, 13.29%), and Neurosurgery (56/775, 7.23%) had the greatest number of published articles. The US represented the highest number of published articles (616/775, 79.48%)., Conclusions: The publication rate of the Spine Summit is among the highest compared to other spine meetings. Many of the abstracts initially presented at the meeting are further published in high-IF journals and had a high citation count. Therefore, the Spine Summit maintains its high standards of scientific papers, which reflects the high quality of the research performed in the spine surgery field in North America.

Purpose: To define the relationship between 3D radiological features, psychological factors, and back pain prevalence and intensity in patients with adolescent idiopathic scoliosis (AIS)., Methods: Consecutive AIS patients answered self-reported questionnaires and underwent simultaneous posterior-anterior and lateral scans of the spine (EOS Imaging, Paris, France). 3D reconstructions of the spine and pelvis reported 18 parameters in the coronal, sagittal, and axial plane., Results: Hundred and twenty-four patients with AIS were included in the study. Overall, 90% of AIS patients reported having some back pain over the last 6 months and 85.8% over the last 30 days. Pain intensity in the last month was reported to be mild in 37.5%, moderate in 31.8%, moderate to severe in 24.3%, and severe in 6.54% of cases. Location of back pain was associated with location of main curve (P = 0.036). Low back pain was associated with higher lumbar apical AVR and lower lumbar lordosis (P < 0.05). Independent risk factors for back pain in AIS were pain catastrophizing (B = 0.061, P = 0.035), poorer self-reported state of mental health (B = - 0.872, P = 0.023), decreased thoracic kyphosis (B = - 0.033, P = 0.044) and greater pelvic asymmetry (B = 0.146, P = 0.047). There was a significant association between self-reported pain intensity in the last 24 h and levels of catastrophizing. Pain catastrophizing level influenced the relationship between deformity severity and pain intensity. In low catastrophizers, there was a significant association between greater deformity severity and higher pain levels., Conclusions: Back pain in AIS is multifactorial and associated with psychological and morphological parameters. Pain catastrophizing is an important construct in AIS-related pain and should be taken into consideration when evaluating these patients.

Background: Adolescent idiopathic scoliosis (AIS) has been associated with diminished postural stability and a greater prevalence of back pain. Currently, the literature is lacking information on the effect of spinal fusion on both postural stability and its association with back pain. Our objectives were to evaluate the postsurgical effect of spinal morphological changes on static standing balance and assess the influence of these alterations on reported pain throughout the perioperative period., Methods: Twenty consecutive AIS patients schedule to undergo spinal fusion surgery were recruited and followed prospectively at the Shriners Hospitals for Children-Canada. Data was collected at the preoperative, 6 weeks and 6 months postoperative visits. Spinal morphology data was collected through 3D reconstructed simultaneous standing biplanar radiographs using the SterEOS software. Postural balance was assessed through Moticon© sensor insoles and analyzed through their software. The data was simultaneously collected as part of the Global Biomechanical and morphological Assessment. Pain was evaluated through self-reported questionnaires., Results: Morphological curve parameters were significantly reduced after surgery. Balance parameters did not change significantly throughout the perioperative period with the exception of the Center of Pressure of the left foot medial/lateral transient shift (P = 0.017) at 6 weeks. Of note, preoperative balance parameters were associated with the degree of right thoracic Cobb angles (P = 0.029 R = 0.528). Pain scores significantly improved 6 weeks and 6 months after the surgery. Pain intensity diminished in the thoracic and lumbar spine but worsen in the neck region at the 6 weeks and 6 months postoperative time points (P = 0.044). Greater residual Cobb angle difference between Mid thoracic and Thoracolumbar/Lumbar curves was associated with greater pain severity at 6 weeks postop (P < 0.005). In addition, greater residual thoracic deformity was associated with significant pain severity 6 months after surgery (P < 0.05)., Conclusions: Improved spinal morphology of postsurgical AIS patients has no significant impact on their static standing balance. Suggesting that other factors apart from the spinal morphology may contribute to AIS patients' balance during stance. Although balance did not influence pain severity, spinal morphology and its correction appear to have influenced the intensity and location of back pain.

Study Design: Prospective experimental study with on-site simulation., Objective: To compare the accuracy and efficiency of different techniques for pedicle screw instrumentation (PSI)., Summary of Background Data: Improving the safety and efficiency of PSI is a critical step to reduce the complication rates and the cost of scoliosis surgery. Innovative operative techniques for PSI have shown to safely improve efficiency, thereby reducing cost. Surgical simulation is a valuable tool to study different operative techniques., Methods: Five spine fellows instrumented 20 simulation models of a scoliotic spine with 10 pedicle screws per model. Four techniques were studied, including the conventional pedicle probe and the innovative sequential drilling technique, with or without computed tomography (CT)-based navigation. Our primary outcome measures were efficiency and accuracy of PSI. We analyzed the data with bivariate analyses using the Chi-square test for categorical variables and the Student t test or ANalysis Of VAriance with Bonferroni post-hoc tests for continuous variables., Results: The drilling techniques (free hand and navigated) were more efficient as compared with the pedicle probe techniques (P < 0.01). The navigated techniques resulted in better accuracy as compared with the free hand techniques (P = 0.036). Most pedicle breaches were medial (n = 32/52). The concave apical pedicle (T4 right side) had the highest incidence of breaches. There was no significant difference in efficiency comparing the free hand and the navigated pedicle probe techniques (P = 0.261) or comparing the free hand drilling and the navigated drilling techniques (P = 1.00)., Conclusion: On site surgical simulation is a promising concept for teaching advanced procedural skills. Our findings suggest that navigation improves the accuracy of PSI while sequential drilling safely improves efficiency. Combining navigation with sequential drilling can significantly improve the accuracy and the efficiency of PSI in scoliosis surgery, as previously suggested with our published clinical data., Level of Evidence: 4.

Background Context: Zero-profile (also called self-locking, anchored or stand-alone cages) have been recently proposed as an interesting alternative for anterior cervical discectomy and fusion (ACDF), as they are supposed to reduce the rates of post-operative cage extrusion without necessarily incurring in the additional surgical time and increased rates of dysphagia associated with plating. Nevertheless, the exact indications of zero-profile anchored cages have not yet been established in the literature., Purpose: To report the first case of a vertebral body fracture between the blades of zero-profile anchored cages after ACDFs in adjacent levels and to review the available literature on hardware-related complications after multi-level ACDFs with zero-profile anchored cages., Study Design: Case report and systematic literature review., Methods: The authors report the first case of a vertebral body fracture between the blades of zero-profile anchored cages after ACDFs in adjacent levels. The patient presented with refractory mechanical neck pain at the 1-month post-operative follow-up, ultimately requiring a posterior instrumented fusion. A comprehensive systematic literature review on the available data regarding the safety, complications as well as radiological and clinical outcomes of zero-profile anchored cages is also performed., Results: In the reported case, the use of zero-profile anchored cages in adjacent levels on the cervical spine led to a fracture of the vertebral body between the cages at the 1-month follow-up, with anterior avulsion of the part of the vertebral body where the blades from the two cages converged. According to the systematic literature review which included 409 patients from 10 different clinical series (with a total cumulative follow-up of approximately 535 patients-year), there were only two reported hardware-related complications after ACDF with zero-profile anchored cages, none of them involving fracture at the level of convergence of blades or screws., Conclusions: Although hardware-related complications after the use of zero-profile anchored cages seem to be rare events, future biomechanical and clinical studies are warranted in order to evaluate the safety of employing such devices for the treatment of multilevel degenerative disc disease in the cervical spine.

Background: The medical literature suggests that facet dislocations (FDs) must be managed surgically, even in the absence of spinal cord injury. In fact, there is no standard guideline for managing FD cases and whether magnetic resonance imaging (MRI) should be utilized for optimizing treatment planning., Methods: Fifteen cases of FD were evaluated twice by nine spine surgeons. The first assessment included computed tomography (CT) images only. Secondarily, original CT studies were supplemented with MRI. In each case, the participating surgeon had to acknowledge whether and what surgical treatment they would offer. Data for the two responses from all nine surgeons were then compared., Results: Based on CT images alone, there was no consensus regarding treatment choices in 13 cases, and a trend toward consensus in just two instances (κ = 0.01). When MRI scans were added to CT studies, among the 15 cases evaluated, 10 cases demonstrated a trend toward consensus, and in 1 case consensus was achieved. The Kappa interpersonal agreement based on MRI was 0.13. The analysis of the answers by each contributor in each case demonstrated that in 58.51% of cases the surgical treatment options were changed when analyzed by CT + MRI, in comparison to the options indicated based on CT alone., Conclusion: It appears that obtaining an MRI in addition to a CT before spine surgery for FD is essential mandatory, as it changed the treatment option in nearly 60% of cases., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Surgical Neurology International.)

Background: Our study aimed to evaluate quality of recovery in elderly patients with postoperative delirium (POD)., Subjects and Methods: An observational prospective study was conducted. Patients aged >60 submitted to elective surgery and admitted to Post Anesthesia Care Unit (PACU) in a tertiary hospital from May to July 2017 were included. POD was evaluated with the Nursing Delirium Screening Scale (NuDESC). Quality of recovery-15 (QoR-15) was used before (T0) and 24 h (T24) after surgery to assess quality of recovery. Data collection include patient's characteristics, respiratory events at the PACU, and other perioperative variables. The Chi-square, Fisher's exact, or Mann-Whitney U -tests were used for comparisons., Results: Of a total of 235 patients, 12.3% developed POD at PACU. POD was more frequently in patients older than 80 years ( P = 0.017), patients with neurological disease ( P = 0.026), dementia ( P = 0.026), peripheral vascular disease ( P = 0.016), and diabetes mellitus ( P = 0.037). At T0, there were no differences at median total QoR-15, whereas at T24, patients POD scored lower in 10 items (including "severe pain" with P = 0.001 and "nausea or vomiting" with P = 0.009) of QoR-15 and in total median lower scores ( P = 0.001). POD patients stayed longer at PACU ( P = 0.017) and they stayed longer at hospital ( P = 0.002)., Conclusions: POD patients were older and had more comorbidities. POD patients had lower QoR scores at T24 suggesting an adverse impact of delirium in postoperative quality of recovery. POD patients stayed for long in the PACU and at hospital., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Saudi Journal of Anesthesia.)

Introduction: Surgical skill training is difficult due to limited resources and the associated risks in the clinical setting. There have been many studies that have looked at optimizing resident skill techniques out of the operating room to optimize intraoperative teaching. Specifically, as seen in spine surgery performing a laminectomy with a high-speed drill is difficult and requires many hours of training and guidance before a resident can feel comfortable to adequately complete the laminectomy with minimal risk of adverse effects., Objective: The objective of this study is to assess if pre-education of residents prior to using the high-speed drill will significantly increase their comfort level, as well as increase the success of laminectomy., Design, Setting and Participants: This was done by a prospective cohort study in evaluating 20 orthopedic surgical residents via the objective structured assessment of technical skills and global rating scale., Results: Results showed that residents who had pre-education were in fact more successful in completing the laminectomy with the high-speed drill., Conclusions: Pre-education, whether via a didactic or simulator-based model are both beneficial to resident's knowledge and surgical skill attainment however the simulator based model did not deem the group more successful in completing the laminectomy with the high-speed drill. Certain technical skills still require unreplaceable hands-on practice to become proficient., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Publication rate can indirectly assess the quality of research presented in scientific meetings. Considering presentations at orthopedic surgery and neurosurgery meetings, 10.5-66% of abstracts are published in scientific journals. Publication rate of abstracts presented at CSS Meetings is unknown. The objective of this study was to evaluate the publication rate of abstracts presented at the Canadian Spine Society(CSS) Annual Meetings from 2005to2014., Methods: In October2018, a systematic PubMed search was performed using title and authors of all abstracts presented at CSS Meetings from 2005 to 2014. The following information was retrieved from the articles and abstracts: year, type of presentation, publication in PubMed, time from presentation to final publication, journal and its impact factor(IF)., Results: A total of 621 abstracts were presented at CSS meetings from 2005 to 2014. Publication rate in PubMed was 54.8%(N=340/621). Oral presentations were more likely to be published than poster presentations(63.8%vs44.0%; OR=1.45; CI95%=1.20-1.75; P<0.0001). The mean time from presentation to publication was 1.76 years(±1.93). The 340 identified articles were published in 87 different journals. Most common journals were Spine(N=75; 22.1%), The Spine Journal(N=40;11.8%), and Journal of Neurosurgery:Spine(N=28;8.2%). IF ranged from 0.18 to 47.66(mean=3.73±4.68). IF of articles presented orally were higher than those presented as poster(P=0.038)., Conclusions: The CSS scientific meeting maintain along the years a steady high quality research presentations as manifested by its significant publication rate(54.8%) in medical journals with mean IF of 3.73. In comparison with other spine scientific meetings, publication rates of abstracts presented at CSS meeting is amongst the highest., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Spine surgeries performed via the posterior approach have a higher infection rate. Several theories have been proposed, including poor hygienic condition of bed sheets and traumatized muscle associated with supine position promoting circulatory impairment. We investigated the influence of supine position on the rate of deep wound infection after spine surgery by the posterior approach., Methods: A total of 106 patients were randomly divided into 2 groups: lateral decubitus only versus dorsal and lateral decubitus. Patient follow-up after hospital discharge was performed at 30, 60, 180, and 360 days. Deep wound infection was diagnosed according to U.S. Centers for Disease Control and Prevention criteria., Results: Patient sample was mainly composed of patients with neoplastic disease and patients with trauma. Postoperative wound infection developed in 12 cases (11.3%), and Streptococcus aureus was the most common pathogen. Incidence of postsurgical deep wound infection was significantly greater in the control group (P = 0.004)., Conclusions: Supine position was significantly correlated with higher rates of wound infection among patients who underwent spine surgery by the posterior approach. Avoidance of supine position may represent a modifiable risk factor to diminish postoperative spine infection rates., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background Context: Although 40% of adolescent idiopathic scoliosis (AIS) patients present with chronic back pain, the pathophysiology and underlying pain mechanisms remain poorly understood. We hypothesized that development of chronic pain syndrome in AIS is associated with alterations in pain modulatory mechanisms., Purpose: To identify the presence of sensitization in nociceptive pathways and to assess the efficacy of the diffuse noxious inhibitory control in patients with AIS presenting with chronic back pain., Study Design: Cross-sectional study., Patient Sample: Ninety-four patients diagnosed with AIS and chronic back pain., Outcome Measures: Quantitative sensory testing (QST) assessed pain modulation and self-reported questionnaires were used to assess pain burden and health-related quality of life., Methods: Patients underwent a detailed pain assessment using a standard and validated quantitative sensory testing (QST) protocol. The measurements included mechanical detection thresholds (MDT), pain pressure threshold (PPT), heat pain threshold (HPT), heat tolerance threshold (HTT), and a conditioned pain modulation (CPM) paradigm. Altogether, these tests measured changes in regulation of the neurophysiology underlying the nociceptive processes based on the patient's pain perception. Funding was provided by The Louise and Alan Edwards Foundation and The Shriners Hospitals for Children., Results: Efficient pain inhibitory response was observed in 51.1% of patients, while 21.3% and 27.7% had sub-optimal and inefficient CPM, respectively. Temporal summation of pain was observed in 11.7% of patients. Significant correlations were observed between deformity severity and pain pressure thresholds (p=.023) and CPM (p=.017), neuropathic pain scores and pain pressure thresholds (p=.015) and temporal summation of pain (p=.047), and heat temperature threshold and pain intensity (p=.048)., Conclusions: Chronic back pain has an impact in the quality of life of adolescents with idiopathic scoliosis. We demonstrated a high prevalence of impaired pain modulation in this group. The association between deformity severity and somatosensory dysfunction may suggest that spinal deformity can be a trigger for abnormal neuroplastic changes in this population contributing to chronic pain syndrome., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Monoaminergic pathways are involved in the process of pain inhibition and facilitation. The objective of this study was to investigate the role of blood monoamines as biomarkers of conditioned pain modulation (CPM) efficacy., Methods: One hundred and five paediatric patients with chronic back pain were enrolled in this observational study. The protocol involved dosage of plasma monoamines (dopamine, DOPA; serotonin, 5-HT; epinephrine, Epi; norepinephrine, NE; metanephrine, ME; and normetanephrine, NME) and clinical assessment (CPM, functional disability, pain, sleep quality, anxiety and depression)., Results: 5-HT and DOPA were positively correlated among each other and were both negatively correlated with Epi, ME, NE and NME. CPM presented a positive correlation with DOPA and 5-HT. On the other hand, Epi, ME, NE and NME correlated negatively with CPM. Different correlation coefficients were observed between genders, with stronger coefficients being observed in the male subpopulation. Stepwise regression controlling for age and gender indicated that ME (B = -0.987, SE(B) = 0.299, p = 0.002) was the only significant predictor for CPM efficacy. Higher blood ME was associated with poorer CPM efficacy. ME explained 53% of variation of CPM in males (R 2  = 0.536, p < 0.0001) and 7% in females (R 2  = 0.074, p = 0.014). In males, blood ME >15 pg/ml predicted inefficient CPM with 88.9% sensitivity and 83.3% specificity., Conclusions: Our findings suggest that ME can be a potential biomarker for CPM efficacy in paediatrics. Future studies are needed to assess the efficacy of tailored treatments for pain according to blood ME., Significance: We were able to demonstrate an association between CPM and circulating monoamines. In the clinical setting, sampling ME could provide the clinician an idea of the individual's pain modulation potential. This may be particularly important for children with cognitive impairment, for whose CPM paradigm cannot be used., (© 2018 European Pain Federation - EFIC®.)

Background: Necrotizing fasciitis (NF) is a surgical diagnosis characterized by a rapidly progressive soft tissue infection, widespread tissue necrosis, and associated systemic illness. Friability of the superficial fascia, dishwater-gray exudate, and absence of pus are surgical characteristics of this diagnosis. Due to rapid progression of the infection, early recognition and aggressive surgical debridement are crucial to reduce mortality. Despite being commonly seen by general, plastic, and orthopedic surgeons, NF is an extremely rare spine surgery emergency. Our objective is to report on a case of NF involving the spine and highlight this unusual surgical emergency for the spine surgeon., Case Description: We present a rare case of a 61-year-old woman who presented to the emergency department in septic shock. She had a 1-week history of increasing back pain before presenting to us. Computed tomography revealed extensive soft tissue emphysema with involvement of the L3 vertebral body and spina canal. She underwent emergency surgical debridement. Despite maximal medical and surgical therapies, the patient died secondary to multisystem organ failure within 36 hours of initial presentation., Conclusions: To the best of our knowledge, the literature presents only 1 previous case reported involving the spine. Necrotizing fasciitis is an unusual surgical spine surgery emergency. Spine surgeons should be aware of this diagnosis in order to provide timely aggressive surgical debridement., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Patient-controlled analgesia (PCA) is common practice for acute postoperative pain management. Postoperative PCA use decreases pain intensity and improves patient satisfaction when compared to non-PCA routes of medication administration. Although PCA has several advantages regarding efficacy and safety, adverse events remain a concern. Programming errors and protocols, patient monitoring, and PCA by proxy or with continuous infusion are recurring silent dangers of PCA use in children and adolescents. Innovative considerations need to be emphasized for future improvement of PCA devices for elective surgical patients. With technology within the healthcare setting advancing at a fast pace, smart pump technology is something to look forward to.

Background: Many practicing spine surgeons believe that instrumentation can be removed during revision surgery in successful posterolateral or anterior spinal fusions, confirmed by computed tomography and intraoperative exploration. The stress-shielding effect of spinal instrumentation was well described in the late 1980s and 1990s but has not received recent attention. Despite the paucity of recent literature, concepts underlying the biology and biomechanics of the spinal fusion mass remain particularly salient given the increasing incidence of revision spinal fusion surgery. The aim of this study was to highlight a potential complication of instrumentation removal owing to stress shielding of instrumentation on the spinal column and fusion mass., Methods: A retrospective review was performed, and a small case series was described., Results: In 3 cases, despite apparent solid fusion demonstrated on preoperative computed tomography and confirmed by intraoperative exploration, new fractures developed after removal of instrumentation. In these cases, fracture occurred at the transition zone between the newly rigid instrumented area and previous fusion. This highlights the relative weakness of the fusion and may be explained by the stress-shielding effect of instrumentation within the fusion mass., Conclusions: Spinal instrumentation revision requires careful consideration, and routine implant removal should not be performed. The presence of a solid fusion on computed tomography and/or at intraoperative exploration may not justify implant removal in these cases. In cases of extension of a fusion, use of a bridging connection to the new implants should be considered. The cases presented demonstrate the consequences of the stress-shielding effect of implants on the spine and fusion mass., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Study Design: Cross-sectional study., Objectives: To continue the line of a previous publication using steroid for acute spinal cord injury (SCI) by spine surgeons from Latin America (LA) and assess the current status of methylprednisolone (MP) prescription in Europe (EU), Asia Pacific (AP), North America (NA), and Middle East (ME) to determine targets for educational activities suitable for each region., Methods: The English version of a previously published questionnaire was used to evaluate opinions about MP administration in acute SCI in LA, EU, AP, NA, and ME. This Internet-based survey was conducted by members of AOSpine. The questionnaire asked about demographic features, background with management of spine trauma patients, routine administration of MP in acute SCI, and reasons for MP administration., Results: A total of 2659 responses were obtained for the electronic questionnaire from LA, EU, AP, NA, and ME. The number of spine surgeons that treat SCI was 2206 (83%). The steroid was used by 1198 (52.9%) surgeons. The uses of MP were based predominantly on the National Acute Spinal Cord Injury Study III study (n = 595, 50%). The answers were most frequently given by spine surgeons from AP, ME, and LA. These regions presented a statistically significant difference from North America ( P < .001). The number of SCI patients treated per year inversely influenced the use of MP. The higher the number of patients treated, the lower the administration rates of MP observed., Conclusions: The study identified potential targets for educational campaigns, aiming to reduce inappropriate practices of MP administration., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: POSSUM system is widely used and validated for 30-day mortality and morbidity prediction. The aim of this study was to evaluate the performance of five POSSUM's equations (POSSUM, P-POSSUM, V-POSSUM, V-POSSUM physiology and V-POSSUM Cambridge) on predicting 30-day mortality and morbidity in elderly patients undergoing major elective vascular surgery., Design: A retrospective longitudinal cohort study., Setting: A study conducted at an University Hospital., Participants: 208 elderly patients (≥ 60 years) undergoing major elective vascular surgery., Measurements: Data collected from the clinical files included patient's characteristics, diagnosis, surgery, comorbidities, parameters from POSSUM score, 30, 60 and 90-day mortality and 30-day morbidity. POSSUM system's goodness-of-fit for predicting mortality and morbidity was assessed by Hosmer-Lemeshow test (H-L T) and Standardized Mortality/Morbidity Ratio (SMR) and discriminative ability by the area under the ROC curves (ROC-AUC). Patients' average age was 70.8 years, 81% males., Interventions: None., Main Results: The overall 30-day mortality rate was 2.97% (n=6) and 30-day morbidity was 29.2% (n=59). POSSUM, P-POSSUM, V-POSSUM, V-POSSUM physiology and V-POSSUM Cambridge equation predicted an overall of 29.1, 4.43, 15.3, 21.9 and 13.5 deaths, respectively. POSSUM morbidity equation predicted 105.0 complications. H-LT p-values were 0.001, 0.164, 0.208, 0.011, 0.331 and <0.001, respectively. SMRs and 95% confidence interval (CI) were 0.21[0.04-0.37], 1.35[0.27-2.44], 0.39[0.08-0.71], 0.27[0.06-0.49], 0.44[0.09-0.80] and 0.56[0.42-0.71], respectively. ROC-AUC and 95% CI were 0.72[0.49-0.95], 0.72[0.49-0.95], 0.73[0.51-0.94], 0.69[0.50-0.89], 0.72[0.52-0.92] and 0.71[0.63-0.79], respectively., Conclusions: P-POSSUM had the best performance predicting 30-day mortality. All the other overestimated 30-day mortality. Prediction of morbidity was inadequate. POSSUM scoring models may not be robust tools for risk prediction in elderly patients undergoing major elective vascular surgery and need further calibration and discrimination., (Copyright © 2017 Elsevier Inc. All rights reserved.)

OBJECTIVE The aim of this study was to evaluate the anatomical and surgical risk factors for screw-related facet joint violation at the superior level in lumbar fusion. METHODS The authors conducted a retrospective review of a consecutive series of posterior lumbar instrumented fusions performed by a single surgeon. Inclusion criteria were primary lumbar fusion of 1 or 2 levels for degenerative disorders. The following variables were analyzed as possible risk factors: surgical technique (percutaneous vs open screw placement), depth of surgical field, degree of anterior slippage of the superior level, pedicle and facet angle, and facet degeneration of the superior level. Postoperative CT scans were evaluated by 2 independent reviewers. Axial, sagittal, and coronal views were reviewed. Pedicle screws were graded as intra-articular if they clearly interposed between the superior and inferior facet joints of the superior level. Multivariate logistic regression analyses were conducted to assess the factors associated with this complication. RESULTS One hundred thirty-one patients were included. Interobserver reliability for facet joint violation assessment was high (κ = 0.789). The incidence of superior facet joint violation was 12.59% per top-level screw (33 of 262 proximal screws). The rate of facet violation was 28.0% in the percutaneous technique group (14 of 50 patients) and 12.3% in the open surgery group (10 of 81 patients) (OR 2.26, 95% CI 1.09-4.21; p = 0.024). In multivariate logistic regression analysis, independent predictors of facet violation were percutaneous screw placement (adjusted OR 3.31, 95% CI 1.42-7.73; p = 0.006), right-side pedicle screw (adjusted OR 3.14, 95% CI 1.29-7.63; p = 0.011), and facet angle > 45° (adjusted OR 10.95, 95% CI 4.64-25.84; p < 0.0001). CONCLUSIONS The incidence of facet joint violation was higher in percutaneous minimally invasive than in open technique for posterior lumbar spine surgery. Also, coronal orientation of the facet joint is a significant risk factor independent of the surgical technique.

Stand-alone cervical laminectomy for degenerative cervical myelopathy (DCM) has become increasingly rare due to risk of postlaminectomy kyphosis. This article discusses the biomechanics of cervical degeneration and how laminectomy effects spine stability, and summarizes relevant clinical studies to help guide surgical decision-making for the posterior treatment of DCM. Laminectomy and fusion remains a safe and efficacious treatment. Stand-alone laminectomy should only be used for a highly selected patient population with relative stiff lordotic cervical spines, using care to not disrupt facets and C2 and C7 muscle attachments., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: Patient-reported outcome measures (PROMs) are the most widely accepted means of measuring outcomes after spine procedures. We sought to determine the current status of worldwide use of PROMs in Latin America (LA), Europe (EU), Asia Pacific (AP), North America (NA), and Middle East (ME) to determine the barrier to its full implementation., Methods: A questionnaire survey was sent by e-mail to members of AOSpine to evaluate their familiarity and use of PROMs instruments and to assess the barriers to their use in spine care practice in LA, EU, AP, NA, and ME., Results: A total of 1634 AOSpine members from LA, EU, AP, NA, and ME answered the electronic questionnaire. The percentage of spine surgeons who were familiar with the generic health-related quality of life questionnaire was 71.7%. In addition, 31.9% of respondents did not use any PROMs routinely. The main barriers to implementing PROMs were lack of time to administer the questionnaires (57%) followed by lack of staff to assist in data collection (55%), and the long time to fill out the questionnaires (46%). The routine use of questionnaires was more frequent in NA and EU and less common in LA and ME (P < 0.001)., Conclusions: We found that 31.9% of spine surgeons do not use the PROMs questionnaire routinely. This appears to occur because of lack of knowledge regarding their importance, absence of reimbursement for this extra work, minimal financial support for clinical research, the cost of implementation, and lack of concern among physicians., (Copyright © 2017 Elsevier Inc. All rights reserved.)

OBJECTIVE The cost of spine management is rising. As diagnostic imaging accounts for approximately 10% of total patient care spending, there is interest in determining if economies could be made with regard to the routine consultation of radiology for image interpretation. In the context of spine trauma, both the spine surgeon and the radiologist interpret perioperative imaging. Authors of the present study investigated the impact of radiologist interpretation of perioperative imaging from patients with traumatic single-level thoracolumbar fractures given that spine surgeons are expected to be comfortable interpreting pathologies of the musculoskeletal system. METHODS The authors conducted a retrospective review of all patients presenting with a single-level thoracolumbar fracture treated at the McGill University Health Centre in the period from January 2003 to December 2010. The time between image capture and radiologist interpretation as well as the number of extraskeletal and/or incidental findings was extracted from the radiology reports on all perioperative images including radiographic, fluoroscopic, and CT images. The cost of interpretation was obtained from the provincial health insurance entity of Quebec. RESULTS Eighty-two patients met the study inclusion criteria. Radiologists took a median of 1 day (IQR 0-5.5 days) to interpret preoperative radiographs. Intraoperative fluoroscopic images and postoperative radiographs were read by the radiologist a median of 19 days (IQR 4-56.75 days) and 34 days (IQR 1-137.5 days) after capture, respectively (p < 0.05). Preoperative radiologist dictations reported extraskeletal and/or incidental findings for 8.1% of radiographs; there were no intraoperative or postoperative extraskeletal findings beyond those previously reported on the preoperative radiographs. Radiologists took a median of 1 day (IQR 0-1 day) to read both preoperative and postoperative CT scans; extraskeletal and/or incidental findings were present in 46.2% of preoperative reports and 4.5% of postoperative reports. There were no intraoperative or postoperative radiological findings that provoked reoperation. A total of 66 intraoperative fluoroscopy images and 225 postoperative radiographs were read for a cost of $1399.20 and $1867.50 (Canadian dollars), respectively, for radiologist interpretation. This cost amounted to 40.3% of all perioperative image interpretation spending. CONCLUSIONS In the management of single-level thoracolumbar fractures, radiologists add information to the diagnostic picture when interpreting preoperative radiographs and perioperative CT scans; however, the interpretation of intraoperative fluoroscopic images and postoperative radiographs comes with significant delay, does not add additional information, and represents an area of potential cost and professional-resource reduction.

Study Design: The authors performed a retrospective controlled study of patients diagnosed with lumbar degenerative disc disease who received surgical intervention (either total disc replacement [TDR]/Activ-L or anterior lumbar interbody fusion [ALIF]) at a single tertiary-care hospital from 2007-2010., Objectives: To investigate the clinical outcomes after TDR in comparison with ALIF for surgical treatment of lumbar degenerative disc disease (DDD)., Methods: Analyzed data included intra-operative blood loss, time to return to work, and clinical outcomes as evaluated through the Oswestry Disability Index (ODI) and the Visual Analog Scale (VAS) pain questionnaires pre-operatively and at 6 weeks, 3 months, 6 months, and 1 year postoperative follow-up., Results: At the univariate analysis, patients submitted to TDR presented significantly lower VAS pain scores than patients who received ALIF starting at 6 weeks ( P < .001) and continuing through one year postoperatively ( P = .007). Patients submitted to TDR also presented significantly lower ODI disability scores at all time points. There was a significant difference in the number of days to return to work, with TDR patients returning to work on average 65 days sooner than ALIF patients ( P = .011). There was no significant difference in the total blood loss between both groups., Conclusions: The results of this retrospective controlled study suggest that, in comparison with patients submitted to ALIF, patients submitted to TDR present quicker return to work, less back pain, and lower disability scores at 1 year follow-up., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Systematic review., Objective: There is a need for synthesizing data on effectiveness of treatments for patients with adult spinal deformity (ASD) due to its increasing prevalence and health care costs for these patients. The objective of this review was to estimate the effectiveness of surgery versus nonoperative care in patients with ASD., Methods: A systematic review of articles in published in English using PubMed between 2005 and 2015. Surgical and nonsurgical series that reported baseline and follow-up health-related quality of life measures of patients with ASD with a minimum 2 years of follow-up were selected. Independent extraction of articles by 2 authors using predefined data fields, including risk of bias assessment., Results: Surgery significantly reduces disability, pain, and improves patients' quality of life. The average postoperative improvement in Oswestry Disability Index was -19.1 (±9.0), Numerical Rating Scale back pain -4.14 (±1.38), Numerical Rating Scale leg pain -3.36 (±1.33), Short-Form Health Survey 36-SF36-Physical Component score 11.2 (±5.07), and Short-Form Health Survey 36-Mental Component score 9.93 (±4.96). The complication rate ranged from 9.52% to 81.52% (mean = 39.62%), and the need for revision surgery ranged from 1.72% to 40.0% (mean = 15.71%). The best existing evidence about nonoperative care of ASD is provided from observational studies with very high risk of bias. Quantitative analyses of nonsurgical cohorts did not demonstrate significant changes in quality of life of patients after 2 years of observation., Conclusions: This data may assist clinicians to counsel patients, as well as to inform health care providers and policymakers about what to expect from the treatment for ASD., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To evaluate the efficacy of postoperative fractionated stereotactic radiosurgery (FSRS) and hypofractionated stereotactic radiotherapy (SRT) to large surgical cavities after gross total resection of brain metastases., Methods: A retrospective analysis of 41 patients who had received tumor-bed FSRS (5 fractions) or SRT (10 fractions) after resection of brain metastasis between 2005 and 2015 was performed. All resection cavities were treated with a frameless linear accelerator-based system. Patients who underwent subtotal resection, single-dose SRS to the resection cavity, or were treated with a fractionation schedule other than 5 or 10 fractions, were excluded., Results: Twenty-six patients were treated with 5 fractions and 15 patients with 10 fractions. The median planning target volume was 19.78 cm 3 (12.3-28 cm 3 ) to the 5-fraction group and 29.79 cm 3 (26.3-47.6 cm 3 ) to the 10-fraction group (P = 0.020). The 1-year and 2-year local control rates for all patients were 89.4% and 77.1%, respectively, and 89.6% and 78.6% were free from distant intracranial progression, respectively. No difference was observed in local control or freedom from distant intracranial progression between the 5-fraction or 10-fraction groups. The median overall survival was 28.27 months (95% confidence interval, 19.42-37.12) for all patients. No patient developed necrosis at the resection cavity., Conclusions: Fractionation offers the potential to exploit the different biological responses between neoplastic and normal tissues to ionizing radiation. The use of 5 daily doses of 5-6 Gy or 10 daily doses of 3 Gy is a good strategy to have a reasonable local control and avoid neurotoxicity., (Copyright © 2016 Elsevier Inc. All rights reserved.)

In order to evaluate the predictive effect of non-invasive preoperative imaging methods on surgical outcomes of lumbar fusion for patients with degenerative disc disease (DDD) and refractory chronic axial low back pain (LBP), the authors conducted a retrospective review of 45 patients with DDD and refractory LBP submitted to anterior lumbar interbody fusion (ALIF) at a single center from 2007 to 2010. Surgical outcomes - as measured by Visual Analog Scale (VAS/back pain) and Oswestry Disability Index (ODI) - were evaluated pre-operatively and at 6 weeks, 3 months, 6 months, and 1 year post-operatively. Linear mixed-effects models were generated in order to identify possible preoperative imaging characteristics (including bone scan/99mTc scintigraphy increased endplate uptake, Modic endplate changes, and disc degeneration graded according to Pfirrmann classification) which may be predictive of long-term surgical outcomes . After controlling for confounders, a combined score, the Lumbar Fusion Outcome Score (LUFOS), was developed. The LUFOS grading system was able to stratify patients in two general groups (Non-surgical: LUFOS 0 and 1; Surgical: LUFOS 2 and 3) that presented significantly different surgical outcomes in terms of estimated marginal means of VAS/back pain (p = 0.001) and ODI (p = 0.006) beginning at 3 months and continuing up to 1 year of follow-up. In conclusion,  LUFOS has been devised as a new practical and surgically oriented grading system based on simple key parameters from non-invasive preoperative imaging exams (magnetic resonance imaging/MRI and bone scan/99mTc scintigraphy) which has been shown to be highly predictive of surgical outcomes of patients undergoing lumbar fusion for treatment for refractory chronic axial LBP.

Objective: To analyze the cumulative effect of risk factors associated with early major complications in postoperative spine surgery., Methods: Retrospective analysis of 583 surgically-treated patients. Early "major" complications were defined as those that may lead to permanent detrimental effects or require further significant intervention. A balanced risk score was built using multiple logistic regression., Results: Ninety-two early major complications occurred in 76 patients (13%). Age > 60 years and surgery of three or more levels proved to be significant independent risk factors in the multivariate analysis. The balanced scoring system was defined as: 0 points (no risk factor), 2 points (1 factor) or 4 points (2 factors). The incidence of early major complications in each category was 7% (0 points), 15% (2 points) and 29% (4 points) respectively., Conclusions: This balanced scoring system, based on two risk factors, represents an important tool for both surgical indication and for patient counseling before surgery.

Within ionic liquids, fluorinated ionic liquids (FILs) present unique physico-chemical properties and potential applications in several fields. However, the melting point of these neoteric compounds is usually higher due to the presence of fluorine atoms. This drawback may be resolved by, for instance, mixing different FILs to create eutectic mixtures. In this work, binary mixtures of fluoro-containing and fluorinated ionic liquids were considered with the aim of decreasing their melting temperatures as well as understanding and characterizing these mixtures and their phase transitions. Five FILs were selected, allowing the investigation of four binary mixtures, each of them with a common ion. Their solid-liquid and solid-solid equilibria were studied by differential scanning calorimetry and the non-ideality of the mixtures was investigated. Overall, a variety of solid-liquid equilibria with systems exhibiting eutectic behavior, polymorphs with solid-solid phase transitions, and the formation of intermediate compounds and solid solutions were surprisingly found. In addition to these intriguing behaviours, novel FILs with lower melting temperatures were obtained by the formation of binary systems, thus enlarging the application range of FILs at lower temperatures.

Herein, solubility experimental data for six monosaccharides, viz.d-(+)-glucose, d-(+)-mannose, d-(-)-fructose, d-(+)-galactose, d-(+)-xylose and l-(+)-arabinose, in four ionic liquids (ILs), at temperatures ranging from 288.2 to 348.2 K, were obtained aimed at gathering a better understanding of their solvation ability and molecular-level mechanisms which rule the dissolution process. To ascertain the chemical features that enhance the solubility of monosaccharides, ILs composed of dialkylimidazolium or tetraalkylphosphonium cations combined with the dicyanamide, dimethylphosphate or chloride anions were investigated. It was found that the ranking of the solubility of monosaccharides depends on the IL; yet, d-(+)-xylose is always the most soluble while d-(-)-fructose is the least soluble monosaccharide. The results obtained show that both the IL cation and the anion play a major role in the solubility of monosaccharides. Finally, from the determination of the respective thermodynamic properties of solution, it was found that enthalpic contributions are dominant in the solubilization process. However, the observed differences in the solubilities of monosaccharides in 1-butyl-3-methylimidazolium dicyanamide are ruled by a change in the entropy of solution.

Object: Lumbar discectomy is one of the most common surgical spine procedures. In order to understand the value of this surgical care, it is important to understand the costs to the health care system and patient for good results. The objective of this study was to evaluate for the first time the cost-effectiveness of spine surgery in Latin America for lumbar discectomy in terms of cost per quality-adjusted life year (QALY) gained for patients in Brazil., Methods: The authors performed a prospective cohort study involving 143 consecutive patients who underwent open discectomy for lumbar disc herniation (LDH). Patient-reported outcomes were assessed utilizing the SF-6D, which is derived from a 12-month variation of the SF-36. Direct medical costs included medical reimbursement, costs of hospital care, and overall resource consumption. Disability losses were considered indirect costs. A 4-year horizon with 3% discounting was applied to health-utilities estimates. Sensitivity analysis was performed by varying utility gain by 20%. The costs were expressed in Reais (R$) and US dollars ($), applying an exchange rate of 2.4:1 (the rate at the time of manuscript preparation)., Results: The direct and indirect costs of open lumbar discectomy were estimated at an average of R$3426.72 ($1427.80) and R$2027.67 ($844.86), respectively. The mean total cost of treatment was estimated at R$5454.40 ($2272.66) (SD R$2709.17 [$1128.82]). The SF-6D utility gain was 0.044 (95% CI 0.03197-0.05923, p = 0.017) at 12 months. The 4-year discounted QALY gain was 0.176928. The estimated cost-utility ratio was R$30,828.35 ($12,845.14) per QALY gained. The sensitivity analysis showed a range of R$25,690.29 ($10,714.28) to R$38,535.44 ($16,056.43) per QALY gained., Conclusions: The use of open lumbar discectomy to treat LDH is associated with a significant improvement in patient outcomes as measured by the SF-6D. Open lumbar discectomy performed in the Brazilian supplementary health care system provides a cost-utility ratio of R$30,828.35 ($12,845.14) per QALY. The value of acceptable cost-effectiveness will vary by country and region.