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• Thoracic spine demonstrated kinematic changes with translation and angular motion. • T8-9 to T11-12 thoracic levels had more translation than upper thoracic levels. • Lower thoracic levels had more advanced disc degeneration than the upper levels. The aim of this study was to evaluate disc degeneration and kinematic changes in translation and angular motion of the thoracic spine using kinematic MRI (kMRI). 105 thoracic spine kMRI were analyzed from T4-5 to T11-12 using MRAnalyzer3. Translational and angular motion were evaluated in neutral, flexion, and extension positions. Thoracic disc height and disc degeneration grading were measured in the neutral position. Intraclass Correlation Coefficients were used to analyze agreement among three observers. The Friedman's test was used to analyze the difference in disc height, disc degeneration, translational motion, and angular motion. The Wilcoxon-signed rank test was used for post-hoc analysis with a Bonferroni correction. A p-value of 0.00625 was used to establish a statistically significant difference. Analysis using the Friedman's test revealed that translational motion, disc height, and disc degeneration were significantly different from T4-5 to T11-12 (p < 0.001). The T4-5 level showed the least translational motion, while the T10-11 showed the most translational motion. The lower thoracic level (T8-12) showed significantly more translational motion, more advanced disc degeneration, and greater disc height than the upper thoracic level (T4-8, p < 0.001). T11-12 showed the most advanced disc degeneration. There was a significant negative correlation between disc degeneration and translational motion at the upper thoracic level (p = 0.013). The lower thoracic region (below T8) had significantly more translational motion, more advanced disc degeneration, and greater disc height. This information is crucial in further understanding thoracic spinal kinematics and may contribute to determining the stopping level in fusion surgeries involving the thoracic spine. [ABSTRACT FROM AUTHOR]

Talus fractures are relatively uncommon; however, the sequelae of talus fractures can cause significant morbidity. Although avascular necrosis has been a consistently reported complication, the reported rates of subsequent arthrodesis have varied widely. The purpose of the present study was to report the complications in a large patient sample of operatively treated talus fractures and to describe the survivorship of open reduction internal fixation (ORIF) of the talus. Patients undergoing talus ORIF for closed or open fractures from 2007 to 2011 were identified in the United Healthcare System database by International Classification of Diseases, 9th revision, code 825.21 and Current Procedural Terminology codes 28445, 28436, and 28430. Patients with a nonoperative talus fracture or isolated osteochondral defect were excluded, leaving 1527 patients in the final analysis. We also identified patients who had required subsequent subtalar, pantalar, and tibiotalocalcaneal arthrodeses using Current Procedural Terminology codes 28725, 28705, and 28715, respectively. Complications and demographic data were recorded. Of the 1527 patients, 29 (1.9%) had undergone subsequent arthrodesis within 4 years; 64 patients (4.2%) developed wound complications that did not require surgical intervention, 11 patients (0.7%) were readmitted, 204 (13.3%) presented to the emergency department (ED), and 96 (6.3%) underwent operative irrigation and debridement (I&D). The overall complication rate was 19.5%. Patients aged >34 years had a significantly greater rate of ED visits (54.7%, p  = .015) and overall complications (56.8%, p  < .001). In conclusion, ORIF of talus fractures has good survivorship when considering the failure of initial surgery or the requirement for secondary arthrodesis. Medical complications and hospital readmission were relatively rare; however, ED visits and infection requiring I&D were relatively common after ORIF of talus fractures. [ABSTRACT FROM AUTHOR]

Studies have demonstrated superior outcomes and cost effectiveness of the spinal cord stimulation (SCS) for the treatment of chronic pain syndromes such as failed back surgery syndrome (FBSS) or complex regional pain syndrome (CRPS). However, little is known about the impact of primary diagnosis or mental disorders on the revision rate. This is the Retrospective cohort study to analyze the reintervention rates based on the primary diagnosis or comorbid mental disorder. Data of the annual trends of SCS use, revision and removal rate of SCS and additional surgical rate after removal was collected and analyzed for patients undergoing SCS between 2007 and 2015, within a private insurance billing database. Trial cases were excluded from this study. The results showed 11,029 patients received SCS implantation with percutaneous electrodes (PE, n = 7418) or surgical electrode (SE, n = 3611). There was a trend of increasing use of SCS from 2007 to 2013, followed by a decrease in last two years. There was no significant difference in the neither removal nor revision rate regardless between the patients with FBSS or CRPS at each time point. Although the removal rates within 2 years were significantly higher in the patients with anxiety disorders compared to the patients without any mental disorders (PE: p < .001, SE: 0.003), the rate of additional surgery after the removal showed no significant difference (PE: p = .532, SE: p = .262). Therefore, we concluded that the primary diagnosis and the presence of anxiety disorders did not have an impact on the additional surgical rate following SCS implantation. [ABSTRACT FROM AUTHOR]

The objective was to evaluate motion, disc degeneration and Space Available for Cord (SAC) at the adjacent segments of degenerative cervical spondylolisthesis (DCS) using kinematic Magnetic Resonance Imaging (kMRI). The cervical spine kMRI of sixty-one DCS spinal levels (38 anterolisthesis and 23 retrolisthesis) were analyzed at the listhesis level and its adjacent segments in three position using kMRI. MRAnalyzer3 was used to analyze translation, angular motion and SAC. The caudad level had significantly less translation motion than the listhesis level in overall DCS or grade 2 anterolisthesis group (P < 0.05). The cephalad level had significant more translational motion than the caudad level in overall DCS or grade 1 retrolisthesis group (P < 0.05). For disc degeneration, the cephalad level had the least disc degeneration and showed significant difference with the listhesis level in overall DCS or overall anterolisthesis or overall retrolisthesis or grade 2 anterolisthesis or grade 1 or 2 retrolisthesis (P < 0.05). For SAC, the listhesis level had the narrowest space in overall DCS groups. In neutral position, grade 1 anterolisthesis had significantly larger SAC at the listhesis and the cephalad level than grade 1 retrolisthesis (P < 0.05). In conclusion, DCS affected cervical spine motion and kinematics. Grade 1 retrolisthesis showed tendency of narrower SAC at the cephalad level more than the same grade anterolisthesis. The likelihood of the adjacent segment disease and spinal cord compression are higher in both grade 2 anterolisthesis and retrolisthesis. [ABSTRACT FROM AUTHOR]

Animal and human studies demonstrate the anabolic properties of low-magnitude mechanical stimulation (LMMS) in its ability to improve bone formation by enhancing the proliferation of mesenchymal stem cells and their subsequent commitment down an osteoblastic lineage. Response to mechanical strains as low as 10 μɛ have been seen, illustrating the sensitivity of mechanosensory cells to mechanotransduction pathways. Applications to the spine include treatment of osteoporosis in preparation for instrumented fusion, fracture reduction in spinal cord injury patients to slow bone mineral density loss, and bone tissue engineering and enhancement of bone-implant osseointegration for pseudarthrosis and hardware failure. This review provides an overview of the fundamentals of LMMS, highlights the cellular basis and biomechanics of how mechanical strain is translated into bone formation, and then discusses current and potential applications of these concepts to spinal disorders. Mechanical signals represent a key regulatory mechanism in the maintenance and formation of bone. Developing practical clinical applications of these mechanotransduction pathways continues to be an important area of investigation in its relation to spinal pathology. [ABSTRACT FROM AUTHOR]

Use of mesenchymal stem cells (MSCs) for spinal fusion has increased in recent years through the use of either cellular bone matrices (CBM) or bone marrow aspiration (BMA). Advantages of these stem cell graft types are their potential ability to provide long-term cell proliferation, self-renewal, and multipotent differentiation afforded by the gold standard of autologous iliac crest bone graft (ICBG) without the known drawbacks of its harvest. The aim of this article is to review the evidence on the use of allogeneic or autologous MSCs in anterior spine surgery through the utilization of CBM or BMA, respectively. Practice recommendations will then be provided based on the available published evidence. [ABSTRACT FROM AUTHOR]

Background Current studies investigating surgical treatment of distal biceps tendon tears largely consist of small, retrospective case series. The purpose of this study was to investigate the current patient demographics, surgical trends, and postoperative complication rates associated with operative treatment of distal biceps tendon tears using a large database of privately insured, non-Medicare patients. Methods Patients who underwent surgical intervention for distal biceps tendon tears from 2007 to 2011 were identified using the PearlDiver database. Demographic and surgical data as well as postoperative complications were reviewed. Statistical analysis was performed using linear regression analysis and χ 2 tests, with statistical significance set at P  < .05. Results A total of 1443 patients underwent surgical treatment for distal biceps tendon tears. Men and patients aged 40 to 59 years accounted for 98% and 72% of the cohort, respectively. Regarding surgical technique, reinsertion to the radial tuberosity was preferred (95%) over tenodesis to the brachialis (5%) ( P  < .01). In total, revision surgery for tendon rerupture occurred in 5.4% of treated patients. The incidence of revision surgery for rerupture in acute and chronic distal biceps tears was 5.1% and 7.0%, respectively ( P  = .36). Postoperative infection and peripheral nerve injury rates were 1.1% and 0.6%, respectively. Conclusion Surgeons strongly preferred anatomic reinsertion to the radial tuberosity for treatment, regardless of the chronicity of the injury. Postoperative complication rates were similar to those found in prior studies, although the true rate of rerupture may be higher than previously thought. [ABSTRACT FROM AUTHOR]

Purpose: To investigate demographic trends in elbow arthroscopy over time, as well as to query complication rates requiring reoperation associated with these procedures.Methods: The Current Procedural Terminology (CPT) billing codes of patients undergoing elbow arthroscopy were searched using a national insurance database. From the years 2007 to 2011, over 20 million orthopaedic patient records were present in the database with an orthopaedic International Classification of Diseases, Ninth Revision diagnosis code or CPT code. Our search for procedures and the corresponding CPT codes for the elbow included diagnostic arthroscopy, loose body removal, synovectomy, and debridement. The type of procedure, date, gender, and region of the country were identified for each patient. In addition, the incidence of reoperation for infection, stiffness, and nerve injury was examined.Results: There was a significant increase in arthroscopic elbow procedures over the study period. Male patients accounted for 71% of patients undergoing these procedures. Of the elbow arthroscopy patients, 22% were aged younger than 20 years, 25% were aged 20 to 39 years, 47% were aged 40 to 59 years, and 6% were aged 60 years or older. Other than synovectomy, there were regional variations in the incidence of each procedure type. The overall rate of reoperation was 2.2%, with specific rates of 0.26% for infection, 0.63% for stiffness, and 1.26% for nerve injury. It should be noted that because only the complications requiring reoperation are recorded in the database, these numbers are lower than the overall complication rate.Conclusions: Overall, the incidence of elbow arthroscopy in this patient population is relatively low and appears to be increasing slightly over time. In the database used in this study, elbow arthroscopy procedures were most commonly performed in male patients and in patients aged 40 to 59 years, with regional variation in the incidence of the different procedures. Furthermore, the rate of complications requiring reoperation was low, with a nerve operation being the most common reoperation performed.Level Of Evidence: Level IV, therapeutic case series. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this study was to evaluate and quantify the demographic characteristics of patients undergoing open and arthroscopic distal clavicle excision (DCE) in the United States while also describing changes in practice patterns over time. Methods Patients who underwent DCE from 2004 to 2009 were identified by Current Procedural Terminology (CPT) codes in a national database of orthopaedic insurance records. The year of procedure, age, sex, geographic region, and concomitant rotator cuff repair or subacromial decompression (SAD) were recorded for each patient. Results were reported as the incidence of procedures identified per 10,000 patients searched in the database. Results Between 2004 and 2009, 73,231 DCEs were performed; 74% were arthroscopic and 26% were open. The incidence of arthroscopic DCE increased from 37.8 in 2004 to 58.5 in 2009 (P < .001), whereas the incidence of open DCE decreased from 21.1 in 2004 to 14.1 in 2009 (P < .001). Sixty-one percent of DCEs were performed in men (P < .001). Women were more likely to undergo an arthroscopic procedure (P < .001). Arthroscopic DCE was most common in patients aged 50 to 59 years (P < .001). Open DCE was most common in patients aged 60 to 69 years (P < .001). Open rotator cuff repair and SAD were concomitantly performed in 38% and 23% of open DCEs, respectively. Arthroscopic rotator cuff repair and SAD were concomitantly performed in 33% and 95% arthroscopic DCEs, respectively. Conclusions This analysis of DCE using a private insurance database shows that arthroscopic DCEs progressively increased, whereas open DCEs concomitantly decreased between 2004 and 2009. The majority of DCEs were performed in men between the ages of 50 and 59 years. Both arthroscopic and open DCEs are frequently performed in conjunction with rotator cuff repair or SAD. Level of Evidence Level IV, cross-sectional study. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate current trends in arthroscopic and open shoulder stabilization in the United States. Methods: Patients who underwent arthroscopic shoulder stabilization (Current Procedural Terminology code 29806) or open stabilization (Current Procedural Terminology codes 23455 [open Bankart repair], 23460 [anterior bone block], and 23462 [coracoid transfer]) were identified using a national database of insurance billing records during the years 2004 through 2009. Demographic data were recorded for each patient. Results: From 2004 through 2009, there were 23,096 cases of shoulder stabilization, of which 84% (19,337) were arthroscopic and 16% (3,759) were open procedures. There were 17,241 male patients (75%) and 5,855 female patients (25%). The incidence of arthroscopic shoulder stabilization nearly doubled during the period studied, increasing from 11.8 cases for every 10,000 patients in 2004 to 22.9 cases for every 10,000 patients in 2009. The percentage of arthroscopic stabilizations increased from 71% of stabilization procedures in 2004 to 89% in 2009, whereas the percentage of open stabilizations decreased from 29% in 2004 to 11% in 2009 (P < .0001). Among open procedures, a significant decline in the incidence of open Bankart repair was observed, from 4.5 cases for every 10,000 patients in 2004 to 2.2 cases for every 10,000 patients in 2009 (P < .0001), whereas the performance of open coracoid transfer increased from 0.17 cases per 10,000 patients in 2004 to 0.40 cases per 10,000 patients in 2009 (P < .0001). For both arthroscopic and open stabilization, the group aged 10 to 19 years had the highest rate of surgery (29%), followed by the group aged 20 to 29 years (25%). Conclusions: The current data indicate that arthroscopic stabilization is performed in nearly 90% of shoulder stabilization surgeries and nearly doubled in incidence from 2004 to 2009 in the United States. Additional research is needed to further investigate the long-term clinical outcomes of this practice pattern. Level of Evidence: Level IV, retrospective database review. [Copyright &y& Elsevier]

Background: Patients undergoing rotator cuff repair typically have a diagnostic evaluation and trial of nonoperative therapy before surgery. Recent studies have evaluated the cost-effectiveness of surgery, but none have attempted to estimate the costs associated with the preoperative evaluation. This study used available data to examine major expenditures during the preoperative period. Materials and methods: We conducted a search using an insurance company database to identify patients undergoing rotator cuff repair from 2004 to 2009. Patients were identified by the common Current Procedural Terminology codes for rotator cuff repair. The associated charge codes for the 90-day period before surgery were categorized as outpatient physician visits, diagnostic imaging studies, injections, physical therapy, laboratory and other preoperative studies, prior surgeries, and miscellaneous. The frequency of each code and the associated charges were noted. Results: In total, 92,688 patients were identified in the study period. A total of $161,993,100 was charged during the preoperative period, for an average of $1,748 per patient. Diagnostic imaging charges totaled $104,510,646 (65%); injections, $5,145,227 (3%); outpatient visits, $29,723,751 (18%); physical therapy, $13,844,270 (8.5%); preoperative studies, $6,792,245 (4.2%); and miscellaneous, $1,164,688 (<1%). Conclusions: The costs for preoperative evaluation of rotator cuff tears are substantial, and the majority of the costs are associated with magnetic resonance imaging. To help reduce costs, future studies should attempt to identify the factors that predict which patients might not respond to nonoperative management and might benefit from early surgical intervention. In addition, magnetic resonance imaging should perhaps be reserved for patients in whom the diagnosis cannot be achieved by other modalities. [Copyright &y& Elsevier]

Purpose: The purposes of this study were to determine the incidence of infection requiring reoperation after arthroscopic knee surgery during a 6-year period and to compare infection rates across different age groups, genders, geographic regions of the United States, and Current Procedural Terminology (CPT) codes through a retrospective review of a large insurance company database. Methods: A retrospective review of an insurance company database was performed for all knee arthroscopies performed in the United States from 2004 to 2009. The database was first queried for all knee arthroscopies, and the number of those cases requiring additional surgery for infection within 30 days was determined to calculate the incidence of infection. The incidence was stratified by gender, age group, region within the United States, and CPT code. A separate analysis for procedures using allografts was also performed. Results: A total of 432,038 arthroscopic surgeries were performed, and the number of infections requiring drainage was 638, for an overall incidence of infection from 2004 to 2009 of 0.15%. Among adults, men were affected almost twice as often as women (P < .001), and among children, boys were affected almost 3 times as often as girls (P < .001). A decreasing incidence was noted in patients 60 years or older between 2004 and 2009 (P = .01). Overall, the incidence did not significantly vary by age, region, or CPT codes that specified the implantation of allograft tissue. Compared with diagnostic arthroscopy, the relative risk of infection was higher for CPT-29889 (posterior cruciate ligament reconstruction). Conclusions: The incidence of infection requiring reoperation after knee arthroscopy from 2004 to 2009 was 0.15%. The incidence was higher among male patients in both the adult and pediatric populations. The incidence of infection decreased from 2004 to 2009 in patients 60 years or older. Among adult patients, the incidence did not vary by age, by region, or by CPT codes that involved implantation of allografts. Level of Evidence: Level IV, cross-sectional study. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to evaluate the trends and report on the demographics of patients undergoing hip arthroscopy in the United States. Methods: Patients who underwent hip arthroscopy from 2004 to 2009 were identified by searching Current Procedural Terminology codes in the PearlDiver Patient Records Database (PearlDiver Technologies, Fort Wayne, IN), a national database of orthopaedic insurance records. The year of procedure, age, gender, and region of the United States were recorded for each patient. Results were reported for each variable as the incidence of procedures identified per 10,000 patients searched in the database. Results: In total, 3,447 cases of hip arthroscopy were identified between 2004 and 2009. The incidence of procedures increased significantly over the study period, from 1.20 cases per 10,000 patients in 2004 to 5.58 in 2009 (P < .001). Hip arthroscopy was performed most commonly in patients aged 20 to 39 years (P < .05), with an incidence of 4.45 cases in each age group. In contrast to other common arthroscopic procedures searched, no gender differences were observed, with a male-to-female ratio of 0.89 (P = .18). The greatest incidence of hip arthroscopy was observed in the Western region with an incidence of 5.24 cases identified compared with 2.94, 2.70, and 2.56 in the Northeast, Midwest, and South, respectively (P < .001). Conclusions: A 365% increase in the rate of hip arthroscopy was observed in the examined cohort of patients between 2004 and 2009. The majority of cases were performed in patients aged 20 to 39 years, with no difference in gender. The Western region of the United States was found to have a higher incidence of hip arthroscopy compared with the Midwest, South, and Northeast. Level of Evidence: Level IV, cross-sectional study. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to identify current trends in open and arthroscopic surgical treatment of rotator cuff tears across sex, age, and region in the United States. Methods: Using the PearlDiver Patient Record Database (PearlDiver, Fort Wayne, IN), a publicly available national database of insurance records, patients who underwent rotator cuff repair from 2004 through 2009 were identified. The number of open (CPT codes 23410, 23412, 23420) and arthroscopic (CPT code 29827) rotator cuff repairs were quantified in isolation and in combination with acromioplasty (CPT codes 23415, 29826). The type of procedure, date, sex, and region of the country was identified for each patient. Trend tests (χ2 and Cochran-Armitage) were used to determine statistical significance. Results: There were 151,866 rotator cuff repair procedures identified in the database from 2004 through 2009, which represented an incidence of 13.6 for every 1,000 patients assigned an orthopaedic International Classification of Diseases, Ninth Revision (ICD-9) or Current Procedural Terminology (CPT) code. Male patients accounted for 60% of the repairs and female patients for 40%. There were 98,174 arthroscopic cuff repairs (65%) and 53,692 open repairs (35%). The annual percentage of arthroscopic cases increased from 48.8% in 2004 to 74.3% in 2009, whereas the percentage of open cases decreased from 51.2% in 2004 to 25.7% in 2009 (P < .0001). Acromioplasty was also performed in 47.3% of cases, and the rate showed only a slight increase (from 46.6% to 47.8%) between 2004 and 2009 (P < .01). All regions of the United States showed similar surgical trends and trends for sex and age distributions. Conclusions: Our analysis shows that the majority of rotator cuff repairs in the United States are now performed arthroscopically (>74%) and there has been a recent steady decline in performance of open rotator cuff repair. Concomitant acromioplasty is performed approximately half the time, and this trend is increasing slightly. These findings were consistent across age, sex, and region in the United States. Level of Evidence: IV, cross-sectional study. [Copyright &y& Elsevier]

Minimally invasive surgical techniques have been adopted to treat conditions in the posterior cervical spine. Through specialized tubular retraction systems and proper technique, multilevel posterior cervical foraminal decompression and instrumented fusion can be accomplished though a single incision. In this report we describe the techniques to perform both cervical foraminotomy and lateral mass fixation at 3 or more levels through an expanding tubular retractor. Complications may include inadequate decompression, poor placement of instrumentation, neurologic injury, or iatrogenic postoperative instability. Preoperative planning and careful technique can help avoid specific complications related to tubular access and poor visualization. The surgeon must always be prepared to convert to a traditional open procedure if an adequate decompression and/or fusion cannot be performed because of difficulties related to visualization, distorted anatomy, or improper access. [Copyright &y& Elsevier]

This work reviews the epidemiology, evaluation, treatment, and return-to-play guidelines for athletes with degenerative disk disease and herniated nucleus pulposus. Although most athletes with degenerative disk disease and herniated nucleus pulposus improve with conservative treatment, athletes with persistent symptoms may benefit from lumbar discectomy surgery. Lumbar interbody spinal fusion or disk-replacement surgery should only be considered after all other treatment options have been exhausted. Although some general consensus exists, return-to-play guidelines for the athlete with lumbar degenerative disk disease or disk herniation are not well-defined and require further investigation. [ABSTRACT FROM AUTHOR]

Abstract: Autogenous bone grafting has traditionally been considered the “gold standard” for spinal fusion. However, the associated morbidity and limitations of autogenous bone grafts have prompted the search for bone graft alternatives, such as a bioabsorbable-calcified triglyceride (BCT). We aimed to assess the capability of BCT in a rat spinal fusion model. Thirty-six Sprague-Dawley rats underwent lumbar fusion surgery: Group 1 rats were implanted with an autograft from the iliac crest; Group 2 rats were implanted with BCT; and Group 3 rats were implanted with BCT and autograft. In Group 2, 66.7% of rats and in Group 3, 83.3% of rats, were judged to have undergone complete fusion. Only 25% of rats in Group 1 showed bridging bone from the transverse processes with some gaps. Our study demonstrated that osteoconductive BCT is a promising autograft extender when applied as an adjunct to spinal fusion. [Copyright &y& Elsevier]

Abstract: Background context: The safety of allograft material has come under scrutiny because of recent reports of allograft-associated bacterial and viral infections in tissue recipients. Gamma irradiation, although being one of the most effective ways of terminal sterilization, has been shown to affect the biomechanical properties of allograft bone. It may also have detrimental effects on the osteoinductivity of allograft material such as demineralized bone matrix (DBM) by the denaturation of proteins because of heat generated by irradiation. Sterilization of DBM material is an important variable in processing graft materials. This is considered to be one of the factors leading to different fusion rates observed with different commercially available DBM products, as the sterilization procedure itself may affect the osteoinductivity of the material. Currently, there is no ideal sterilization technique that limits the detrimental effect on osteoinductivity and fusion rates. Purpose: To evaluate the effects of a range of hydrogen peroxide exposures with or without the controlled high-dose gamma irradiation after processing with radioprotectant solutions (Clearant radiation sterilization procedure) on the fusion rates of human DBM. Study design: A prospective in vivo animal study. Methods: Eighty mature athymic nude female rats were used for this study, which formed 10 equal groups. Human DBM exposed to hydrogen peroxide for different time periods (0, 1, 6, and 24 hours) was divided into two major subgroups. One group was further treated with controlled high-dose radiation using radioprotectants (radiation treated), whereas the other group was frozen immediately without specific treatment (non-radiation treated). Both radiation-treated and non–radiation-treated DBM material from each group of hydrogen peroxide exposure times were implanted between L4 and L5 transverse processes of the rats forming eight test groups including eight animals in each. The remaining 16 rats were divided into two additional groups to form negative (only decortication, n=8) and positive (bone morphogenetic protein [BMP]-2, n=8) control groups. The rats were evaluated for fusion by radiographs (2, 4, and 8 weeks), manual palpation (8 weeks), and histological analysis after sacrificing. Comparison of fusion rate among all groups was made using these three evaluation methods. Results: Increasing the time period of hydrogen peroxide (0, 1, 6, or 24 hours) exposure for preparation of DBM from bone allograft did not affect the fusion rates significantly (p<.05), although there was a trend toward decreasing fusion rates with longer exposure times. When the hydrogen peroxide washed DBM preparations were also radiation treated, the resulting fusion rates were again not significantly different (p<.05). Agreement among fusion detection methods was found to be high. Conclusions: Hydrogen peroxide processing was not detrimental to fusion rates. The additional terminal sterilization technique with special gamma irradiation protocols (Clearant process) also did not decrease the fusion rates but could provide an additional margin of safety. [Copyright &y& Elsevier]

By providing a more detailed representation of human anatomy, magnetic resonance imaging (MRI) has expanded our understanding of many of the pathologic conditions that affect the spine. Recent developments in MRI technology has made it possible for surgeons to use this modality intraoperatively to visualize soft tissue and bony structures for diagnostic and therapeutic purposes without the ionizing radiation associated with computerized tomography scans, conventional fluoroscopy, or plain radiographs. This article provides a brief overview of both the current and the theoretical applications of intraoperative/interventional MRI for spinal surgery. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Because pseudarthrosis remains a clinically significant complication after spinal arthrodesis, the role of recombinant bone morphogenetic proteins (BMPs) is continually evaluated in spine surgery. Purpose: This article reviews the important literature in clinical research involving the use of BMPs in the augmentation of spinal fusion. Study design/setting: Review article. Methods: A literature search was performed via MEDLINE through PubMed with the dates January 1960 to July 2007 using the keywords “bone morphogenetic protein, BMP, spinal arthrodesis, and/or bone healing.” Pertinent preclinical and clinical publications were chosen based on relevance and quality for inclusion in this study. Results: Publications focused on the historical context and potential clinical applications using BMP were selected to delineate the risks, benefits, and current indications for the augmentation of spinal arthrodesis. Conclusions: Although multiple commercially available recombinant BMPs have demonstrated clinical success in interbody and posterolateral fusions, the associated costs preclude its routine use in spinal arthrodesis. The spine surgeon must assess each patient individually based on age, bone quality, diagnosis, comorbidities, and risks of nonunion to determine the cost effectiveness of the use of BMP to augment spinal fusion. [Copyright &y& Elsevier]

Imaging the cervical spine in the acute trauma patient continues to spark controversy and debate. Although several organizations have attempted to established guidelines for the evaluation of the cervical spine following blunt trauma, a universally accepted consensus on which imaging modalities should be employed and the timing of their acquisition has not been achieved. This article reviews the current standard of care for the evaluation of the cervical spine following blunt trauma, as well as updating the current controversies surrounding this issue. [ABSTRACT FROM AUTHOR]

Millions of people worldwide suffer from degenerative disk disease. When conservative measures fail, patients often pursue more aggressive treatment options, including surgery. Lumbar fusion is the standard surgical treatment for this malady, but it is imperfect. Many forward-thinking spine surgeons have been drawn to the concept of lumbar disc arthroplasty. Herein we review the available literature on in vivo human clinical trials involving the currently available prostheses for lumbar disc arthroplasty. During this review, we hope to put in context both the achievements and the failures of these prostheses. [ABSTRACT FROM AUTHOR]

Demineralized bone matrix, which is created through the acid extraction of the mineralized phase of bone, has been demonstrated to have rich osteoconductive capabilities as bone graft extenders in the augmentation of spinal arthrodesis. However, despite its promise as a scaffold in the induction of bone formation, many questions remain when given the choice between the number of commercial preparations available on the market today. Variations in the production of demineralized bone matrix such as the carrier used, quality of donor bone, and unique sterilization methods result in unpredictable biologic characteristics. For this reason, further study of efficacy in clinical and laboratory trials is needed. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Painful lumbar disc degeneration is one of the most common ailments treated by spine surgeons. Currently, early disc disease and herniation are often treated with microdiscectomy. Late disc degeneration is usually treated with arthrodesis. With the advent of new technology and techniques in lumbar disc arthroplasty, interest in preserving spinal motion at degenerated motion segments has increased. The goals of lumbar disc arthroplasty are to provide long-term pain relief at the degenerated disc level, to restore disc height to protect neural elements and to preserve motion to prevent posterior facet arthropathy and adjacent segment disease. Purpose: The purpose of this review is to examine the anatomy and biomechanics of the lumbar motion segment to determine the features that successful disc arthroplasty prosthesis must possess. In addition, the early clinical results of three prostheses currently being used in humans are reviewed. Study design/setting: Review of the literature. Methods: A systematic review of Medline for articles related to lumbar disc arthroplasty was conducted up to and including journal articles published in August 2003. In addition, the abstracts from the annual meetings of the North American Spine Society and Scoliosis Research Society from 1998 to 2003 were searched. The literature was then reviewed and summarized. Results/conclusions: Short-term results of lumbar disc arthroplasty as measured by pain relief and disability are good in some studies. Implants are relatively safe in the short term, and with newer designs complications are usually related to the surgical approach rather than early implant failure. Recovery times appear to be shorter than arthrodesis. Despite the relatively good early clinical results of these devices, questions remain about the long-term efficacy in pain relief and maintenance of motion, the results of randomized comparative trials with fusion and the life span of the devices. In addition, late sequelae and revision options are unknown. Current indications for lumbar disc arthroplasty are in the setting of a Food and Drug Administration trial in young, nonosteoporotic patients with one or two level symptomatic disc degeneration without severe facet arthropathy, segmental instability or neural element compression requiring a posterior decompression. [Copyright &y& Elsevier]

Abstract: Background context: The use of minimally invasive lumbar intradiscal heating techniques, including intradiscal electro-thermal therapy (IDET), endoscopic radio-frequency annuloplasty, nucleoplasty and laser discectomy, for chronic lumbar discogenic pain and contained disc herniation has recently gained popularity. The purported therapeutic mechanisms of these interventions include subtotal nuclectomy, annular nociceptor ablation, and stabilization of the annular fibers. Basic science data elucidating the biomechanical and histomorphologic alterations of heat treatments on disc remain sparse. Purpose: The purpose of this study is to examine the effects of uniform heating on biomechanical properties and histomorphology of intervertebral disc tissues using a porcine model. Study design/setting: In a laboratory setting, porcine functional spinal units consisting of vertebra-nucleus pulposus-vertebra core and porcine hamstring tendons were harvested. Studies were performed on these tissue samples by uniformly heating the specimens in a constant temperature water bath. Ten porcine lumbar disc core and twenty-five porcine hamstring tendons were utilized as the subjects for this study. The effects of uniform heat treatments on disc core and hamstring tendon were measured for shrinkage, stiffness, and load to failure strength. Histomorphological study was also carried on the same specimen. Methods: The porcine vertebra-nucleus pulposus-vertebra segments were cored to a uniform 1-cm diameter. The hamstring tendons were cut to uniform 1.2-inch lengths. The tendon specimens were divided into groups of five each and heated in constant temperature water baths of 60°C, 65°C, 70°C, or 75°C for 10 min. Unheated specimens served as controls. The disc core specimens were divided in two group of five each, and tested at room temperature or after immersion in a 70°C bath. The shrinkage was monitored during immersion in the water bath. Biomechanical testing to failure was carried out using mechanical loading on an MTS servohydraulic testing machine operating under stroke control. Strength and stiffness of the tissue was determined. Histomorphology was studied by staining the specimen with hematoxylin and eosin (H&E), and examined under 200 times magnification. Non-heated controls were used for comparisons. Results: The porcine hamstring tendons had no measurable shrinkage in specimens heated up to 65°C. At temperatures above 65°C, the shrinkage was concluded within 2 min of immersion and 70°C appeared to be the optimal temperature, as temperatures higher than this did not demonstrate incremental effects. The disc core samples were heated to 70°C (optimum temperature), and there appeared to be gross contraction of the disc core circumference to visual inspection, but no measurable lengthwise shrinkage could be appreciated. Histologically, the specimens demonstrated progressive loss of individual collagen fiber outline as the temperature increased. In the tendons, at 75°C all of the fibers appear to be fused together, and the voids between individual collagen fibers were no longer present. Biomechanical testing revealed that the tendons undergo a substantial reduction in stiffness after heating. The mean tendon stiffness for the unheated specimens was 19,356 psi, while the corresponding value for the heated tendons was 1023 psi. These were significantly different using the paired t-test at p=0.0043. For the disc core samples, there was no significant difference in either stiffness (p=0.182) or failure strength (p=0.998) after heating. All failures occurred in mid-substance of the specimen. Conclusions: The application of uniform heating to nucleus pulposus disc core caused visible contraction of its circumference but not lengthwise shrinkage. The same heating shrinks the hamstring tendon and reduces its stiffness. Ultimate failure strength of the disc core specimen remains unchanged. The failure data was not obtainable for the tendon due to premature slippage from the fixation apparatus before failure. The results of this study fail to support a biomechanical justification for the application of uniform heat treatment to the whole intervertebral disc. Heating annulus fibrosus and nucleus pulposus separately to specific temperatures may have potential clinical benefits. [Copyright &y& Elsevier]

The number of spinal procedures utilizing metallic implants has significantly increased in the past decade. Unfortunately, a small percentage of the cases are complicated by spinal infections in the setting of instrumentation. The clinical, laboratory, and radiographic assessment of this difficult patient population can be quite challenging to even the astute clinician. Traditional radiographic techniques including CT scan and MRI are significantly less useful in this situation secondary to the confusing postoperative changes and the presence of internal fixation. In this article, we review the nuclear medicine imaging modalities which can be used to assist in the diagnosis and management of patients with postoperative spinal infections with metallic implants. These include 99Technetiumm-methylene diphosphonate (99Tcm-MDP) scan, SPECT scan, three-phase bone scan, 67Gallium citrate scan, 111Indium oxine labeled leukocytes scan, 18-F-Fluoro-deoxy-d-glucose (FDG) labeled PET scanning, as well as combinations of the different modalities. Combinations of the radiopharmaceutical isotope scans and the new FDG PET scan appear to demonstrate the most optimal sensitivity and specificity for infection detection in this patient population. [ABSTRACT FROM AUTHOR]

COMMENTARY ON: Olabisi RM, Lazard ZW, Heggeness MH, et al. An injectable method for noninvasive spine fusion. Spine J 2011;11:545–56 (in this issue). [ABSTRACT FROM AUTHOR]

With the health care environment becoming increasingly patient centric and cost-conscious, interest levels in spinal endoscopy are at an all-time high. Patient demand for the least invasive procedures combined with surgeon desire to maximally shorten the postoperative recovery period has further driven this surgical evolution. Mounting scientific evidence demonstrates the noninferiority and perhaps even superiority of endoscopic techniques to more conventional spinal surgery for the treatment of spinal stenosis and disc herniations. Although higher level evidence is much needed to support the clinical utility of the latest endoscopic techniques and surgical indications, it appears that the entrance of spinal endoscopy into the mainstream arena of spinal surgery is inevitable. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the utilization and charges related to physical therapy (PT) after rotator cuff repair in privately insured and Medicare patients and between arthroscopic and open/mini-open repair techniques. Methods: The PearlDiver insurance database was queried for patients receiving postoperative PT using Current Procedural Terminology codes. Data were available from 2007 to 2011 for United Healthcare and from 2005 to 2011 for Medicare patients. Patients undergoing arthroscopic (CPT 29827) or open/mini-open approaches (CPT 23410, 23412, 23420) were identified in both populations. Utilization was determined by both the percentage of patients with at least one postoperative PT-related code and the average number of encounters per patient. Per-patient average charge was determined by dividing total charges within the billing period by the patient total. Results: A total of 365,891 patients undergoing rotator cuff repair were identified. There was an increase in the number of arthroscopic repairs (+29.1%, P = .027, United Healthcare; +78.9%, P < .001, Medicare) and a decrease in the number of open/mini-open repairs (-18.2%, P = .038, United Healthcare; -18.2%, P < .001, Medicare) across the study period. At 6 months postoperatively, PT utilization was greater in the United Healthcare groups (82.9% arthroscopic, 81.0% open/mini-open) than in the Medicare groups (41.8% arthroscopic, 43.2% open/mini-open). Utilization-weighted per-patient average charge was comparable among all 4 groups, with slightly higher charges in the United Healthcare groups ($3,376 arthroscopic, $3,251 open/mini-open) compared with the Medicare groups ($2,940 arthroscopic, $2,807 open/mini-open). The United Healthcare groups had a greater number of utilization-weighted billed encounters (36.1 for open/mini-open, 9.5 for arthroscopic) than their Medicare counterparts (12.8 open/mini-open, 16.7 arthroscopic). Conclusions: Utilization of PT after rotator cuff repair is substantially higher in privately insured than in Medicare patients. Utilization rates appear to be comparable between surgical approaches. Per-patient costs were comparable irrespective of surgical approach and insurance modality. Level Of Evidence: Level IV, economic. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to evaluate trends in procedures and to report on demographic data of patients undergoing arthroscopic vs. open biceps tenodesis. Methods A retrospective review of a commercially available database (PearlDiver) was conducted to identify cases of arthroscopic and open biceps tenodesis performed between 2007 and 2011 with concurrent diagnoses of commonly associated shoulder disorders. Each record provided the patient's age, gender, and region within the United States, and statistical significance was determined with respect to each of these demographics. Results There were 9011 patients who underwent arthroscopic biceps tenodesis and 11,678 patients who underwent open biceps tenodesis between 2007 and 2011. The number of biceps tenodesis cases increased from 2007 to 2011 (2047 to 5832; P = .015). Both arthroscopic and open biceps tenodesis procedures were performed most commonly in the 30- to 59-year-old age group (76.3% and 76.1%; P < .00001). Men underwent arthroscopic or open biceps tenodesis more commonly than women did (66.1% and 71.9%; P < .00001). Rates of both open and arthroscopic biceps tenodesis varied significantly among the Midwest, South, Northeast, and West regions ( P = .009; P = .007); 49.8% of arthroscopic and 44.6% of open biceps tenodesis cases were associated with rotator cuff tears, whereas 14.4% of arthroscopic and 16.2% of open cases were associated with biceps tendon disorders. Conclusion Both arthroscopic and open biceps tenodesis cases increased annually from 2007 to 2011. The majority of biceps tenodesis cases were performed in men aged 30 to 59 years, and the South had the highest overall number of cases. Further studies are required to evaluate the efficacy of these procedures with and without concomitant pathologic processes. [ABSTRACT FROM AUTHOR]

Anterior cervical discectomy and fusion (ACDF) is a treatment for degenerative spine conditions when symptoms become refractory to conservative management. While pain and neurological function often improve after ACDF, some patients continue to have persistent pain and disability which can benefit from postoperative physical therapy (PT). With the potential advent of bundled payments in spine surgery, it is necessary to determine if the use of postoperative PT is cost-effective. To analyze the health care utilization associated with patients who underwent 1-2 level ACDF alone compared to those who underwent ACDF and postoperative PT. Retrospective database study. Patients who underwent 1,2-level ACDF for degenerative cervical pathologies from 2010-2021 (n=355,188) either with or without postoperative physical therapy. Health care utilization (advanced imaging, revisions, opioid use). PearlDiver database was used to identify patients who underwent 1,2-level ACDF for degenerative cervical spine disorders without or with postoperative PT from 2010-2021. Demographic and procedural data was obtained using International Classification of Disease 9th and 10th Revision (ICD-9, ICD-10) and Current Procedural Terminology (CPT) codes. Postoperative PT included active and passive PT CPT codes. Both Non-PT and PT groups were 1:1 propensity-matched for age, sex, and Elixhauser Comorbidity Index (ECI) scores. Health care utilization included revision surgery, opioid use, and advanced imaging. Advanced imaging was defined by computer tomography (CT) and/or magnetic resonance imaging (MRI) of the cervical spine. Chi-squared analysis, and independent t-test were performed to assess differences in health care utilization, between non-PT and PT subgroups at 2-, 6-, and 12 weeks postoperatively. A total of 355,188 patients underwent 1,2-level ACDF (n=215,764 no PT, n=139,424 with postoperative PT). PT cohort had significantly greater proportions of female patients (57.7% vs 53.5%, p<0.001), myelopathy (26.2% vs 23.3%; p<0.001) and preoperative opioid use (50.5% vs 48.8%; p<0.001). Non-PT cohort had higher proportions of obesity (9.7% vs 8.5%; p<0.001), smoking (21% vs 19.4%; p<0.001), and depression (13% vs 11.9%; p<0.001). Postoperative PT initiated at 2 weeks was associated with significantly more advanced imaging at 3,6 months (p=.012) and 30-day opioid use.(p=.047) and significantly less revisions (p=0.007) and opioid use at 18 months (p=.031); PT at 6 weeks was associated with significantly more advanced imaging at 3,6, 18 months (p<0.001, p=.008) and opioid use at 30 days, 3 months (p<0.001, p=.004) and significantly less opioid use at 9 months (p,.001); PT at 12 weeks was associated with significantly more advanced imaging at 30 days, 3-, 6-,18 months (p=.002, p<0.001) and opioid use at 30 days, 3 months (p<0.001, p=.032) although significantly less opioid use at 9 months (p=.011). No significant difference for other time points and groups. The benefits of postoperative PT for ACDF become more appreciable in the long-term for revisions and postoperative opioid use despite higher proportions of myelopathy and preoperative opioid use. Revision rates in the short-term were not significantly different between non- PT/PT cohorts. Advance imaging appears to be utilized significantly more when initiating postoperative PT at 6,12 weeks vs 2 weeks or no PT. Postoperative PT may aid in long term opioid usage after 1-2 level ACDF surgeries and may be initiated as early as 2 weeks without increased rate of revision surgery. Future prospective RCTs are needed to determine association of these findings with patient reported outcomes, return to work and quality of life. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Context: Adjacent segment disease (ASD) is a potential complication following lumbar spinal fusion.Purpose: This study aimed to demonstrate the demographic, clinical, and operative risk factors associated with ASD development following lumbar fusion.Study Design/setting: Systematic review and meta-analysis.Patient Sample: We identified 35 studies that reported risk factors for ASD, with a total number of 7,374 patients who had lumbar spine fusion.Outcome Measures: We investigated the demographic, clinical, and operative risk factors for ASD after lumbar fusion.Methods: A literature search was done using PubMed, Embase, Medline, Scopus, and the Cochrane library databases from inception to December 2019. The methodological index for non-randomized studies (MINORS) criteria was used to assess the methodological quality of the included studies. A meta-analysis was done to calculate the odds ratio (OR) with the 95% confidence interval (CI) for dichotomous data and mean difference (MD) with 95% CI for continuous data.Results: Thirty-five studies were included in the qualitative analysis, and 22 studies were included in the meta-analyses. The mean quality score based on the MINORS criteria was 12.4±1.9 (range, 8-16) points. Significant risk factors included higher preoperative body mass index (BMI) (mean difference [MD]=1.97 kg/m2; 95% confidence interval [CI]=1.49-2.45; p<.001), floating fusion (Odds ratio [OR]=1.78; 95% CI=1.32-2.41; p<.001), superior facet joint violation (OR=10.43; 95% CI=6.4-17.01; p<.001), and decompression outside fusion construct (OR=1.72; 95% CI=1.25-2.37; p<.001).Conclusions: The overall level of evidence was low to very low. Higher preoperative BMI, floating fusion, superior facet joint violation, and decompression outside fusion construct are significant risk factors of development of ASD following lumbar fusion surgeries. [ABSTRACT FROM AUTHOR]

Background Context: The concept of frailty has become increasingly recognized, and while patients with cancer are at increased risk for frailty, its influence on perioperative outcomes in metastatic spine tumors is uncertain. Furthermore, the impact of frailty can be confounded by comorbidities or metastatic disease burden.Purpose: The purpose of this study was to evaluate the influence of frailty and comorbidities on adverse outcomes in the surgical management of metastatic spine disease.Study Design/setting: Retrospective analysis of a nationwide database to include patients undergoing spinal fusion for metastatic spine disease.Patient Sample: A total of 1,974 frail patients who received spinal fusion with spinal metastasis, and 1,975 propensity score matched non-frail patients.Outcome Measures: Outcomes analyzed included mortality, complications, length of stay (LOS), nonroutine discharges and costs.Methods: A validated binary frailty index (Johns Hopkins Adjusted Clinical Groups) was used to identify frail and non-frail groups, and propensity score-matched analysis (including demographics, comorbidities, surgical and tumor characteristics) was performed. Sub-group analysis of levels involved was performed for cervical, thoracic, lumbar and junctional spine. Multivariable-regression techniques were used to develop predictive models for outcomes using frailty and the Elixhauser Comorbidity Index (ECI).Results: 7,772 patients underwent spinal fusion with spinal metastasis, of which 1,974 (25.4%) patients were identified as frail. Following propensity score matching for frail (n=1,974) and not-frail (n=1,975) groups, frailty demonstrated significantly greater medical complications (OR=1.58; 95% CI 1.33-1.86), surgical complications (OR=1.46; 95% CI 1.15-1.85), LOS (OR=2.65; 95% CI 2.09-3.37), nonroutine discharges (OR=1.79; 95% CI 1.46-2.20) and costs (OR=1.68; 95% CI 1.32-2.14). Differences in mortality were only observed in subgroup analysis and were greater in frail junctional and lumbar spine subgroups. Models using ECI alone (AUC=0.636-0.788) demonstrated greater predictive ability compared to those using frailty alone (AUC=0.633-0.752). However, frailty combined with ECI improved the prediction of increased LOS (AUC=0.811), cost (AUC=0.768), medical complications (AUC=0.723) and nonroutine discharges (AUC=0.718). Predictive modeling of frailty in subgroups demonstrated the greatest performance for mortality (AUC=0.750) in the lumbar spine, otherwise performed similarly for LOS, costs, complications, and discharge across subgroups.Conclusions: A high prevalence of frailty existed in the current patient cohort. Frailty contributed to worse short-term adverse outcomes and could be more influential in the lumbar and junctional spine due to higher risk of deconditioning in the postoperative period. Predictions for short term outcomes can be improved by adding frailty to comorbidity indices, suggesting a more comprehensive preoperative risk stratification should include frailty. [ABSTRACT FROM AUTHOR]

This abstract contains content that is significantly similar to the authors' previously published abstract in the Global Spine Journal Rapid Fire. For access to the original publication, please visit the following DOI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10226053/. [ABSTRACT FROM AUTHOR]

In recent years, the use of intraoperative computer tomography-guided (CT-guided) navigation has gained significant popularity among health care providers who perform minimally invasive spine surgery. This review aims to identify and analyze trends in the literature related to the widespread adoption of CT-guided navigation in spine surgery, emphasizing the shift from conventional fluoroscopy-based techniques to CT-guided navigation. Articles pertaining to this study were identified via a database review and were hierarchically organized based on the number of citations. An "advanced document search" was performed on September 28th, 2022, utilizing Boolean search operator terms. The 25 most referenced articles were combined into a primary list after sorting results in descending order based on the total number of citations. The "Top 25" list for intraoperative CT-guided navigation in spine surgery cumulatively received a total of 2742 citations, with an average of 12 new citations annually. The number of citations ranged from 246 for the most cited article to 60 for the 25th most cited article. The most cited article was a paper by Siewerdsen et al., with 246 total citations, averaging 15 new citations per year. Intraoperative CT-guided navigation is 1 of many technological advances that is used to increase surgical accuracy, and it has become an increasingly popular alternative to conventional fluoroscopy-based techniques. Given the increasing adoption of intraoperative CT-guided navigation in spine surgery, this review provides impactful evidence for its utility in spine surgery. [ABSTRACT FROM AUTHOR]

Abstract: Spinal arthrodesis continues to expand in clinical indications and surgical practice. Despite a century of study, failure of bone formation or pseudarthrosis can occur in individual patients with debilitating clinical symptoms. Here we review biological and technical aspects of spinal fusion under active investigation, describe relevant biomechanics in health and disease, and identify the possibilities and limitations of translational animal models. The purpose of this article is to foster collaborative efforts with researchers who model bone hierarchy. The induction of heterotopic osteosynthesis requires a complex balance of biologic factors and operative technique to achieve successful fusion. Anatomical considerations of each spinal region including blood supply, osteology, and biomechanics predispose a fusion site to robust or insufficient bone formation. Careful preparation of the fusion site and appropriate selection of graft materials remains critical but is sometimes guided by conflicting evidence from the long-bone literature. Modern techniques of graft site preparation and instrumentation have evolved for every segment of the vertebral column. Despite validated biomechanical studies of modern instrumentation, a correlation with superior clinical outcomes is difficult to demonstrate. In many cases, adjuvant biologic therapies with allograft and synthetic cages have been used successfully to reproduce the enhancement of fusion rates observed with cancellous and tricortical autograft. Current areas of investigation comprise materials science, stem cell therapies, recombinant growth factors, scaffolds and biologic delivery systems, and minimally invasive surgical techniques to optimize the biologic response to intervention. Diverse animal models are required to approach the breadth of spinal pathology and novel therapeutics. [ABSTRACT FROM AUTHOR]

Abstract: Background Context: Lumbar discectomy is one of the most common spine surgical procedures. With the exception of true emergencies (eg, cauda equina syndrome), lumbar discectomy is usually performed as an elective procedure after a prudent trial of nonoperative treatment. Although several studies have compared costs of definitive operative or nonoperative management of lumbar disc herniation, no information has been published regarding the cost of conservative care in patients who ultimately underwent surgical discectomy. Purpose: The purpose of this study was to determine the financial costs (and relative distribution of those costs) associated with the nonoperative management of lumbar disc herniation in patients who ultimately failed conservative care and elected to undergo surgical discectomy. Study Design: This is a retrospective database review. Patient Sample: The sample comprises patients within the database who underwent lumbar discectomy. Outcome Measures: The outcome measures were frequency of associated procedures and the costs of those procedures. Materials and Methods: A search was conducted using a commercially available online database of insurance records of orthopedic patients to identify all patients within the database undergoing lumbar discectomy between 2004 and 2006. Patients were identified by American Medical Association Current Procedural Terminology code. The associated charge codes for the 90-day period before the surgery were reviewed and categorized as outpatient physician visits, imaging studies, physical therapy, injection, chiropractic manipulation, medication charges, preoperative studies, or miscellaneous charges. The frequency of each code and the percentage of patients for whom that code was submitted to the insurance companies were noted, as were the associated charges. Results: In total, 30,709 patients in the database met eligibility criteria. A total of $105,799,925 was charged during the 90 days preoperatively, an average of $3,445 per patient. Average charge for discectomy procedure was $7,841. Charges for injection procedures totaled $16,211,246 or 32% of total charges, diagnostic imaging $15,648,769 (31%), outpatient visits $6,552,135 (13%), physical therapy visits $5,723,644 (11%), chiropractic manipulation $1,177,406 (2%), preoperative studies $426,976 (0.8%), medications $263,039 (0.5%), and miscellaneous charges $1,177,371 (2%). Conclusions: Charges for preoperative care of patients with lumbar disc herniation are substantial and are split almost evenly between diagnostic charges (outpatient visits, imaging, laboratory studies, and miscellaneous) and therapeutic charges (injections, physical therapy, chiropractic manipulation, and medications). Although a large number of patients will ultimately require surgical intervention, given that many patients will improve with nonoperative therapy, a trial of conservative management is appropriate. Additional studies to identify patients who may ultimately fail nonoperative treatment and would benefit from early discectomy would be beneficial. [Copyright &y& Elsevier]

The aim of the current study was to classify and analyze trends in lumbar disc degeneration across age, sex, and disc level using weightbearing kinematic MRI. Between January 2019 and July 2019, 1198 cases were retrospectively analyzed with kinematic MRI. Patients were divided into 5 groups based on age (20–29, 30–39, 40–49, 50–59, and 60+) and evaluated using the Pfirrmann classification to assess for disc degeneration at 5 vertebral levels: L1/2, L2/3, L3/4, L4/5, and L5/S1. Trends in degeneration were analyzed with regression and time series. The L5/S1 vertebral disc had the highest prevalence of severe degeneration across all age groups. The most common multi-level degeneration combinations were L4/5 and L5/S1 for two levels and L3/4, L4/5, and L5/S1 for three levels. All vertebral levels showed significant difference in mean Pfirrmann grade among the age groups (p < 0.001 at all levels). Statistically significant differences in mean Pfirmmann grade among males and females were found only in ages 20–29 and 30–39, in which males showed more degeneration. Our findings using kinematic MRI demonstrate that degeneration increases with age and is most severe in the L5/S1 disc. In multi-level degeneration the most prevalent combinations are those that are contiguous and include L5/S1. Young males were more likely to have degeneration than young females, but there was no significant difference from the fifth decade of life on. • Lumbar disc degeneration increases in severity with age. • Men tend to degenerate at an earlier age than women. • The 5th decade of life is most common for people to develop severe degeneration. [ABSTRACT FROM AUTHOR]