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Study Design: Guideline., Objectives: To develop an international guideline (AOGO) about the use of osteobiologics in anterior cervical discectomy and fusion (ACDF) for treating degenerative spine conditions., Methods: The guideline development process was guided by AO Spine Knowledge Forum Degenerative (KF Degen) and followed the Guideline International Network McMaster Guideline Development Checklist. The process involved 73 participants with expertise in degenerative spine diseases and surgery from 22 countries. Fifteen systematic reviews were conducted addressing respective key topics and evidence was collected. The methodologist compiled the evidence into GRADE Evidence-to-Decision frameworks. Guideline panel members judged the outcomes and other criteria and made the final recommendations through consensus., Results: Five conditional recommendations were created. A conditional recommendation is about the use of allograft, autograft or a cage with an osteobiologic in primary ACDF surgery. Other conditional recommendations are about the use of osteobiologic for single- or multi-level ACDF, and for hybrid construct surgery. It is suggested that surgeons use other osteobiologics rather than human bone morphogenetic protein-2 (BMP-2) in common clinical situations. Surgeons are recommended to choose 1 graft over another or 1 osteobiologic over another primarily based on clinical situation, and the costs and availability of the materials., Conclusion: This AOGO guideline is the first to provide recommendations for the use of osteobiologics in ACDF. Despite the comprehensive searches for evidence, there were few studies completed with small sample sizes and primarily as case series with inherent risks of bias. Therefore, high-quality clinical evidence is demanded to improve the guideline., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Systematic review., Objectives: The aim of this study is to analyze the complications related to multilevel anterior cervical discectomy and fusion (ACDF) using osteobiologics other than bone morphogenetic protein (BMP)., Methods: A systematic review of the literature was conducted using PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases. The search to identify studies reporting complications in multilevel ACDF surgery using osteobiologics other than bone morphogenetic protein was performed in August 2020. The study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)., Results: A total of 584 articles were found after searching the databases and removing duplicates. Next, screening was performed in a double reviewer process, and 153 eligible articles-with 4 retrospective studies-in full-text were selected; these met all inclusion criteria. A total of 197 patients received 3-level ACDF, while 72 patients received 4-level ACDF. Osteobiologics were used in all selected articles, allograft was used in 4 studies, autologous bone graft was utilized in 3 articles, and hydroxyapatite was used in 1 article. The main complications reported were dysphagia, adjacent segment disease, and pseudarthrosis., Conclusions: Given the limited evidence, no conclusions on complications in multilevel ACDF using osteobiologics other than BMP could be made. However, descriptively, the most common complications found were dysphagia, adjacent segment disease, and pseudoarthrosis. Further prospective studies separately analyzing complications in multilevel ACDF by osteobiologics and a number of treated levels are needed., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Systematic literature review Objective: To critically analyze the literature and describe the complications associated with the use of allograft in 1- or 2- level anterior cervical discectomy and fusion (ACDF) Methods: A systematic search of PubMed/MEDLINE, EMBASE, and ClinicalTrials.gov databases was conducted for literature published between January 2000 and August 2020 reporting complications associated with the use of allograft in 1- or 2- level ACDF. Results: From 584 potentially relevant citations, 21 met the inclusion criteria (4 randomized controlled trials (RCT), 4 prospective, and 13 retrospective studies). The patient number varied between 26 and 463 in comparative studies (RCT and non-RCT) and between 29 and 345 in non-comparative studies. Fusion rate was reported in 14 studies and ranged between 68.5-100%. The most frequently reported complication was post-operative dysphagia or dysphonia, with incidences ranging between .5% and 14.4%. Revision surgery was the second most reported complication (14 studies) and ranged between 0% and 10.3%. Wound-related complications were reported in 6 studies and ranged between 0% and 22.8%. Conclusion: The overall reporting of complications was low with very few comparative studies. Reported complications with allografts are within the range of other osteobiologics and autografts and in most cases may not attributable to the use of osteobiologics and may be complications of the procedure itself. Comparative studies with a more robust methodology analyzing complications with allograft and other osteobiologics are needed to inform current practice with strong recommendations., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Systematic literature review., Objectives: To analyze the evidence available reporting complications in single or two-level anterior cervical discectomy and fusion (ACDF) using a demineralized bone matrix (DBM), hydroxyapatite (HA), or beta-tricalcium phosphate (β-TCP)., Methods: A systematic review of the literature using PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases was performed in August 2020 to identify studies reporting complications in one or two-level ACDF surgery using DBM, HA, or β-TCP. The study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines., Results: A total of 1857 patients were included, 981 male and 876 female, across 17 articles; 5 prospective, and 12 retrospectives. We noted heterogeneity among the included studies concerning the study design and combination of graft materials utilized in them. However, we noted a higher incidence of adjacent segment disease (17.7%) and pseudoarthrosis (9.3%) in fusion constructs using DBM. Studies using β-TCP reported a higher incidence of pseudoarthrosis (28.2%) and implant failures (17.9%)., Conclusions: Degenerative cervical conditions treated with one or two-level ACDF surgery using DBM, HA, or β-TCP with or without cervical plating are associated with complications such as adjacent segment disease, dysphagia, and pseudarthrosis. However, consequent to the study designs and clinical heterogeneity of the studies, it is not possible to correlate these complications accurately with any specific graft material employed. Further well-designed prospective studies are needed to correctly know the related morbidity of each graft used for achieving fusion in ACDF., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: ATEC-attended course in San Diego, travel and lodging supported by ATEC, ATEC-own stock options that were purchased personally. Fehling Instruments GmbH, Stayble Therapeutics Via Regenerate Life Sciences GmbH, Mundipharma Via Regenerate Life Sciences GmbH, Spinplant GmbH. Depuy Synthes. Yes, various lawfirms me, AO Foundation Board reimbursements, Bone biologics Personal investment, Surgitech Personal investment, Pearldiver Personal investment. SeaSpine (past, paid to the institution), Next Science (paid directly to institution), Motion Metrics (past, paid to the institution), NIH SBIR grant NIH SBIR Subaward, MAX BioPharma, Cerapedics (past), The Scripps Research Institute (past), AO Spine (past), Xenco Medical (past), AO Spine, North American Spine Society, US 2014O194364A1, US010391142B2, North American Spine Society: committee member, Lumbar Spine Society: Co-chair Educational Committee, AOSpine Knowledge Forum Degenerative: Associate member, AOSNA Research committee-committee member. Medtronic, Baxter, SafeOrthopaedics, Croatian Society of Vertebrology, Medtronic, Paid consultant for company, SI Bone Research support to institution, AO Spine Research support to institution, Mizuho Orthopedics Systems Research support to institution, Medtronic Paid consultant for company.

Study Design: Network meta-analysis., Objectives: To compare the fusion outcome and complications of different 1 or 2-level anterior cervical decompression and fusion (ACDF) constructs performed with and without the application of autografts., Methods: We performed an independent and duplicate search in electronic databases including PubMed, Embase, Web of Science, Cochrane, and Scopus for relevant articles published between 2000 and 2020. We included comparative studies reporting fusion rate and complications with and without the use of autografts in ACDF across 5 different fusion constructs. A network meta-analysis was performed in Stata, categorized based on the type of fusion constructs utilized. Fusion constructs were ranked based on p-score approach and surface under cumulative ranking curve (SUCRA) scores. The confidence of results from the analysis was appraised with Cochrane's CINeMA approach., Results: A total of 2216 patients from 22-studies including 6 Randomized Controlled Trials (RCTs) and 16 non-RCTs were included in network analysis. The mean age of included patients was 49.3 (±3.62) years. Based on our meta-analysis, we could conclude that use of autograft in 1- or 2-level ACDF did not affect the fusion and mechanical implant-related complications. The final fusion and mechanical complication rates were also not significantly different across the different fusion constructs. The use of plated constructs was associated with a significant increase in post-ACDF dysphagia rates [OR 3.42; 95%CI (.01,2.45)], as compared to stand-alone constructs analysed., Conclusion: The choice of fusion constructs and use of autografts does not significantly affect the fusion and overall complication rates following 1 or 2-level ACDF surgery., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Depuy Synthes. Medtronic, Baxter, SafeOrthopaedics, Croatian Society of Vertebrology. Medtronic Paid consultant for company, SI Bone Research support to institution, AO Spine Research support to institution, Mizuho Orthopedics Systems Research support to institution. ATEC-attended course in San Diego, travel and lodging supported by ATEC, ATEC-own stock options that were purchased personally. Zimmer, Depuy, Seaspine, various lawfirms, AO Foundation Board reimbursements, AO Foundation Board, Bone biologics Personal investment, Surgitech Personal investment, Pearldiver Personal investment. Fehling Instruments GmbH, Stayble Therapeutics Via Regenerate Life Sciences GmbH, Mundipharma Via Regenerate Life Sciences GmbH, Spinplant GmbH. SeaSpine (past, paid to the institution), Next Science (paid directly to institution), Motion Metrics (past, paid to the institution), NIH SBIR grant NIH SBIR Subaward, MAX BioPharma, Cerapedics (past), The Scripps Research Institute (past), AO Spine (past), Xenco Medical (past), AO Spine, North American Spine Society, US 2014O194364A1, US010391142B2, North American Spine Society: committee member, Lumbar Spine Society: Co-chair Educational Committee, AOSpine Knowledge Forum Degenerative: Associate member, AOSNA Research committee- committee member.

Study Design: Cross-sectional survey., Objective: Although literature does not recommend routine wound drain utilization, there is a disconnect between the evidence and clinical practice. This study aims to explore into this controversy and analyze the surgeon preferences related to drain utilization, and the factors influencing drain use and criterion for removal., Methods: A survey was distributed to AO Spine members worldwide. Surgeon demographics and factors related to peri-operative drain use in 1 or 2-level open fusion surgery for lumbar degenerative pathologies were collected. Multivariate analyses by drain utilization, and criterion of removal were conducted., Results: 231 surgeons participated, including 220 males (95.2%), orthopedics (178, 77.1%), and academic/university-affiliated (114, 49.4%). Most surgeons preferred drain use (186, 80.5%) and subfascial drains (169, 73.2%). Drains were removed based on duration by 52.87% of the surgeons, but 27.7% removed drains based on outputs. On multivariable analysis, significant predictors of drain use were surgeon's aged 35-44 (OR = 11.9, 95% CI = 1.2-117.2, P = .034), 45-54 (29.1, 3.1-269.6, P = .003), 55-64 (8.9, 1.4-56.5, .019), and wound closure using coaptive films (6.0, 1.2-29.0, P = .025). Additionally, surgeons from Asia Pacific (OR = 5.19, 95% CI = 1.65-16.38, P = .005), Europe (3.55, 1.22-10.31, P = .020), and Latin America (4.40, 1.09-17.83, .038) were more likely to remove drain based on time duration, but surgeons <5 years of experience (10.23, 1.75-59.71, P = .010) were more likely to remove drains based on outputs., Conclusions: Most spine surgeons worldwide prefer to place a subfascial wound drain for degenerative open lumbar surgery. The choice for drain placement is associated with the surgeon's age and use of coaptive films for wound closure, while the criterion for drain removal is associated with the surgeons' region of practice and experience., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study design: Systematic Review and Meta-analysis. Objective: Surgical alternatives to treat lumbar spinal stenosis and instability include indirect (ALIF, OLIF, and LLIF) and direct (TLIF or posterior lumbar interbody fusion) decompression and fusion interventions. Although both approaches have proven to be effective in reducing symptoms, it is unknown if there is any difference in effectiveness between them. In this systematic review and meta-analysis, we aimed to evaluate postoperative pain and disability in patients treated whit indirect vs direct decompression and fusion approaches. Methods: We conducted a systematic review of the literature consulting several databases and identified studies that enrolled patients diagnosed with degenerative lumbar spinal stenosis and instability treated with indirect or direct decompression and fusion techniques. Our primary endpoints were the visual analogue scale, Oswestry Disability Index, and the Japanese Orthopedics Association Back Pain Evaluation Questionnaire 1 year after the procedure. Secondary outcomes included complication rate, blood loss, and surgical time. Results: Nine retrospective and comparative studies were included enrolling a total of 1004 participants. Both surgical strategies had satisfactory clinical outcomes with no significant difference at 1 year. Although the complication rate was similar for both groups, the profile of the adverse events was different. In addition, patients treated with indirect decompression and fusion had significantly less blood loss and operative times. Conclusions: Indirect and direct decompression and fusion techniques are similarly effective in treating patients with lumbar spinal stenosis and instability. The ID group had significantly lower intraoperative blood loss and surgical time values.

Study Design: Cross-sectional survey., Objectives: Assessment of subaxial cervical facet injuries using the AO Spine Subaxial Cervical Spine Injury Classification System is based on CT scan findings. However, additional radiological evaluations are not directly considered. The aim of this study is to determine situations in which spine surgeons request additional radiological exams after a facet fracture., Methods: A survey was sent to AO Spine members from Latin America. The evaluation considered demographic variables, routine use of the Classification, as well as the timepoint at which surgeons requested a cervical MRI, a vascular study, and/ or dynamic radiographs before treatment of facet fractures., Results: There was 229 participants, mean age 42.9 ± 10.2 years; 93.4% were men. Orthopedic surgeons 57.6% with 10.7 ± 8.7 years of experience in spine surgery. A total of 86% used the Classification in daily practice. An additional study (MRI/vascular study/and dynamic radiographs) was requested in 53.3%/9.6%/43.7% in F1 facet injuries; 76.0%/20.1%/50.2% in F2; 89.1%/65.1%/28.4% in F3; and 94.8%/66.4%/16.6% in F4. An additional study was frequently required: F1 72.5%, F2 86.9%, F3 94.7%, and F4 96.1%., Conclusions: Spine surgeons generally requested additional radiological evaluations in facet injuries, and MRI was the most common. Dynamic radiographs had a higher prevalence for F1/F2 fractures; vascular studies were more common for F3/F4 especially among surgeons with fewer years of experience. Private hospitals had a lower spine trauma cases/year and requested more MRI and more dynamic radiographs in F1/F2. Neurosurgeons had more vascular studies and dynamic radiographs than orthopedic surgeons in all facet fractures.

Most COVID-19 mortality scores were developed at the beginning of the pandemic and clinicians now have more experience and evidence-based interventions. Therefore, we hypothesized that the predictive performance of COVID-19 mortality scores is now lower than originally reported. We aimed to prospectively evaluate the current predictive accuracy of six COVID-19 scores and compared it with the accuracy of clinical gestalt predictions. 200 patients with COVID-19 were enrolled in a tertiary hospital in Mexico City between September and December 2020. The area under the curve (AUC) of the LOW-HARM, qSOFA, MSL-COVID-19, NUTRI-CoV, and NEWS2 scores and the AUC of clinical gestalt predictions of death (as a percentage) were determined. In total, 166 patients (106 men and 60 women aged 56±9 years) with confirmed COVID-19 were included in the analysis. The AUC of all scores was significantly lower than originally reported: LOW-HARM 0.76 (95% CI 0.69 to 0.84) vs 0.96 (95% CI 0.94 to 0.98), qSOFA 0.61 (95% CI 0.53 to 0.69) vs 0.74 (95% CI 0.65 to 0.81), MSL-COVID-19 0.64 (95% CI 0.55 to 0.73) vs 0.72 (95% CI 0.69 to 0.75), NUTRI-CoV 0.60 (95% CI 0.51 to 0.69) vs 0.79 (95% CI 0.76 to 0.82), NEWS2 0.65 (95% CI 0.56 to 0.75) vs 0.84 (95% CI 0.79 to 0.90), and neutrophil to lymphocyte ratio 0.65 (95% CI 0.57 to 0.73) vs 0.74 (95% CI 0.62 to 0.85). Clinical gestalt predictions were non-inferior to mortality scores, with an AUC of 0.68 (95% CI 0.59 to 0.77). Adjusting scores with locally derived likelihood ratios did not improve their performance; however, some scores outperformed clinical gestalt predictions when clinicians' confidence of prediction was <80%. Despite its subjective nature, clinical gestalt has relevant advantages in predicting COVID-19 clinical outcomes. The need and performance of most COVID-19 mortality scores need to be evaluated regularly., Competing Interests: Competing interests: None declared., (© American Federation for Medical Research 2022. No commercial re-use. See rights and permissions. Published by BMJ.)