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Study Design: Meta-analysis., Objective: The objective of this study was to determine whether adjunctive intrathecal morphine (ITM) reduces postoperative analgesic consumption following pediatric spine surgery., Summary of Background Data: Previous studies that have tested supplemental ITM to manage pain after pediatric spine surgery have been limited by small sample sizes., Methods: A comprehensive search of PubMed, Web of Science, Clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials was performed for clinical trials and observational studies. Time to first analgesic demand, postoperative analgesic use, pain scores, and complication data were abstracted from each study. Mean difference (MD) and 95% confidence interval (CI) were used to compare continuous outcomes and odds ratios (OR) and 95% CI were used for dichotomous outcomes., Results: A total of 5 studies, including 3 randomized controlled trials and 2 retrospective chart reviews, containing 636 subjects, were incorporated into meta-analysis. Subjects that were administered ITM in addition to postoperative analgesics (ITM group) were compared with those receiving postoperative analgesics only (control group). In the ITM group, time to first analgesic demand was longer (MD, 8.79; 95% CI, 4.20-13.37; P<0.001), cumulative analgesic consumption was reduced at 24 hours (MD, -0.40; 95% CI, -0.56 to -0.24; P<0.001), and cumulative analgesic consumption was reduced at 48 hours (MD, -0.43; 95% CI, -0.59 to -0.27; P<0.001). Neither postoperative pain scores at 24 hours (P=0.16) nor 48 hours (P=0.18) were significantly different between ITM and control groups. Rates of respiratory depression, nausea, vomiting, and pruritus were not different between groups (all Ps>0.05)., Conclusions: Addition of ITM in pediatric spine surgery produced a potent analgesic effect in the immediate postoperative period. Patients administered ITM did not request opiates as early as control and consumed fewer opiates by the second postoperative day. Furthermore, use of ITM did not increase complications such as respiratory depression, nausea, vomiting, or pruritus.

Study Design: This is a cross-sectional study., Objective: To investigate spine surgeons' attitudes regarding preoperative anxiety measurement, management, and responsibility., Summary of Background Data: The vast majority of patients scheduled for spine surgery experience preoperative anxiety. However, there are currently no consensus guidelines for measure or management of preoperative anxiety in spinal operations., Materials and Methods: An anonymous questionnaire was sent online to spine surgeons of AO Spine North America to capture their views regarding preoperative anxiety., Results: Of 69 complete responses, most respondents were male (n=66, 95.7%), orthopedic surgeons (n=52, 75.4%), and practicing at an academic setting (n=39, 56.5%). Most spine surgeons practiced for at least 20 years (n=52, 75.4%), operated on 100-300 patients per year (n=48, 69.6%), and were attending physicians (n=61, 88.4%). Most did not measure preoperative anxiety (n=46, 66.7%) and would not use a rating scale to measure it (n=38, 55.1%). However, most would discuss it if mentioned by the patient (n=40, 58.0%). Other spine surgeons measured anxiety verbally (n=22, 31.9%) or with a rating scale or survey (n=6, 8.7%). Although preferences for preoperative anxiety management varied, most respondents used patient education (n=54, 78.3%) and permitting family members' presence (n=36, 52.2%) to reduce patient anxieties. Spine surgeons held themselves, anesthesiologists, and patients most responsible to manage preoperative anxiety., Conclusions: The majority of spine surgeons surveyed did not regularly measure preoperative anxiety, but would discuss its management if the subject was broached by the patient. Spine surgeons relied on a variety of methods to manage a patient's anxiety, but most preferred preoperative education and permitting the presence of family members. Responsibility for controlling preoperative anxiety was chiefly allocated to surgeons, anesthesiologists, and patients. Future avenues for research may include developing a preoperative anxiety measurement scale and management protocol specific to spine surgery., Level of Evidence: Level IV.

Study Design: This was a cross-sectional study., Objective: The objective of this study was to determine spine surgeons' preferences for the intraoperative and postoperative management of intraoperative durotomy (IDT) in decompression and spinal fusion surgeries., Summary of Background Data: Management guidelines for IDT remain elusive. Traditionally, management consists of intraoperative suturing and postoperative bed rest. However, preferences of North American spine surgeons may vary, particularly according to type of surgery., Materials and Methods: Spine surgeons of AO Spine North America (AOSNA) were surveyed online anonymously to determine which techniques they preferred to manage IDT in decompression and fusion. Differences in preferences according to surgery type were compared using the Fisher exact test. A series of linear regressions were conducted to identify demographic predictors of spine surgeons' preferences., Results: Of 217 respondents, most were male (95%), orthopedic surgeons (70%), practiced at an academic center (50%), were in practice 0-19 years (71%) and operated on 100-300 patients per year (70%). The majority of surgeons applied sutures (93%-96%) and sealant (82%-84%). Surgeons also used grafts (26%-27%), drains (18%), other techniques (4%-5%), blood patch (2%-3%), or no intraoperative management (1%-2%). Postoperatively, most surgeons recommended bed rest (74%-75%). Antibiotics (22%), immediate mobilization (18%-20%), reoperation (14%-16%), other techniques (6%), or no postoperative management (5%) were also preferred. Management preferences did not vary significantly between decompression and fusion surgeries (all P-values>0.05). Specialty, practice facility, years in practice, and patients per year were identified as independent predictors of IDT management preferences (P<0.05)., Conclusions: Although North American spine surgeons preferred to manage IDT with sutures augmented by sealant followed by bed rest after surgery, less common techniques were also preferred during the intraoperative and postoperative periods. Notably, intraoperative and postoperative IDT management preferences did not change in accordance to the type of surgery being conducted., Level of Evidence: Level V.

Study Design: Retrospective review., Objective: To review the feasibility of a posterior-only approach for instrumented reconstruction in lumbar burst fractures., Background: Burst fractures of the lumbar spine have been treated through a variety of techniques, including anterior, posterior, or combined approaches. Here we review series of patients undergoing posterior-only transpedicular corpectomy with instrumented fusion for traumatic lumbar burst fracture., Methods: All patients treated at the Los Angeles County+University of Southern California (LAC+USC) Medical Center who had sustained traumatic lumbar burst fractures from February 2005 to February 2014 were reviewed., Results: A total of 178 traumatic lumbar burst fractures were identified of which 89 required operative intervention. Of those 89 operations, 7 patients underwent posterior-only approach for transpedicular corpectomy. Levels operated on were at L1 (4 patients), L2 (1 patient), and L4 (2 patients). The mean age was 35 years of age (range, 21-56 y), and mechanism of injury was either motor vehicle accident (5 patients) or fall (2 patients). Initial neurological examination was American Spinal Injury Association (ASIA) B in 3 patients, ASIA D in 3 patients, and 1 patient was neurologically intact. Mean thoracolumbar injury classification and severity score on presentation was 6.4 (range, 5-8), whereas the mean load sharing classification score was 7.4 (range, 7-9). Of patients who were not immediately lost to follow-up on hospital discharge, mean clinical follow-up was 45.3 months (range, 18.8-68.6 mo), whereas mean radiographic follow-up was 28.8 months (range, 1.3-63.6 mo). At the last known radiographic follow-up, no patient had gross hardware fracture, pseudoarthrosis, or adjacent segment disease. One patient with the longest radiographic follow-up of 63.6 months was noted to have some minimal subsidence of his cage with no other change in his other hardware., Conclusion: A posterior-only approach for transpedicular corpectomy and instrumented fusion is a viable treatment option for lumbar burst fracture which allows for reconstruction of the anterior column while avoiding many of the risks and complications associated with an anterior or combined approach.