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Although several studies have suggested that minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) may be especially beneficial in the elderly population due to lower operative morbidity and faster postoperative recovery, there are limited studies investigating the functional outcomes, quality of life, and satisfaction in elderly patients after MIS-TLIF. Furthermore, existing studies had substantial clinical, diagnostic, and surgical heterogeneity.We asked if elderly patients could experience comparable (1) patient-reported pain, disability and quality of life, (2) perioperative complications, and (3) radiological fusion rates as their younger counterparts after MIS-TLIF.Prospectively collected registry data of patients undergoing primary, single-level, MIS-TLIF for degenerative spondylolisthesis between 2012 and 2014 were reviewed. We included 168 patients, 39 of whom were at least 70 years old. Of the 129 patients younger than 70 years old, propensity-score matching was used to select 39 younger controls with adjustment for sex, BMI, American Society of Anesthesiologists score, and baseline clinical outcomes. Perioperative complications and radiologic data were compared.There was no difference in back pain (mean difference -0.3 [95% confidence interval -1.0 to 0.5]; p = 0.52); leg pain (mean difference -0.1 [95% CI to 0.6-0.5]; p = 0.85); Oswestry Disability Index (mean difference -2.9 [95% CI -8.0 to 2.2]; p = 0.26); and SF-36 physical (mean difference 3.0 [95% CI -0.7 to 6.8]; p = 0.107); and mental component summary (mean difference 1.9 [95% CI -4.5 to 8.2]; p = 0.56); up to 2 years postoperatively; 85% of younger patients and 85% of elderly patients were satisfied (p0.99) while 87% and 80%, respectively, had fulfilled expectations (p = 0.36). Four perioperative adverse events occurred in each group. There was also no difference in the rate of fusion (87% in younger patients and 90% in elderly patients; p = 0.135).When clinical and surgical heterogeneity were minimized, elderly patients undergoing minimally invasive transforaminal lumbar interbody fusion not only had comparable rates of perioperative complications but also experienced similar improvements in pain, function, and quality of life. A high rate of satisfaction was achieved.Level II, prognostic study.

Skeptics of the KIPP (Knowledge Is Power Program) charter school network argue that these schools rely on selective admission, attrition, and replacement of students to produce positive achievement results. We investigate this using data covering 19 KIPP middle schools. On average, KIPP schools admit students disadvantaged in ways similar to other local students, and attrition patterns are typically no different at KIPP than at nearby schools. Unlike district schools, however, KIPP schools tend to replace students who exit with higher achieving students, and fewer students are replaced in the later years of middle school. Overall, KIPP’s positive achievement impacts do not appear to be explained by advantages in the prior achievement of KIPP students, even when attrition and replacement patterns are taken into account.

Spinal deformities can result in increasing thoracic kyphosis or loss of lumbar lordosis, leading to imbalance in the sagittal plane. Such deformities can be functionally and psychologically debilitating. The Smith-Petersen osteotomy can achieve approximately 10 degrees of correction in the sagittal plane at each spinal level at which it is performed. This osteotomy is beneficial for patients who have a degenerative imbalance in the sagittal plane. The pedicle subtraction osteotomy can achieve approximately 30 degrees to 40 degrees of correction in the sagittal plane at each spinal level at which it is performed. It is the preferred osteotomy for patients with ankylosing spondylitis who have an imbalance of the spine in the sagittal plane. The cervical extension osteotomy is performed in the cervical spine, at the cervicothoracic junction, in patients who have a cervical flexion deformity that impedes their ability to look straight ahead while walking or who have difficulty swallowing. The vertebral column resection is used when the imbalance is severe enough that the other osteotomies cannot correct the deformity, especially in patients who have a combined sagittal and coronal spinal imbalance. Neurologic problems, whether transient or permanent, are the most commonly encountered complications following these procedures. Recent results have shown a high patient satisfaction rate and good functional outcomes after spinal osteotomies done to treat a variety of disorders.

Background: Antifibrinolytic agents have been shown to decrease the blood loss associated with major orthopaedic surgical procedures. Spine surgery, particularly procedures performed for deformity correction and procedures involving long arthrodesis constructs, can be associated with a large amount of blood loss requiring blood transfusions. The purpose of the present study was to determine if antifibrinolytic agents reduced blood transfusions in patients managed with spine surgery and to see if one agent had a greater effect than another. Methods: A systematic review and meta-analysis of the available literature were performed to investigate the efficacy of aprotinin, tranexamic acid, and epsilon-aminocaproic acid in terms of reducing blood loss and blood transfusions in patients undergoing spine surgery. This meta-analysis was focused on the role of these agents in major spine operations as reported in eighteen clinical trials that included information on the drug dosage, the age of the patient, blood loss, blood transfusions, surgery complexity, and complications. Results: Compared with control groups, the treatment groups for all three antifibrinolytic agents maintained lower levels of total blood loss and transfusions associated with spine surgery. The effect size ( d) of the differences in total blood loss between the treatment and control groups ranged from −0.668 (95% confidence interval, −0.971 to −0.365) to −0.936 (95% confidence interval, −1.240 to −0.632) across all three agents. The effect size ( d) of the differences in total blood transfusions between the treatment and control groups ranged from −0.466 (95% confidence interval, −0.764 to −0.167) to −0.749 (95% confidence interval, −1.046 to −0.453) across all three agents. Conclusions: Aprotinin, tranexamic acid, and epsilon-aminocaproic acid are effective for reducing blood loss and transfusions in patients managed with spine surgery. With the exception of aprotinin, the side-effect profiles of these agents have not been shown to cause any substantial morbidity or to increase the rate of thromboembolic events. Epsilon-aminocaproic acid had a greater effect on reducing blood transfusions as the complexity of surgery increased. The surgeon and/or the anesthesiologist should consider the use of antifibrinolytic agents for patients undergoing spinal procedures in which a large amount of blood loss can be expected; however, at the present time, this is not a United States Food and Drug Administration-approved indication for these agents. Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Background: Osteoporosis with subsequent osteoporotic vertebral compression fractures is an increasingly important disease due not only to its significant economic impact but also to the increasing age of our population. Pain reduction and stabilization are of primary importance with osteoporotic vertebral compression fractures. Although many patients heal with conservative treatment consisting of rest or activity modification, analgesics, and bracing, the management of severe pain compels some patients to seek surgical intervention via 2 procedures: vertebroplasty and kyphoplasty. Although there is abundant support in the literature for both procedures, there remains debate over which procedure can most successfully reduce patients’ perception of pain. Objective: To determine the amount of pain reduction using the visual analog scale (VAS) with kyphoplasty and vertebroplasty in the treatment of osteoporotic vertebral compression fractures. Design: Meta-analysis Methods: A systematic review and meta-analysis of the available literature was performed to quantify the amount of pain reduction using the visual analog scale (VAS) between vertebroplasty and kyphoplasty for osteoporotic vertebral compression fractures. Results: Twenty-one studies, 14 vertebroplasty and 7 kyphoplasty, qualified for inclusion representing totals of 1,046 vertebroplasty and 263 kyphoplasty patients treated, respectively. Kyphoplasty and vertebroplasty resulted in a more than 5 point drop in the VAS in the immediate postoperative period (p

Isolated distal fibular fractures most commonly result from a supination-external rotation injury of the ankle. Deltoid ligament ruptures can also be associated with these injuries, resulting in an unstable ankle fracture due to incompetent lateral and medial restraints. We hypothesized that a gravity stress radiograph is equivalent to a manual stress radiograph for the detection of deltoid ligament injury in association with an isolated fibular fracture.All patients presenting to a level-1 trauma hospital emergency department with an isolated fibular fracture were screened. Ankle stability was determined on the basis of radiographic measurements of the medial clear space and talar shift. A manual stress radiograph and a gravity stress radiograph of the injured ankle were made for each patient. The manual stress radiograph was used to determine whether the ankle was stable or unstable.A total of twenty-five patients (thirteen with a supination-external rotation type-II fracture and twelve with a supination-external rotation type-IV-equivalent injury) were enrolled in the study. In the type-II group, the average medial clear space was 4.15 and 4.26 mm on the manual and gravity stress radiographs, respectively (p = 0.50). In the type-IV group, the average medial clear space was 5.21 and 5.00 mm on the manual and gravity stress radiographs, respectively (p = 0.69).The gravity stress radiograph is equivalent to the manual stress radiograph for determining deltoid ligament injury in association with an isolated distal fibular fracture, and thus it can be used to determine ankle stability in patients who present with an isolated distal fibular fracture.

Total hip arthroplasty is associated with significant blood loss that often requires allogenic blood transfusions. Tranexamic acid and aprotinin have been shown to reduce blood loss and transfusions in clinical trials with variable results. This meta-analysis evaluates whether tranexamic acid and aprotinin significantly reduces blood loss and transfusion requirements in total hip arthroplasty. Thirteen clinical trials were identified. Combined, these agents were significant across all outcome measures in reducing blood loss and transfusions. Separately, only aprotinin was found to be significant. The data also showed that aprotinin (tranexamic acid is inconclusive) is only beneficial in revision total hip arthroplasty. Therefore, only aprotinin is effective in reducing both blood loss and transfusion requirements without an increase in thromboembolic complications in patients undergoing revision total hip arthroplasty.

✓ A total of 93 patients with intractable spasticity due to either spinal cord injury (59 cases), multiple sclerosis (31 cases), or other spinal pathology (three cases) were entered into a randomized double-blind placebocontrolled screening protocol of intrathecal baclofen test injections. Of the 88 patients who responded to an intrathecal bolus of 50, 75, or 100 µg of baclofen, 75 underwent implantation of a programmable pump system for chronic therapy. Patients were followed for 5 to 41 months after surgery (mean 19 months). No deaths or new permanent neurological deficits occurred as a result of surgery or chronic intrathecal baclofen administration. Rigidity was reduced from a mean preoperative Ashworth scale score of 3.9 to a mean postoperative score of 1.7. Muscle spasms were reduced from a mean preoperative score of 3.1 (on a fourpoint scale) to a mean postoperative score of 1.0. Although the dose of intrathecal baclofen required to control spasticity increased with time, drug tolerance was not a limiting factor in this study. Only one patient withdrew from the study because of a late surgical complication (pump pocket infection). Another patient received an intrathecal baclofen overdose because of a human error in programming the pump. The results of this study indicate that intrathecal baclofen infusion can be safe and effective for the long-term treatment of intractable spasticity in patients with spinal cord injury or multiple sclerosis.

Background: The geometry of the tibial plateau is complex and asymmetric. Previous research has characterized subject-to-subject differences in the tibial plateau geometry in the sagittal plane on the basis of a single parameter, the posterior slope. We hypothesized that (1) there are large subject-to-subject variations in terms of slopes, the depth of concavity of the medial plateau, and the extent of convexity of the lateral plateau; (2) medial tibial slope and lateral tibial slope are different within subjects; (3) there are sex-based differences in the slopes as well as concavities and convexities of the tibial plateau; and (4) age is not associated with any of the measured parameters. Methods: The medial, lateral, and coronal slopes and the depth of the osseous portion of the tibial plateau were measured with use of sagittal and coronal magnetic resonance images that were made for thirty-three female and twenty-two male subjects, and differences between the sexes with respect to these four parameters were assessed. Within-subject differences between the medial and lateral tibial slopes also were assessed. Correlation tests were performed to examine the existence of a linear relationship between various slopes as well as between slopes and subject age. Results: The range of subject-to-subject variations in the tibial slopes was substantive for males and females. However, the mean medial and lateral tibial slopes in female subjects were greater than those in male subjects (p < 0.05). In contrast, the mean coronal tibial slope in female subjects was less than that in male subjects (p < 0.05). The correlation between medial and lateral tibial slopes was poor. The within-subject difference between medial and lateral tibial slopes was significant (p < 0.05). No difference in medial tibial plateau depth was found between the sexes. The subchondral bone on the lateral part of the tibia, within the articulation region, was mostly flat. Age was not associated with the observed results. Conclusions: The geometry of the osseous portion of the tibial plateau is more robustly explained by three slopes and the depth of the medial tibial condyle. Clinical Relevance: The sex and subject-to-subject-based differences in the tibial plateau geometry found in the present study could be important to consider during the assessment of the risk of knee injury, the susceptibility to osteoarthritis, and the success of unicompartmental and total knee arthroplasty.

Complex biological structures involve uncertain parameters that may produce unexpected responses in the structures. The cervical spine is one of the most complex structures in human body. It is essential to consider the uncertainties contained in the cervical spine for accurate injury analysis. For this research, a finite element (FE) model of cervical spine column is created based on medical images. The FE model involves the skull, the vertebral body (C1-T1), the disc between adjacent vertebral bodies, and the ligaments. The disc consists of the annulus, nucleus, and fiber. The material property and disc height are adjusted for the disc degeneration levels in FE analysis. The FE model is validated with the experimental data. Probabilistic FE analysis is used to account for uncertainties of cervical spine components. Material properties of the disc are considered as random variables, which are defined by means, standard deviations, and distributions. In this study, the probability of injury of the disc, under dynamic loading, is investigated at various disc degeneration levels under dynamic loads. The result shows that the probability of injury was drastically increased with the disc degeneration levels. Even if the disc fracture was not reported and the magnitude of stress was small in whiplash loading, the possibility of disc injuries is increased when a degenerated disc was exposed to whiplash loading. The results presented in this research make a contribution to the understanding of age-related whiplash injuries. The results also provide evidence that the reliability of biomechanical injury analysis is also increased by accounting for uncertain factors contained in biological structures.Copyright © 2008 by ASME

The Accreditation Council for Graduate Medical Education (ACGME) is an independent accrediting organization that works in conjunction with each medical specialty's governing body to provide quality education for resident physicians. In 1999, the ACGME identified six core competencies that are important to the practice of medicine. They are: (1) patient care, (2) medical knowledge, (3) interpersonal and communication skills, (4) professionalism, (5) practice-based learning and improvement, and (6) systems-based practice. One of the core competencies, systems-based practice, enables a physician to interact effectively with the health care system, utilizing resources properly without compromising care. This competency is not well delineated; thus, the specific skills needed are not well understood. The systems-based competency does, however, incorporate practice management. Practice management skills are becoming increasingly important in navigating the health care system. A physician can no longer be concerned only with the clinical aspects of his or her practice but must also be able to interact with multiple health-care entities such as insurance companies and hospitals. Additionally, physicians must develop the skills needed to run a business (a practice) as well as know how to code and bill correctly for their services. The purpose of this article was to review the current trends in practice management training during graduate medical education that have been reported in the literature. Furthermore, we wanted to gain a better understanding of how graduating orthopaedic residents are educated with regard to one aspect of practice management, coding and billing issues, during their residency training program. Coding and billing issues are largely overlooked in residency training programs, and it is often left to the institution's graduate medical education office to provide training in this area. Unfortunately, this education is often inadequate because it is not reinforced with practice activities. Finally, we wanted to compare our practice management education …

Introduction. Visual impairment apparently is a rare but significant complication following epidural fluid injection and epiduroscopy. We report a review of cases reported in the literature with the aim of gaining an understanding of how the complication occurs as well as how to avoid it. Materials and Methods. A literature review was performed using PubMed to find 1) case reports and 2) factors that contribute to the development of visual loss in the cases. Results. Twelve cases of visual impairment following epiduroscopy or epidural fluid injection have been reported in the literature. The average age of the patients was approximately 50 years, 83.3% of the patients were female, 16.7% were male. Bolus injection of fluid with or without epiduroscopy was considered to be the precipitating event. The volume of solution injected epidurally varied from 20 mL to 120 mL (average = 59.4 mL). The common finding was retinal hemorrhage, with 58.3% occurring bilaterally. Recovery occurred in 79.2% of the cases. Conclusion. Retinal hemorrhage following epidural fluid injections/epiduroscopy apparently is due to an increase in cerebrospinal fluid pressure proportional to the rate and the amount of fluid injected. A sudden increase in epidural pressure is transmitted into the subarachnoid space to the optic nerve sheath, compressing the optic nerve and its vasculature. The vasculature compression ruptures retinal blood vessels.

Postoperative visual loss associated with spine surgery is a rare complication with no established definitive etiology. Multiple case reports have been published in the literature, and an overview of the case reports of the various visual disturbances following spine surgery is presented. Our objective was to review the current literature and determine if there were any risk factors that suggest what kind of patients have a higher likelihood of developing postoperative visual loss. Furthermore, analysis of factors common to the cases may offer a better understanding of possible etiologies leading to prevention strategies of postoperative visual loss. We used PubMed to perform a search of literature with spine surgery cases that are associated with visual disturbances. A total of 7 studies representing 102 cases were reviewed and evaluated in regard to age, sex, comorbidities, diagnosis, operative time, blood loss, systolic blood pressure, lowest hematocrit, and visual deficits and improvement. Ischemic optic neuropathy, especially posterior ischemic optic neuropathy, was the most common diagnosis found in the studies. The average age of the patients ranged from 46.5 years to 53.3 years with the majority having at least one comorbidity. Operative time ranged on average from 385 min to 410 min with a median in one case series of 480 min, average blood loss ranged from 3.5 l to 4.3 l and no visual improvement was seen in the majority of the cases. The etiology of postoperative visual loss is probably multifactorial, however, patients with a large amount of blood loss producing hypotension and anemia along with prolonged operative times may be causing a greater risk in developing visual disturbances. An acute anemic state may have an additive or synergistic effect with other factors (medical comorbidities) leading to visual disturbances. Although our study failed to provide definitive causative factors of postoperative visual loss, suggestions are made that warrant further studies.