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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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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: Secondary analysis of data from a prospective multicenter observational study., Objective: The aim of this study was to evaluate the occurrence of surgical site infection (SSI) in patients with and without intrawound vancomycin application controlling for confounding factors associated with higher SSI after elective spine surgery., Summary of Background Data: SSI is a morbid and expensive complication associated with spine surgery. The application of intrawound vancomycin is rapidly emerging as a solution to reduce SSI following spine surgery. The impact of intrawound vancomycin has not been systematically studied in a well-designed multicenter study., Methods: Patients undergoing elective spine surgery over a period of 4 years at seven spine surgery centers across the United States were included in the study. Patients were dichotomized on the basis of whether intrawound vancomycin was applied. Outcomes were occurrence of SSI within postoperative 30 days and SSI that required return to the operating room (OR). Multivariable random-effect log-binomial regression analyses were conducted to determine the relative risk of having an SSI and an SSI with return to OR., Results: .: A total of 2056 patients were included in the analysis. Intrawound vancomycin was utilized in 47% (n = 966) of patients. The prevalence of SSI was higher in patients with no vancomycin use (5.1%) than those with use of intrawound vancomycin (2.2%). The risk of SSI was higher in patients in whom intrawound vancomycin was not used (relative risk (RR) -2.5, P < 0.001), increased number of levels exposed (RR -1.1, P = 0.01), and those admitted postoperatively to intensive care unit (ICU) (RR -2.1, P = 0.005). Patients in whom intrawound vancomycin was not used (RR -5.9, P < 0.001), increased number of levels were exposed (RR-1.1, P = 0.001), and postoperative ICU admission (RR -3.3, P < 0.001) were significant risk factors for SSI requiring a return to the OR., Conclusion: The intrawound application of vancomycin after posterior approach spine surgery was associated with a reduced risk of SSI and return to OR associated with SSI., Level of Evidence: 2.

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 10μɛ 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., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Stimulation of bone formation by osteoinductive materials is of great clinical importance in spinal fusion surgery, repair of bone fractures, and in the treatment of osteoporosis. We previously reported that specific naturally occurring oxysterols including 20(S)-hydroxycholesterol (20S) induce the osteogenic differentiation of pluripotent mesenchymal cells, while inhibiting their adipogenic differentiation. Here we report the characterization of two structural analogues of 20S, Oxy34 and Oxy49, which induce the osteogenic and inhibit the adipogenic differentiation of bone marrow stromal cells (MSC) through activation of Hedgehog (Hh) signaling. Treatment of M2-10B4 MSC with Oxy34 or Oxy49 induced the expression of osteogenic differentiation markers Runx2, Osterix (Osx), alkaline phosphatase (ALP), bone sialoprotein (BSP), and osteocalcin (OCN), as well as ALP enzymatic activity and robust mineralization. Treatment with oxysterols together with PPARγ activator, troglitazone (Tro), inhibited mRNA expression for adipogenic genes PPARγ, LPL, and aP2, and inhibited the formation of adipocytes. Efficacy of Oxy34 and Oxy49 in stimulating bone formation in vivo was assessed using the posterolateral intertransverse process rat spinal fusion model. Rats receiving collagen implants with Oxy 34 or Oxy49 showed comparable osteogenic efficacy to BMP2/collagen implants as measured by radiography, MicroCT, and manual inspection. Histological analysis showed trabecular and cortical bone formation by oxysterols and rhBMP2 within the fusion mass, with robust adipogenesis in BMP2-induced bone and significantly less adipocytes in oxysterol-induced bone. These data suggest that Oxy34 and Oxy49 are effective novel osteoinductive molecules and may be suitable candidates for further development and use in orthopedic indications requiring local bone formation., (Copyright © 2011 Wiley-Liss, Inc.)

Nell-1 (Nel-like molecule-1; Nel: protein strongly expressed in neural tissue containing epidermal growth factor-like domain) is a promising osteoblast-specific growth factor for osteoinductive therapies that may circumvent adverse effects, such as nonspecific function and ectopic bone formation, associated with more established osteogenic growth factors such as bone morphogenetic proteins. Beta-tricalcium phosphate (beta-TCP), an osteoconductive, biodegradable ceramic biomaterial, has been used successfully to deliver osteoinducers for bone regeneration. The aim of this study was to develop a carrier system for efficiently delivering biologically active Nell-1 protein. After a 40% initial burst release, beta-TCP particles retained the majority of adsorbed Nell-1 protein in vitro. To test this system in vivo, L4/L5 spinal fusion was performed in three groups of rats (n = 8 each): (1) 5 microg Nell-1 in beta-TCP/demineralized bone matrix putty (DBX); (2) 2.5 microg Nell-1 in beta-TCP/DBX; (3) beta-TCP/DBX only. Fusion was assessed by radiography, palpation, microcomputed tomography, and histological analysis. After 4 weeks, 75% of Nell-1-treated animals exhibited fusion, with a significant increase in new bone volume, whereas only 25% of Nell-free control animals exhibited fusion. Our findings suggest that beta-TCP/DBX can increase both the biochemical stability and biological efficiency of Nell-1 protein.

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 2009 Elsevier Ltd. All rights reserved.)

Study Design: The kinematic study of human lumbar spinal movements., Objective: To investigate how disc degeneration and the degeneration of facet joint, ligaments, and paraspinal muscles are associated with lumbar segmental mobility., Summary of Background Data: Previous studies revealed relationship between spinal motion and osteoarthritic changes of facet joint as well as disc degeneration; however, little is known about the association of disc, facet joint, ligament, and muscle degeneration with lumbar segmental motion characteristics., Methods: The 1580 lumbar motion segments from 316 patients (200 male, 116 female) underwent Kinetic magnetic resonance imaging, which were used to assess disc degeneration (grade I-V) and facet joint degeneration (grade 1-4), interspinous ligament (ISL) degeneration (grade 1-4), ligamentum flavum hypertrophy (LFH), and fatty degeneration of muscles. Segmental translational and angular motion in the flexion, extension, and neutral postures were digitally automatically measured by MR analyzer., Results: Grade II (46.77%) disc, grade 1 (48.35%) facet joint degeneration, and grade 1 (64.1%) ISL were most common. LFH was most common in L4-L5 (49/330, 14.8%). In younger age (<35), grade I disc and grade 1 facet joint were predominant compared with the older age (35< or = and <45) in which grade III, IV, and V disc and grade 2 facet joint were predominant (P < 0.05). Translational motion increased significantly in high grade of disc and facet joint (except grade V disc and grade 4 facet joint) and with LFH in L1-L5 (P < 0.05). Angular motion significantly decreased in grade V disc, grade 4 ISL, and without LFH in L1-L5 (P < 0.05). According to muscle fatty degeneration, translational and angular motions were not significantly changed., Conclusion: Our results support that facet joint degeneration is followed by disc degeneration according to age. Increased translational movements of the lumbar segments occurred in severe disc degeneration accompanied by facet joint degeneration or the presence of LFH even if the movements were stabilized in the advanced status. Therefore, the current status of the intervertebral discs, facet joints, and ligamentum flavum should be taken into consideration when evaluating stability within the lumbar spine.

Study Design: The effect of postural change on degenerative lumbar discs was quantified using novel kinematic magnetic resonance imaging (kMRI)., Objective: The purpose is to describe the bulging of degenerative intervertebral lumbar discs in vivo subjected to different postural loads using a novel kMRI., Summary of Background Data: Symptomatic lumbar disc degeneration is a leading cause of pain and disability throughout the world. Over 70% of US citizens will experience a debilitating episode of low back pain. Earlier reports of degenerative disc changes are cadaver studies or are performed with recumbent MRI that eliminates the functional effects of gravity and muscle power. Little data are available on the behavior of degenerative intervertebral discs in vivo under physiologic loads., Methods: A total of 513 patients obtained kMRI. Disc bulging beyond the intervertebral space was quantified during upright neutral, flexion, and extension imaging. The degree of intervertebral disc degeneration was correlated using the Pfirrmann Classification., Results: Moderately degenerated intervertebral discs (grade III and IV) demonstrated greater bulging than mildly degenerated discs (grade II). Severely degenerated discs (grade V) also showed a trend toward greater bulging, but this was not significant. Grade I discs at all levels moved posteriorly in flexion and anteriorly in extension when compared to neutral posture. However, mild to severe (grade II-V) degenerative discs behaved differently in response to postural loads. Extension resulted in significant posterior bulging, while flexion did not demonstrate obvious anterior derangement., Conclusion: Disc bulging increases with the severity of disc degeneration. Grade I discs demonstrate the expected sagittal migration in response to postural load. However, more degenerative discs behave less predictably, and spine extension may result in significant posterior disc bulging. Degenerative changes in the intervertebral disc significantly affect the kinematic patterns under postural load in vivo. kMRI is a useful tool to quantify the kinematic behavior of degenerative intervertertebral discs.

Spinal fusion remains the gold standard for surgical management of instability and mechanical low back or neck pain. However, even in carefully selected patients, successful clinical results can be difficult to achieve. Reasons for failure include pseudarthrosis and adjacent spine segment disease. The theoretic advantages of removing the painful disk while preserving motion have led to increasing interest in total disk arthroplasty. Although disk replacements have been implanted in Europe for decades, the procedure is relatively new in the United States. Recently, two artificial disks for symptomatic lumbar degenerative disk disease have been approved by the US Food and Drug Administration; several others are undergoing clinical trials. Short-term studies demonstrate similar clinical improvements for both disk replacements and fusion procedures at up to 2-year follow-up. Issues requiring further research include optimal design specifications, potential complications, and appropriate patient selection. Consequently, the long-term benefit of total disk arthroplasty over fusion for the treatment of axial low back or neck pain remains to be determined.

Background Context: Bone grafting is used to augment bone healing and provide stability after spinal surgery. Autologous bone graft is limited in quantity and unfortunately associated with increased surgical time and donor-site morbidity. Alternatives to bone grafting in spinal surgery include the use of allografts, osteoinductive growth factors such as bone morphogenetic proteins and various synthetic osteoconductive carriers., Purpose: Recent research has provided insight into methods that may modulate the bone healing process at the cellular level in addition to reversing the effects of symptomatic disc degeneration, which is a potentially disabling condition, managed frequently with various fusion procedures. With many adjuncts and alternatives available for use in spinal surgery, a concise review of the current bone grafting alternatives in spinal surgery is necessary., Study Design/setting: A systematic review of the contemporary English literature on bone grafting in spinal surgery, including abstract information presented at national meetings., Methods: Bone grafting alternatives were reviewed as to their efficacy in extending or replacing autologous bone graft sources in spinal applications., Results: Alternatives to autologous bone graft include allograft bone, demineralized bone matrix, recombinant growth factors and synthetic implants. Each of these alternatives could possibly be combined with autologous bone marrow or various growth factors. Although none of the presently available substitutes provides all three of the fundamental properties of autograft bone (osteogenicity, osteoconductivity and osteoinductivity), there are a number of situations in which they have proven clinically useful., Conclusions: Alternatives to autogenous bone grafting find their greatest appeal when autograft bone is limited in supply or when acceptable rates of fusion may be achieved with these substitutes (or extenders) despite the absence of one or more of the properties of autologous bone graft. In these clinical situations, the morbidity of autograft harvest is reasonably avoided. Future research may discover that combinations of materials may cumulatively result in the expression of osteogenesis, osteoinductivity and osteoconductivity found in autogenous sources.

PurposeThe focus of SPINE20 is to develop evidence-based policy recommendations for the G20 countries to work with governments to reduce the burden of spine disease, and disability.MethodsOn September 17-18, 2021, SPINE20 held its annual meeting in Rome, Italy. Prior to the meeting, the SPINE20 created six proposed recommendations. These recommendations were uploaded to the SPINE20 website 10 days before the meeting and opened to the public for comments. The recommendations were discussed at the meeting allowing the participants to object and provide comments.ResultsIn total, 27 societies endorsed the following recommendations. SPINE20 calls upon the G20 countries: (1) to expand telehealth for the access to spine care, especially in light of the current situation with COVID-19. (2) To adopt value-based interprofessional spine care as an approach to improve patient outcomes and reduce disability. (3) To facilitate access and invest in the development of a competent rehabilitation workforce to reduce the burden of disability related to spine disorders. (4) To adopt a strategy to promote daily physical activity and exercises among the elderly population to maintain an active and independent life with a healthy spine, particularly after COVID-19 pandemic. (5) To engage in capacity building with emerging countries and underserved communities for the benefit of spine patients. (6) To promote strategies to transfer evidence-based advances into patient benefit through effective implementation processes.ConclusionsSPINE20's initiatives will make governments and decision makers aware of efforts to reduce needless suffering from disabling spine pain through education that can be instituted across the globe.

* BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is a common surgical procedure for cervical radiculopathy. While postoperative physical therapy (PT) has been shown to be effective after many orthopaedic surgeries, there is limited evidence available regarding postoperative PT after ACDF for cervical radiculopathy. * CASE PRESENTATION: A 61-year-old male initiated early in-person PT 2 weeks following 2-level ACDF, which utilized a multimodal PT program (manual therapy, patient education, therapeutic exercise, self-management, HEP, modalities) guided by tissue healing, achievement of clinical objective milestones, and clinical reasoning. * OUTCOME AND FOLLOW-UP: Significant improvement in outcome measures (numeric pain-rating scale, neck disability index, 36-item short-form health survey, global rating of change, fear avoidance beliefs questionnaire, cervical active range of motion) was achieved 12 weeks postoperatively and maintained up to 2 years with no adverse events. * DISCUSSION: Early initiated in-person multimodal postoperative PT may be safe and effective for patients at all stages of healing after ACDF. Further research is needed to address the benefits to larger patient populations. [ABSTRACT FROM AUTHOR]

The Global Spine Journal (GSJ) is the official journal of AO Spine International and is associated with the annual Global Spine Congress. The congress is an international meeting that travels to different locations around the world, with the most recent meeting taking place in Bangkok, Thailand. The congress was successful, with nearly 2000 participants and industry sponsors gathering to exchange ideas and research on spinal disorders. The GSJ announced its annual awards at the meeting and held sessions such as a journal club and a symposium in collaboration with Neurospine. The GSJ also had its annual board meeting, where new partnerships and strategies were discussed, including a collaboration with AO Spine Knowledge Forums to provide concise summaries of the latest research. [Extracted from the article]

The Global Spine Congress (GSC) 2024 is an annual congress organized by AO Spine that will take place in Bangkok, Asia. The congress aims to bring together spine surgeons from around the world to exchange ideas, network, and learn about the latest research and techniques in spine surgery. The event will feature various sessions, including pre-courses, symposia, and presentations of peer-reviewed abstracts. The abstracts accepted for presentation at the congress are published in a special online issue of the Global Spine Journal. The congress is open to surgeons, spine practitioners, healthcare professionals, and researchers. [Extracted from the article]

Study Design: Methodological study for guideline development. Objective: AO Spine Guideline for Using Osteobiologics (AO-GO) project for spine degenerative pathologies was an international, multidisciplinary collaborative initiative to identify and evaluate evidence on existing use of osteobiologics in Anterior Cervical Fusion and Decompression (ACDF). The aim was to formulate precisely defined, clinically relevant and internationally applicable guidelines ensuring evidence-based, safe and effective use of osteobiologics, considering regional preferences and cost-effectiveness. Methods: Guideline was completed in two phases: Phase 1- evidence synthesis; Phase 2- recommendation development based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. In Phase 1, key questions identified by a panel of experts were addressed in a series of systematic reviews of randomized and non-randomized studies. In Phase 2, the GRADE approach was used to formulate a series of recommendations, including expert panel discussions via web calls and face-to-face meetings. Discussion: AO-GO aims to bridge an important gap between evidence and use of osteobiologics in spine fusion surgeries. Owing to differences in osteobiologics preparation and functional characteristics, regulatory requirements for approval may vary, therefore it is highly likely that these products enter market without quality clinical trials. With a holistic approach the guideline aims to facilitate evidence-based, patient-oriented decision-making processes in clinical practice, thus stimulating further evidence-based studies regarding osteobiologics usage in spine surgeries. In Phase 3, the guideline will be disseminated and validated using prospectively collected clinical data in a separate effort of the AO Spine Knowledge Forum Degenerative in a global multicenter clinical study. [ABSTRACT FROM AUTHOR]

Study Design: Systematic review and meta-analysis. Objective: To compare clinical and radiographic outcomes as well as complications of unplated vs plated anterior cervical discectomy and fusion (ACDF) surgery considering the role of osteobiologics in single- and multi-level procedures. Methods: A systematic search of PubMed/MEDLINE, Scopus, CINAHL, EMBASE, CENTRAL, Cochrane and ClinicalTrials.gov databases was performed. Briefly, we sought to identify studies comparing unplated vs. plated ACDF for cervical degenerative disc disease reporting the use of osteobiologics in terms of clinical outcomes, radiographic fusion, and complications. Data on study population, follow-up time, type of cage and plate used, type of osteobiologic employed, number of levels treated, patient-reported outcomes (PROs), radiographic outcomes and complications were collected and compared. Relevant information was pooled for meta-analyses. Results: Thirty-eight studies met the inclusion criteria. No significant difference was found in terms of clinical outcomes between groups. Unplated ACDF was characterized by reduced blood loss, operation time and length of hospital stay. Fusion was achieved by the majority of patients in both groups, with no evidence of any specific contribution depending on the osteobiologics used. Dysphagia was more commonly associated with anterior plating, while cage subsidence prevailed in the unplated group. Conclusion: Unplated and plated ACDF seem to provide similar outcomes irrespective of the osteobiologic used, with minor differences with doubtful clinical significance. However, the heterogeneity and high risk of bias affecting included studies markedly prevent significant conclusions. [ABSTRACT FROM AUTHOR]

Background: Despite the extensive use of cellular bone matrices (CBMs) in spine surgery, there is little evidence to support the contribution of cells within CBMs to bone formation. The objective of this study was to determine the contribution of cells to spinal fusion by direct comparisons among viable CBMs, devitalized CBMs, and cell-free demineralized bone matrix (DBM).Methods: Three commercially available grafts were tested: a CBM containing particulate DBM (CBM-particulate), a CBM containing DBM fibers (CBM-fiber), and a cell-free product with DBM fibers only (DBM-fiber). CBMs were used in viable states (CBM-particulatev and CBM-fiberv) and devitalized (lyophilized) states (CBM-particulated and CBM-fiberd), resulting in 5 groups. Viable cell counts and bone morphogenetic protein-2 (BMP-2) content on enzyme-linked immunosorbent assay (ELISA) within each graft material were measured. A single-level posterolateral lumbar fusion was performed on 45 athymic rats with 3 lots of each product implanted into 9 animals per group. After 6 weeks, fusion was assessed using manual palpation, micro-computed tomography (μ-CT), and histological analysis.Results: The 2 groups with viable cells were comparable with respect to cell counts, and pairwise comparisons showed no significant differences in BMP-2 content across the 5 groups. Manual palpation demonstrated fusion rates of 9 of 9 in the DBM-fiber specimens, 9 of 9 in the CBM-fiberd specimens, 8 of 9 in the CBM-fiberv specimens, and 0 of 9 in both CBM-particulate groups. The μ-CT maturity grade was significantly higher in the DBM-fiber group (2.78 ± 0.55) compared with the other groups (p < 0.0001), while none of the CBM-particulate samples demonstrated intertransverse fusion in qualitative assessments. The viable and devitalized samples in each CBM group were comparable with regard to fusion rates, bone volume fraction, μ-CT maturity grade, and histological features.Conclusions: The cellular component of 2 commercially available CBMs yielded no additional benefits in terms of spinal fusion. Meanwhile, the groups with a fiber-based DBM demonstrated significantly higher fusion outcomes compared with the CBM groups with particulate DBM, indicating that the DBM component is probably the key determinant of fusion.Clinical Relevance: Data from the current study demonstrate that cells yielded no additional benefit in spinal fusion and emphasize the need for well-designed clinical studies on cellular graft materials. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective, observational, case series. Purpose: To elucidate the prevalence of degenerative changes in the cervical and lumbar spine and estimate the degenerative changes in the cervical spine based on the degeneration of lumbar disc through a retrospective review of magnetic resonance (MR) images. Overview of Literature: Over 50% of middle-aged adults show evidence of spinal degeneration. However, the relationship between degenerative changes in the cervical and lumbar spine has yet to be elucidated. Methods: A retrospective review of positional MR images of 152 patients with symptoms related to cervical and lumbar spondylosis with or without a neurogenic component was conducted. The degree of intervertebral disc degeneration (IDD) was assessed on a grade of 1-5 for each segment of the cervical and lumbar spine using MR T2-weighted sagittal images. The grades across all segments were summed to produce the degenerative disc score (DDS) for the cervical and lumbar spine. The patients were divided into two groups based on the IDD grade for each lumbar segment: normal (grades 1 and 2) and degenerative (grades 3-5). Results: DDSs for the cervical and lumbar spine were positively correlated. Significant differences in cervical DDSs between the groups were observed in all lumbar segments. Although there were no significant differences in cervical DDSs among the degenerative lumbar segment, cervical DDSs at the L1-2 and L2-3 segments tended to be higher than those at the L3-4, L4-5, and L5-S degenerative segments. Conclusions: Our study shows that participants with degenerative changes in the upper lumbar segments are more likely to have a certain amount of cervical spondylosis. This information could be used to lower the incidence of a missed diagnosis of cervical spine disorders in patients presenting with lumbar spine symptomology. [ABSTRACT FROM AUTHOR]

Purpose: To review the current understanding and data of sagittal balance and alignment considerations in paraplegic patients.Methods: A PubMed literature search was conducted to identify all relevant articles relating to sagittal alignment and sagittal balance considerations in paraplegic and spinal cord injury patients.Results: While there are numerous studies and publications on sagittal balance in the ambulatory patient with spinal deformity or complex spine disorders, there is paucity of the literature on "normal" sagittal balance in the paraplegic patients. Studies have reported significantly alterations of the sagittal alignment parameters in the non-ambulatory paraplegic patients compared to ambulatory patients. The variability of the alignment changes is related to the differences in the level of the spinal cord injury and their differences in the activations of truncal muscles to allow functional movements in those patients, particularly in optimizing sitting and transferring. Surgical goal in treating paraplegic patients with complex pathologies should not be solely directed to achieve the "normal" radiographic parameters of sagittal alignment in the ambulatory patients. The goal should be to maintain good coronal balance to allow ideal sitting position and to preserve motion segment to optimize functions of paraplegia patients.Conclusion: Current available literature data have not defined normal sagittal parameters for paraplegic patients. There are significant differences in postural sagittal parameters and muscle activations in paraplegic and non-spinal cord injury patients that can lead to differences in sagittal alignment and balance. Treatment goal in spine surgery for paraplegic patients should address their global function, sitting balance, and ability to perform self-care rather than the accepted radiographic parameters for adult spinal deformity in ambulatory patients. [ABSTRACT FROM AUTHOR]

The Global Spine Congress is unique in its approach to sharing knowledge and developing new approaches to the treatment of spinal disorders to help advance spine care and improve patient care. Welcome to the Global Spine Congress 2023 (GSC). This event provides an outstanding forum to exchange ideas, network with fellow spine professionals, and learn about the latest research, techniques, and technologies in spine surgery. [Extracted from the article]

The article compares total disc replacement (TDR) with fusion and motion sparing devices with fusion to determine which procedure is associated with a lower risk of radiographical or clinical adjacent segment pathology (ASP). Results indicate low rate of ASP after lumbar spinal fusion. Compared with TDR, risk of clinical ASP is higher following fusion but there is no evidence that fusion may increase risk of ASP compared with other motion sparing procedures.

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]

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]

Provides information on advancements in spine surgery. Popularity of laminoplasty for the treatment of cervical myelopathy secondary to ossification of the posterior longitudinal ligament and spondylosis with spinal stenosis; Continued effort to enhance the process of achieving spine fusion; Developments in spinal deformity surgery; Discovery of novel approaches in the treatment of the lumbar spine.

However, given that 664 patients in our study were identified with myocardial infarction and were further stratified based on the approach and timing, the propensity matching was not possible. We believe that information of the surgical approach and timing of myocardial infarction after lumbar surgery is novel and important information. [Extracted from the article]

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]

Background Context: The thoracic spine was previously known as a relatively stable region in human spine. Several studies reported that the motion of the thoracic spine and changes in the cross-sectional area of the spinal cord changed with positions in the sagittal plane. The kinematic relationship between the thoracic disc and the space available for cord (SAC) with the positional change is still not well investigated.Purpose: The objective of this study was to evaluate the kinematic change of the intervertebral disc and space available for the spinal cord of the thoracic spine using kinematic magnetic resonance imaging (kMRI).Study Design: This is a retrospective study.Patient Sample: The patient sample included 105 patients who underwent thoracic spine kMRI.Outcome Measurement: Disc bulging and the SAC were evaluated from T4-T5 to T11-T12 in flexion, neutral, and extension positions.Methods: MRAnalyzer3 (TrueMRI Corporation, Bellflower, CA, USA) was used to analyze disc bulging and SAC from T4-T5 to T11-T12. The Friedman test was used to analyze the differences in disc bulging and SAC between neutral, flexion, and extension positions at each segment. The Wilcoxon signed-rank test was used for post hoc analysis for the significant levels from the Friedman test.Results: The mean value of the thoracic intervertebral disc area from T4-T5 to T11-T12 tended to be larger in flexion than in extension. Initial analysis with the Friedman test revealed a significant difference in disc bulging at T8-T9, T9-T10, and T11-T12 among the three positions (p<.05). Post hoc analysis showed that disc bulging was only significant at T8-T9 between flexion and extension (p<.001), at T9-T10 between neutral and flexion (0.003), and at T9-T10 between flexion and extension (p=.004). The SAC from T4-T5 to T11-T12 tended to be widest in extension and narrowest in flexion. Only T5-T6 exhibited a statistically significant difference in SAC between flexion and extension (p=.002).Conclusions: The thoracic discs and the SAC from T4-T5 to T11-T12 showed kinematic changes from flexion to extension. The thoracic spinal canal tended to be narrowest in flexion and widest in the extension. Thus, kyphotic deformities could be one of the etiologies for neurogenic deterioration in patients with thoracic myelopathy. [ABSTRACT FROM AUTHOR]

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. 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. Retrospective Cohort Study. A total of 7,772 patients underwent spinal fusion with spinal metastasis within the Nationwide Readmissions Database (NRD). Mortality, medical complications, surgical complications, increased length of stay (LOS), nonroutine discharge and increased costs. 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. Outcomes analyzed included mortality, complications, length of stay (LOS), nonroutine discharges and costs. Multivariable-regression techniques were used to develop predictive models for outcomes using frailty and the Elixhauser Comorbidity Index (ECI). A total of 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. 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. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective radiographical study. Objective. To define the relationship between the grade of disc degeneration and the motion of the lumbar spine by using kinetic magnetic resonance imaging. Summary of Background Data. Disc degeneration is common after middle age. Lumbar instability has generally been recognized as a potential risk factor of low back pain. However, correlations between the grade of disc degeneration and the motion of the lumbar spine need more investigation. Methods. Kinetic magnetic resonance imaging was performed in 162 patients with symptomatic low back pain without prior history of surgery. The lumbar intervertebral discs were graded by spine surgeons according to the degenerative grading system (grades I-V). Translational motion and angular variation were measured at each segment from L1-L2 through L5-S1. The relationship between the degree of lumbar disc degeneration and extent of lumbar spine mobility was analyzed. Results. The translational motion in discs with grade I through IV increased gradually, but decreased with grade V. Compared with other less degenerative grades, grade V discs had significantly decreased total intervertebral translational motion ( P < 0.05). The angular variation in discs with grade I through IV was fairly constant, but decreased with grade V. Compared with other degenerative grades (I-IV), grade V discs had significantly decreased total intervertebral translational motion ( P < 0.05). For less degenerative grades I and II discs, the L2-L3 and L3-L4 segmental units contributed the majority of total angular mobility of the spine. However, for the severely degenerated segments, grade V discs, the contributions of the L2-L3 and L3-L4 significantly decreased ( P < 0.01). Conclusion. As disc degeneration developed from the normal to an increasingly severe stage, the motion of lumbar spine progressed from the normal stage to an unstable phase with higher mobility and finally to an ankylosed stage where stability was increased. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective case series. Objective. To evaluate reoperations for lumbar adjacent segment pathology (ASP) during a 10-year period. Summary of Background Data. ASP after lumbar arthrodesis is an important clinical problem. There remains controversy, however, on the distribution of the most commonly affected levels. Methods. Thirty-one patients undergoing revision operation for ASP in the lumbar spine were included in this study. Patients' charts were evaluated for demographic data including age at index and revision operations, time to revision operation, and index and revision levels fused. Results. L4-L5 was the most commonly instrumented level in both single-level (n = 12), and multilevel (n = 13)index fusions. The mean length of time from the index operation to revision surgery was 81 months (range, 11-570 too). Kaplan-Meier analysis predicted a disease-free survival rate of 32.3% at 5 years and of 12.9% at 10 years after the index operation. L3-L4 was the most commonly affected level by ASP with 75% (16/20) requiring reoperation. L2-L3 was the next most commonly affected level at 52% (14/27). The L5-$1 disk was relatively protected from ASP, with only 4/17 (24%) disks at risk developing ASP. A subgroup analysis of patients undergoing revision after a single-level L4-L5 arthrodesis revealed ASP at L3-L4 in 83% (10/12) of patients, compared with only 3/12 (25%) at L5-S1 (P < 0.05). Of all cases of ASP, the proximal segments were involved 90% of the time. Conclusion. ASP most commonly affects proximal levels in the lumbar spine. In this cohort of patients undergoing revision fusion for ASP, 90% of affected levels were rostral to the index level(s). In patients undergoing L4-L5 single-level arthrodesis, L3-L4 is at high risk, whereas L5-S1 is somewhat protected. Surgeons should pay particular attention to proximal levels when planning a lumbar arthrodesis, however, motion segments distal to fusion may not be as protected as previously thought. [ABSTRACT FROM AUTHOR]

The article presents a kinematic study on the connection between lumbar segmental mobility and degenerations of intervertebral disc and facet joints. It states that kinetic magnetic resonance imaging (KMRI) was used to examine disc degeneration and facet joint degeneration of 316 patients' 1580 lumbar motion segments. Results show that the status of intervertebral discs, facet joints and the ligamentum flavum need to be considered in evaluating lumbar spine stability.

The article presents a medical research on the relationship between the grade of disc degeneration and motion unit of the cervical spine. It has shown that as the degenerative process progresses, the motion moves from a normal stable disc to a more unstable phase with early degeneration. It has also demonstrated the contribution of different levels to overall motion that occurs with degeneration.