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Cervical deformity is a major cause of cervical myelopathy and often leads to poor health-related quality-of-life outcomes. These deformities are complex in nature and require a thorough understanding of the radiographic parameters used to measure the degree of malalignment in order to develop an appropriate pre-operative plan. The magnitude and rigidity of the deformity often dictates whether an anterior, posterior, or combined approach is required to achieve the goals of surgery, which are to decompress the neural elements, as well as reestablish regional and global spinal alignment.

Study design Cohort study. Objective To determine the effect of cervical spine pathology on athletes entering the National Football League. Summary of background data The association of symptomatic cervical spine pathology with American football athletes has been described; however, it is unknown how preexisting cervical spine pathology affects career performance of a National Football League player. Methods The medical evaluations and imaging reports of American football athletes from 2003 to 2011 during the combine were evaluated. Athletes with a cervical spine diagnosis were matched to controls and career statistics were compiled. Results Of a total of 2965 evaluated athletes, 143 players met the inclusion criteria. Athletes who attended the National Football League combine without a cervical spine diagnosis were more likely to be drafted than those with a diagnosis (P = 0.001). Players with a cervical spine diagnosis had a decreased total games played (P = 0.01). There was no difference in the number of games started (P = 0.08) or performance score (P = 0.38). In 10 athletes with a sagittal canal diameter of less than 10 mm, there was no difference in years, games played, games started, or performance score (P > 0.24). No neurological injury occurred during their careers. In 7 players who were drafted with a history of cervical spine surgery (4 anterior cervical discectomy and fusion, 2 foraminotomy, and 1 suboccipital craniectomy with a C1 laminectomy), there was no difference in career longevity or performance when compared with matched controls. Conclusion This study suggests that athletes with preexisting cervical spine pathology were less likely to be drafted than controls. Players with preexisting cervical spine pathology demonstrated a shorter career than those without; however, statistically based performance and numbers of games started were not different. Players with cervical spinal stenosis and those with a history of previous surgery demonstrated no difference in performance-based outcomes and no reports of neurological injury during their careers.

Objectives: Previous studies in the evidence-based literature suggest that lumbar spine injuries can lead to a significant decrease in athletic performance. This phenomenon is particularly evident in sports that require repetitive truncal rotation, such as baseball. Although we have previously characterized the natural history of symptomatic spondylolysis and spondylolisthesis in professional baseball players, no prior study has investigated the impact of pars injuries on player performance in this patient population. The purpose of this study was to report performance-based outcomes following symptomatic pars injuries in elite-level baseball athletes. Methods: A retrospective cohort study was conducted among all professional baseball players who presented with a symptomatic pars defect between 2011 and 2016. Both Major League and Minor League players were enrolled using a de-identified injury surveillance database maintained by the MLB. Lumbar spine imaging reports were reviewed to confirm the radiologic diagnosis of spondylolysis or spondylolisthesis. Players were stratified according to baseball position (pitcher vs. position player). Primary outcome measures for pitchers were earned run average (ERA) and walks plus hits per inning pitched (WHIP), while primary outcomes for position players were batting average (AVG) and on-base plus slugging (OPS). Paired t tests were used to compare pre-injury statistical performance to post-injury performance, with p < 0.05 treated as statistically significant. Results: During the defined study period, 75 players presented with low-back pain in the setting of a pars defect. 47 players were diagnosed with spondylolysis (62.7%), while 28 were diagnosed with spondylolisthesis (37.3%). Of those individuals, 19 players were excluded due to incomplete statistical data in the MLB injury surveillance system. Pre-injury vs. post-injury statistical comparisons are presented in Table 1. Pitching performance after the pars injury did not significantly differ with regard to the primary outcome measures, ERA (3.45 vs. 4.73; p = 0.25) and WHIP (1.28 vs. 1.47; p = 0.26). There was also no significant difference in any of the secondary outcomes - runs per 9 innings (R/9), hits per 9 innings (H/9), walks per 9 innings (BB/9), strikeouts per 9 innings (K/9), home runs per 9 innings (HR/9), and strikeout-to-walk ratio (K/BB). Similarly, batting performance among position players did not significantly differ from pre-injury to post-injury with regard to the primary outcomes, AVG (.261 vs. .256; p = 0.59) and OPS (.672 vs. .667; p = 0.87), or any of the secondary outcomes - on-base percentage (OBP), slugging percentage (SLG), runs per plate appearance (R/PA), hits per plate appearance (H/PA), runs batted in per plate appearance (RBI/PA), extra-base hits per plate appearance (XBH/PA), home runs per plate appearance (HR/PA), and walk-to-strikeout ratio (BB/K). Conclusion: This study represents the most comprehensive analysis of the impact of symptomatic pars injuries on MLB player performance. While previous studies suggest that lumbar injuries lead to shorter careers in both pitchers and position players, our current data demonstrate that pars defects do not cause a significant decrease in performance when MLB athletes return to play following these injury episodes. Given the limitations of our study design, larger prospective investigations are needed to validate these conclusions. [Table: see text]

Background context Despite an increase in physician and public awareness and advances in infection control practices, surgical site infection (SSI) remains to be one of the most common complications after an operation. Surgical site infections have been shown to decrease health-related quality of life, double the risk of readmission, prolong the length of hospital stay, and increase hospital costs. Purpose To critically evaluate the literature and identify modifiable factors to reduce the risk of SSI. Study design/setting Systematic review of the literature. Methods A critical review of the literature was performed using OVID, Pubmed, and the Cochrane database and focused on eight identifiable factors: preoperative screening and decolonization of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus protocols, antiseptic showers, antiseptic cloths, perioperative skin preparation, surgeon hand hygiene, antibiotic irrigation and/or use of vancomycin powder, closed suction drains, and antibiotic suture. Results Screening protocols have shown that 18% to 25% of patients undergoing elective orthopedic surgery are nasal carriers of S. aureus and that carriers are more likely to have a nosocomial infection and SSI. The evidence suggests that an institutionalized prescreening program, followed by an appropriate eradication using mupirocin ointment and chlorhexidine soap/shower, will lower the rate of nosocomial S. aureus infections. Based on the current literature, definitive conclusions cannot be made on whether preoperative antiseptic showers effectively reduce the incidence of postoperative infection. The use of a chlorhexidine bathing cloth before surgery may decrease the risk of SSI. There is no definitive clinical evidence that one skin preparation solution effectively lowers the rate of postoperative infection compared with another. The use of dilute betadine irrigation or vancomycin powder in the wound before closure likely decreases the incidence of SSI. Conclusions There is strong evidence in the literature that optimizing specific preoperative, intraoperative, and postoperative variables can significantly lower the risk of developing an SSI.

Lumbar facet cysts are a rare but increasingly common cause of symptomatic nerve root compression and can lead to radiculopathy, neurogenic claudication, and cauda equina syndrome. The cysts arise from the zygapophyseal joints of the lumbar spine and commonly demonstrate synovial herniation with mucinous degeneration of the facet joint capsule. Lumbar facet cysts are most common at the L4-L5 level and often are associated with spondylosis and degenerative spondylolisthesis. Advanced imaging studies have increased diagnosis of the cysts; however, optimal treatment of the cysts remains controversial. First-line treatment is nonsurgical management consisting of oral NSAIDs, physical therapy, bracing, epidural steroid injections, and/or cyst aspiration. Given the high rate of recurrence and the relatively low satisfaction with nonsurgical management, surgical options, including hemilaminectomy or laminotomy to excise the cyst and decompress the neural elements, are typically performed. Recent studies suggest that segmental fusion of the involved levels may decrease the risks of cyst recurrence and radiculopathy.

Lumbar disk herniations occur frequently and are often associated with leg pain, weakness, and paresthesias. Fortunately, the natural outcomes of radiculopathy due to a disk herniation are generally favorable, and the vast majority of patients improve with nonoperative care. Surgical intervention is reserved for patients who have significant pain that is refractory to at least 6 weeks of conservative care, patients who have a severe or progressive motor deficit, or patients who have any symptoms of bowel or bladder dysfunction. This paper reviews the preoperative and postoperative considerations, as well as the surgical technique, for a microdiscectomy for a lumbar intervertebral disk herniation.

STUDY DESIGN A questionnaire survey. OBJECTIVE To report the current use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in lumbar fusion procedures for the treatment of degenerative spondylolisthesis (DS), and identify associated factors including fusion technique, surgeon location, surgeon specialty, or surgeon practice model. SUMMARY OF BACKGROUND DATA The prevalence of rhBMP-2 use in fusions increased dramatically from 0.7% in 2002 to 24.7% in 2006, however more recent studies have identified significant complications with its use. Furthermore, an independent review of the industry-sponsored trial data has demonstrated no significant difference in fusion rates or clinical results with the use of rhBMP-2 compared with iliac-crest autograft. METHODS In July 2014, a survey was sent requesting information on the usage of rhBMP-2 in the treatment of DS. Determinants included the fusion technique, geographic location, specialty, and associated practice models. No funding was received for this work. RESULTS Overall, 7.8% +/- 2.0% of surgeons reported using rhBMP-2 when performing an open L4-L5 posterolateral fusion for DS; 6.2% +/- 1.8% reported using rhBMP-2 for an open L4-L5 interbody fusion, and 12.1% +/- 2.5% reported using rhBMP-2 for a L4-L5 minimally invasive (MIS) interbody fusion. The variables that were statistically associated with the use of rhBMP-2 were North America surgeons (P

Retrospective Cross-Sectional Study OBJECTIVE.: Identify the pathoanatomical features of the cervical spine associated with congenital stenosis SUMMARY OF BACKGROUND DATA.: Congenital cervical stenosis (CCS) describes a patient with a decreased spinal canal diameter at multiple levels of the cervical spine in the absence of degenerative changes. Despite recognition of CCS throughout the literature, the anatomical features that lead to this condition have not been established. Knowledge of the pathoanatomy behind CCS may lead to alterations in surgical technique for this patient population that may improve outcomes.From 1000 cervical MRIs between January 2000 and December 2014, CCS was identified in 68 patients using a strict definition of age less than 50 years with mid-sagittal canal diameters (mid-SCD) (10 mm) at multiple sub-axial cervical levels (C3-C7). A total of 68 patients met the inclusion criteria for this group. Fourteen controls with normal SCDs (14 mm) at all cervical levels were used for comparison. Anatomic measurements obtained at each level (C3-C7) included: coronal vertebral body, AP vertebral body, pedicle width, pedicle length, laminar length, AP lateral mass, posterior canal distance, lamina-pedicle angle, and lamina-disc angle (LDA). Statistical significance was defined as P 0.01.CCS patients demonstrated significantly different anatomical measurements when compared with controls. Significantly smaller lateral masses, lamina lengths, lamina-pedicle angles, and larger LDAs were identified at levels C3 to C7 in the CCS group (P 0.01). These anatomic components form a right triangle that illustrates the cumulative narrowing effect on space for the spinal cord.The pathoanatomy of CCS is associated with a decrease in the lamina-pedicle angle and an increase in the LDA ultimately leading to a smaller SCD. The global changes in CCS are best illustrated by this triangle model and are driven by the posterior elements of the cervical spine.4.

Background context Several fusion techniques are used to treat atlantoaxial instability. Recent literature suggests that intralaminar screw (LS) fixation and pedicle screw (PS) fixation offer similar stability and comparable pullout strength. No studies have compared these characteristics after cyclic loading. Purpose To compare the stability and pullout strength of intra-LSs and PSs in a C1–C2 instability model after 1,000 cycles of axial loading. Study design In vitro biomechanical study. Outcome measures Stability in axial rotation and screw pullout strength after cyclic loading. Methods Six fresh-frozen human cadaveric cervical spines (C1–C2) were used in this study. C1–C2 instability was mimicked via odontoidotomy at its base and posterior soft-tissue release, including the supraspinous ligaments and facet joint capsules. Specimens were tested to 1,000 cycles after stabilization with two fixation constructs: C1 lateral mass (LM) screws and C2 intra-LSs (C1LM–C2LS) and C1 LM screws and C2 PSs (C1LM–C2PS). Angular motion was recorded for right and left axial rotation using an Optotrak 3020 system (Northern Digital, Waterloo, Ontario, Canada). Tensile loading to failure was then performed collinear to the longitudinal axis of the screw, and the data were recorded as peak pullout strength in newtons. Results There was no statistically significant difference in stability (measured in degrees of rotation) between the intra-LS and PS constructs at 250, 500, 750, and 1,000 cycles of axial rotation. Furthermore, there was no significant difference in stability at 250 cycles versus 1,000 cycles for the LS (1.30 vs. 1.49, p=.80) or PS (0.84 vs. 0.85, p=.96). Pedicle screws had higher pullout strength when compared with the intra-LSs (757.5±239 vs. 583.4±472 N); however, high standard deviation precluded statistical significance (p=.44). Conclusions Our data suggest that a C1LM and C2LS construct has similar biomechanical stability when compared with a C1LM and C2PS construct after 1,000 cycles of axial rotation. Furthermore, PSs had higher pullout strength when compared with LSs; however, this result was not statistically significant.

OBJECTIVE It is currently unknown how a lumbar disk herniation (LDH) impacts a professional athlete's performance and/or career. No studies have evaluated the effects of LDH on National Football League (NFL) skill position players. Our objective was to determine if NFL athletes who sustain an LDH and subsequently undergo discectomy can return to competitive play with no significant effects on performance. DESIGN Retrospective cohort study. SETTING National Football League. PATIENTS During a 22-year period (1986-2008), offensive skill position players in the NFL (quarterbacks, running backs, wide receivers, and tight ends) who sustained an LDH and subsequently underwent a lumbar discectomy were included in this study. INTERVENTION Lumbar discectomy. MAIN OUTCOME MEASURES Performance-based outcomes were analyzed, and data were recorded for games played, yards gained, and touchdowns scored. RESULTS : Data were analyzed for 23 NFL offensive skill position players who had an LDH and underwent discectomy. Seventy-four percent of players returned to competitive play in the NFL. The average length of career after treatment was 36 games over a 4.1-year period. There was no significant difference in performance when comparing pre-injury and post-injury statistics. CONCLUSIONS Although an LDH has career-threatening implications for NFL athletes, 74% of players who underwent lumbar discectomy returned to competitive play in the NFL. There was no significant change in performance when comparing pre-injury and post-injury statistics.

BACKGROUND CONTEXT Surgical site infection is a rare yet potentially serious complication impacting 0.3%–9% of patients undergoing surgery. While it is clear that patient and procedure-related risk factors affect the risk of infection, it is likely that environmental factors also affect rates of infection. PURPOSE To investigate the effect of operating room size on surgical site infection following lumbar fusion surgery. STUDY DESIGN/SETTING Retrospective case-control study. PATIENT SAMPLE Adult patients with a one- to three-level lumbar fusion at a single institution between January 1, 2012 and December 31, 2016. OUTCOME MEASURES Surgical site infection. METHODS Data were collected for all one- to three-level lumbar fusion surgery cases performed at a single institution by fellowship-trained spine surgeons between 2012 and 2016. Infection data was provided by the Infection Control Committee of the institution, and patients were considered to have an SSI if they met the Centers for Disease Control and Prevention's National Healthcare Safety Network definition of a surgical site infection. Data was analyzed to assess the relationship of operating room size and surgical site infection along with the effect of other medical comorbidities and covariates on infection. OR size was recorded as both floor surface area and room volume, and subsequently analyzed using dichotomous (small vs. large) classifications with a transition point as the mean measurement for each category. The mean surface area was 533.39 ft2 and volume was 5071.28ft2. These were selected as the cutoff point between small and large operating rooms as they represent the 50th percentile measurement. Of the 17 ORs analyzed, nine fit the criteria for “large” and eight fit the criteria for “small.” RESULTS A total of 1,864 patients were included and 33 were determined to have an SSI (1.77%). Demographics were not significantly different between the patient groups. OR size was not significantly associated with surgical site infection (multivariate p=.319). Laminar flow, vancomycin powder use, levels decompressed and the presence of several other covariates were also not significantly associated with surgical site infection (multivariate p>0.05). Factors that were found to increase the odds of infection included age>65, BMI>30 and smoking status (multivariate p CONCLUSIONS Operating room size is not significantly related to an increased incidence of surgical site infection following 1, 2 or 3 level lumbar fusion surgery. Conversely, this study reaffirmed that at age, BMI and smoking are risk factors for infection.

Cross-sectional observational study.To formulate a reliable method and modality for preoperative planning and to determine the effects of height, body mass index (BMI), and age on accessibility to the upper thoracic vertebrae through an anterior cervical approach.Various modalities have been proposed to determine the lowest spinal-level accessible through a traditional anterolateral cervical approach and the consequent need for manubriotomy. Past methods have routinely involved a variety of imaging studies such as plain radiographs and computed tomography but the reliability of these methods has not been assessed.The Magnetic Resonance Imaging (MRI) images of 180 patients classified by age and gender were evaluated and the most caudal accessible intervertebral disc space was determined from an approach angle beginning at the suprasternal notch. Plain cervical radiographs were also reviewed when available. In patients with multiple imaging studies, the reliability of the measurements was compared. Rate of accessibility was compared across different heights, BMIs, and ages.A novel algorithm that utilized both the scout and mid-sagittal T2 MRIs was able to determine the most caudal cervicothoracic level accessible for anterior access in 93.3% of patients with a reliability of 96.8%. Conversely, plain radiograph evaluation led to low reliability (66.7%) and low agreement with MRI (60%) with an average error of one spinal level. In this patient sample, the T1 to T2 disc space was accessible in 82.7% of patients. Age and BMI were independent variables associated with accessibility (p 0.01) while height was determined not to be significant (p = 0.09).Data in this study suggest an MRI-based algorithm with a combination of scout and sagittal T2 images offers a reliable and consistent assessment of accessibility to upper thoracic levels through an anterior approach. Age and body mass index are major determinants of accessibility.

Vertically unstable and complex bilateral sacral fractures are a result of high-energy mechanisms that are often associated with other injuries1-19. Vertically unstable sacral fractures result in the separation of the hemipelvis from the lumbar spine, whereas complex bilateral fractures result in a complete dissociation of the appendicular and axial skeleton. Recently, the surgical treatment algorithm for these fractures has changed, with an increasing number of surgeons advocating for the use of spinopelvic fixation or triangular osteosynthesis, a combination of spinopelvic fixation along with sacroiliac or transsacral screw fixation, to increase the stability of the construct and to allow for early weight-bearing with decreased concern for secondary displacement1-19. ### Osseous and Ligamentous Anatomy The sacrum is a rhomboid-shaped bone consisting of five fused segments that is the lowest functional section of the spinal column and acts as the keystone of the pelvic ring20. When force enters the sacrum, it propagates laterally across the sacroiliac joints into the pelvis. Because of the shape of the sacrum and the orientation of the sacroiliac joints, axial forces stabilize the sacroiliac articulation in the pelvic outlet plane; however, in the pelvic inlet plane, the osseous configuration lacks inherent stability. The interosseous ligaments and posterior sacroiliac ligaments provide the majority of the intrinsic stability. Comparatively, the sacrospinous and sacrotuberous ligaments provide the extrinsic stability21. The osseous architecture of the sacrum can be …

Bone morphogenetic proteins (BMPs) are members of the transforming growth factor-beta (TGF-β) superfamily and are essential cytokines involved in the development, homeostasis, and repair of the musculoskeletal system as well as other tissues. They are potent biological agents that can induce bone formation and eliminate morbidity associated with autologous bone-grafting. The U.S. Food and Drug Administration (FDA) approved recombinant human bone morphogenetic protein-2 (rhBMP-2) (INFUSE; Medtronic, Memphis, Tennessee) for use in single-level anterior lumbar interbody fusions in 2002, open tibial fractures in 2004, and sinus and alveolar ridge augmentations associated with extraction sockets in 2007. Because growth factors such as BMP stimulate proliferation of some cell types, the potential stimulation or progression of neoplasms is of concern. In a randomized controlled trial studying posterior lumbar spine arthrodesis, AMPLIFY (Medtronic), a high-dose (20-mg/side) formulation of rhBMP-2 with a compression matrix ceramic carrier, led to an increased incidence of cancer; however, the increase was not significant1. Similarly, the FDA Executive Summary for AMPLIFY noted a higher rate of neoplasms in the rhBMP-2 group than in the controls at the time of twenty-four and sixty-month follow-up2. Consequently, AMPLIFY was not approved by the FDA, stating a possible increased risk of cancer as the primary safety concern2. A recent critical review of rhBMP-2 clinical trials and FDA safety data highlighted the possible cancer risk and questioned the statistical methods used to analyze an infrequent, but serious, adverse event3. Population-based studies can provide insight into the true prevalence of rare events. Because low risks are difficult to detect in a small sample size such as that in a phase-3 controlled trial of a medical device, the effects on carcinogenesis may be detectable only in a large population. The aim of this study was to compare the incidence of new malignant neoplasms after spinal arthrodesis with and without exposure to BMP, using a large administrative database. We estimated the relative risk of cancer in the population exposed to BMP in clinical use relative to that in the population without such exposure.

Background Surgical-site infections (SSIs) can lead to greater postoperative morbidity, mortality, and health care costs. Despite current prophylactic measures, rates of SSIs have been reported in up to 15% of patients undergoing spine surgery. The adjunctive local application of vancomycin powder in spine surgery is a low-cost strategy to help reduce SSIs. Vancomycin is active against skin pathogens that can potentially contaminate the wound during spinal surgery. The local application of vancomycin in its powder form ensures adequate surgical-site concentrations while minimizing adverse effects caused by undetectable systemic distribution. However, clinical studies have produced conflicting results, and the clinical evidence behind the use of vancomycin powder in modern spinal surgery practices is not clear. Purpose To examine the current clinical evidence on the use of vancomycin powder in spine surgery. Study Design Systematic review and meta-analysis of literature. Methods A comprehensive search of the English literature was conducted with PubMed (MEDLINE). The inclusion criteria consisted of intrawound vancomycin powder use in spine surgery as a prophylactic agent for SSIs. Studies that investigated nonspine surgeries, selected patients on the basis of clinical suspicion, or included patients with infections were excluded. Studies that compared intrawound vancomycin in spine surgery against their standard practice were pooled in the meta-analysis using a random-effects model. Results A total of 671 abstracts were reviewed, and 18 papers met inclusion/exclusion criteria and were included in this review. These included 1 randomized controlled trial, 13 comparative studies, and 4 case series. The level of evidence in hierarchical order was as follows: 1 level II, 13 level III, and 4 level IV. Fourteen of the studies, 1 randomized controlled trial and 13 comparative studies, were eligible for the meta-analysis. The odds of developing a deep infection with intrawound vancomycin powder were 0.23 times the odds of experiencing an infection without intrawound vancomycin (95% confidence interval 0.11–0.50, P = 0.0002, I 2 = 47%). For combined superficial and deep infections the odds ratio was 0.43 (95% confidence interval 0.22–0.82, P = 0.01, I 2 = 36%). Conclusions Numerous clinical studies have confirmed the safety of using vancomycin powder in the surgical site. The pooled clinical data supports the use of vancomycin to prevent SSIs in adult spine surgeries. The majority of the supporting literature is class III evidence. Existing studies use different definitions for surgical site infections and different pre-, peri-, and postoperative antibiotic regimens. Further high-quality investigations should use standardized protocols to confirm these findings.

Objectives: The purpose of this study is to determine if a pre-existing lumbar diagnosis such as spondylosis, a herniated lumbar disc, or spondylolysis affects a football player’s draft status or his performance and longevity in the NFL. Methods: The written medical evaluations and imaging reports of prospective professional American football athletes from 2003-2011 from one NFL franchise during the NFL combine (annual college football player evaluation prior to the NFL draft) were compiled and evaluated. All players were evaluated for a pre-existing lumbar diagnosis which were compiled from previous injury/medical records including radiographic imaging reports. Those players with a lumbar spine diagnosis and with appropriate radiograph, MRI and CT imaging were included in this study. These athletes were then matched by age, position, year, and round drafted to control draftees without a lumbar spine diagnosis. Career statistics were compiled including length of play and number of games started. Additionally, a previously established “Performance Score” was calculated for all players excluding offensive linemen. The continuous variables of each cohort were compared using a two-sided (tailed) Student’s t-test for normally distributed data. A chi-squared analysis was performed to analyze the categorical data. Statistical significance was accepted with a p < 0.05. Results: Out of a total of 2,965 athletes evaluated from the NFL combine, 414 players were identified with a pre-existing lumbar spine diagnosis. Athletes who attended the NFL combine without a lumbar spine diagnosis were significantly more likely to be drafted than those with one (74% vs. 61% respectively, p < 0.01). There was no difference between the investigational and control group with regard to round drafted, age, year drafted, or position. Overall, athletes with a lumbar spine injury compared to the control group had no difference in the number of years played (4.0 vs. 4.3 years, respectively, p = 0.13), games played (46.5 vs. 50.7, respectively, p = 0.15), games started (28.1 vs. 30.6, respectively, p = 0.39) or performance score (1.4 vs. 1.8, respectively, p = 0.3) (Figure 1). Conclusion: The data in this study suggests that a pre-existing lumbar spine diagnosis was associated with a significantly lower draft status for NFL athletes. However, the data in our study suggests that such a diagnosis did not affect a player’s career longevity or performance. Further study will be required to determine the individual effects of specific conditions on performance.

Study Design Literature review. Objective To discuss the evaluation and management of fixed sagittal plane imbalance. Methods A comprehensive literature review was performed on the preoperative evaluation of patients with sagittal plane malalignment, as well as the surgical strategies to address sagittal plane deformity. Results Sagittal plane imbalance is often caused by de novo scoliosis or iatrogenic flat back deformity. Understanding the etiology and magnitude of sagittal malalignment is crucial in realignment planning. Objective parameters have been developed to guide surgeons in determining how much correction is needed to achieve favorable outcomes. Currently, the goals of surgery are to restore a sagittal vertical axis Conclusion Sagittal plane malalignment is an increasingly recognized cause of pain and disability. Treatment of sagittal plane imbalance varies according to the etiology, location, and severity of the deformity. Fixed sagittal malalignment often requires complex reconstructive procedures that include osteotomy correction. Reestablishing harmonious spinopelvic alignment is associated with significant improvement in health-related quality-of-life outcome measures and patient satisfaction.

STUDY DESIGN A questionnaire survey. OBJECTIVE To characterize surgeons' current perspectives on the administration of methylprednisolone for acute spinal cord injury (SCI) and determine how this has changed during the last 7 years. SUMMARY OF BACKGROUND DATA The determinants of and complications associated with off-label steroid use for acute SCI remain controversial. METHODS A survey was sent to surgeon members of the Cervical Spine Research Society requesting information regarding their use of steroids for acute SCI. Determinants included surgeons' specialty, trauma center level, number of SCIs treated per year, severity of injury, and location of injury. These results were compared across groups as well as with a historical control. RESULTS In the case of cervical complete and incomplete SCIs, 47.4% and 56.4% of respondents, respectively, reported using steroids. For complete and incomplete thoracolumbar spine injuries, the usage rate was 46.2% and 55.1%, respectively. There has been a significant (P < 0.0001) decrease in the number of surgeons using high-dose steroids in the treatment of acute SCIs when compared with a previous report in 2006 (56% vs. 89%).More than 80% of respondents reported sepsis, active gastrointestinal bleeding, and SCI occurring earlier than 8 hours as contraindications. Seventy-one percent of respondents reported observing complications from the use of steroids, and 76.3% thought that the complications were severe enough to limit steroid use. Of the surgeons who used steroids for SCI, 26% thought that steroids improved neurological recovery, 19.2% used steroids to adhere to institutional protocol, and 25.6% stated they did not think steroids were beneficial but used them because of medicolegal concerns. CONCLUSION There has been a significant decrease in the number of surgeons using high-dose steroids for acute SCIs. Sepsis, gastrointestinal bleeding, and an injury occurring more than 8 hours prior to presentation were agreed upon as contraindications to steroid use.

With the increased survival of oncologic patients, evaluation and management of patients with spinal metastasis is crucial to reducing morbidity and maximizing function. In this chapter, we present some guidelines for the initial systematic evaluation of patients with spinal lesions, as well as the risks, benefits, and alternatives to nonoperative and operative management of metastatic spinal disease, and the overall survival of these patients.

Background: Postoperative spinal wound infections are relatively common and are often associated with increased morbidity and poor long-term patient outcomes. The purposes of this study were to identify the common bacterial flora on the skin overlying the lumbar spine and evaluate the efficacy of readily available skin-preparation solutions in the elimination of bacterial pathogens from the surgical site following skin preparation. Methods: A prospective randomized study was undertaken to evaluate 100 consecutive patients undergoing elective lumbar spine surgery. At the time of surgery, the patients were randomized to be treated with one of two widely used, and Food and Drug Administration (FDA)-approved, surgical skin-preparation solutions: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol) or DuraPrep (0.7% available iodine and 74% isopropyl alcohol). Specimens for aerobic and anaerobic cultures were obtained prior to skin preparation (pre-preparation), after skin preparation (post-preparation), and after wound closure (post-closure). A validated neutralization solution was used for each culture to ensure that the antimicrobial activity was stopped immediately after the sample was taken. Positive cultures and specific bacterial pathogens were recorded. Results: Coagulase-negative Staphylococcus, Propionibacterium acnes, and Corynebacterium were the most commonly isolated organisms prior to skin preparation. The overall rate of positive cultures prior to skin preparation was 82%. The overall rate of positive cultures after skin preparation was 0% (zero of fifty) in the ChloraPrep group and 6% (three of fifty) in the DuraPrep group (p = 0.24, 95% confidence interval [CI] = 0.006 to 0.085). There was an increase in positive cultures after wound closure, but there was no difference between the ChloraPrep group (34%, seventeen of fifty) and the DuraPrep group (32%, sixteen of fifty) (p = 0.22, 95% CI = 0.284 to 0.483). Body mass index (BMI), duration of surgery, and estimated blood loss did not a show significant association with post-closure positive culture results. Conclusions: ChloraPrep and DuraPrep are equally effective skin-preparation solutions for eradication of common bacterial pathogens on the skin overlying the lumbar spine. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Although clinical outcomes after lumbar disc herniations (LDHs) in the general population have been well studied, those in elite professional athletes have not. Because these athletes have different measures of success, studies on long-term outcomes in this patient population are necessary.This study seeks to define the outcomes after an LDH in a large cohort of professional athletes of American football, baseball, hockey, and basketball.Retrospective cohort study.A total of 342 professional athletes from four major North American sports from 1972 to 2008 diagnosed with an LDH were identified via a previously published protocol. Two hundred twenty-six players underwent lumbar discectomy, and 116 athletes were treated nonoperatively. Only those players who had at least 2 years of follow-up were included.Functional outcome measures as defined by successful return-to-play (RTP), career games, and years played for each player cohort were recorded both before and after treatment. Conversion factors based on games/regular season and expected career length (based on individual sport) were used to standardize the outcomes across each sport.Using Statistical Analysis Software v. 9.1, outcome measures were compared in each cohort both before and after treatment using linear and mixed regression analyses and Cox proportional hazards models. A Kaplan-Meier survivorship curve was calculated for career length after injury. Statistical significance was defined as p.05.After the diagnosis of an LDH, professional athletes successfully returned to sport 82% of the time, with an average career length of 3.4 years. Of the 226 patients who underwent surgical treatment, 184 successfully returned to play (81%), on average, for 3.3 years after surgery. Survivorship analysis demonstrated that 62.3% of players were expected to remain active 2 years after diagnosis. There were no statistically significant differences in outcome in the surgical and nonoperative cohorts. Age at diagnosis was a negative predictor of career length after injury, whereas games played before injury had a positive effect on outcome after injury. Major League Baseball (MLB) players demonstrated a significantly higher RTP rate than those of other sports, and conversely, National Football League (NFL) athletes had a lower RTP rate than players of other sports (p.05). However, the greatest positive treatment effect from surgery for LDH was seen in NFL players, whereas for MLB athletes, a lumbar discectomy led to a shorter career compared with the nonoperative cohort (p.05).Professional athletes diagnosed with an LDH successfully returned to play at a high rate with productive careers after injury. Whereas older athletes have a shorter career length after diagnosis of LDH, experienced players (high number of games played) demonstrate more games played after treatment than inexperienced athletes. Notably, surgical treatment in baseball players led to significantly shorter careers, whereas for NFL athletes, posttreatment careers were longer than those of the corresponding nonoperative cohort. The explanation for this is likely multifactorial, including the age at diagnosis, respective contractual obligations, and different physical demands imposed by each individual professional sport.

The pedicle screw diameter, composite and design are variables that can affect the threshold of intraoperative electromyographic monitoring. Even though we know that larger diameter objects tend to have less resistance, no study documented the effect that this variable could have on pedicle screw resistance. Using high quality equipment, resistance and resistivity of ten pedicle screws (from four manufacturers) were calculated based on known constant current and measured voltage. Voltage was measured three times for each screw to determine intraobserver measurement variability. Resistance of all screws ranged from 1.4 to 3.9 m ohm (mean = 2.69+/-0.71 m ohm). The screw with largest diameter (7.75 mm) had lower resistance than screws with other diameters. Resistivity of screws ranged from 7.12 to 12.63 micro ohm*m (mean = 9.9+/-1.82 micro ohm*m). Based on the screw design, one manufacturer's pedicle screws (A) had significantly lower resistivity compared to three other manufacturers (p

Background context During the last decade, vertebral augmentation techniques with cement (kyphoplasty and vertebroplasty) have revealed that 75% to 100% of individuals with osteoporotic vertebral compression fractures have good to moderate pain relief postoperatively, as well as adequate restoration of the vertebral body height. The volume of cement injected into a vertebra varied in different reports. To our knowledge, there are no studies that report on the physiological distribution of thoracic and lumbar vertebrae body volumes. Purpose The purpose of this study was to quantitatively evaluate thoracic and lumbar vertebral body volumes. Study design/setting Forty computed tomography (CT) scans of the thoracic and lumbar spines were used to measure a volume of each vertebral body. Methods Forty CT scans with standard 2.5-mm bone window cuts of the thoracic and lumbar vertebrae (20 men and 20 women) were analyzed to measure the volumetric capacity of vertebral bodies using a BrainLAB Software (iPlan RT image 4.0) program. The software was tested for validity and reliability in two pilot studies. Mean and standard deviations for each vertebral body volume were calculated and recorded. The vertebral body working distance and the so-called “safe zone” were also measured to determine a size of a balloon to be used in kyphoplasty. Results Vertebral body volume increased gradually from T1 to L4 with the exception of L5, which measured to be smaller than L4. The mean thoracic vertebrae volume was 15.0 cm3 (ranged in the absolute values from 5.2 to 39.5 cm3), and the mean lumbar vertebrae volume was 35 cm3 (ranged in the absolute values from 19.7 to 61.5 cm3). Men had larger volume vertebral bodies only in the lumbar spine compared with women. The average vertebral body working distances from T1 to T4 was 23.4±2.7 mm, from T5 to T9 was 30.3±3.6 mm, and from T10 to L5 was 35.5±3.9 mm. Conclusions Knowing the physiological variability of vertebral body volumes may help prevent complications as a result of underaugmentation or overaugmentation with excessive amount of cement during kyphoplasty or vertebroplasty in osteoporotic compression fractures. We recommend using 10 mm balloons from T1 to T4, 15 mm balloons from T5 to T9, and 20 mm balloons from T10 to L5 for kyphoplasty.

OBJECT The authors compared the rates of postoperative adverse events and reoperation of patients who underwent lumbar spinal fusion with bone morphogenetic protein (BMP) to those of patients who underwent lumbar spinal fusion without BMP. METHODS The authors retrospectively analyzed the PearlDiver Technologies, Inc., database, which contains the Medicare Standard Analytical Files, the Medicare Carrier Files, the PearlDiver Private Payer Database (UnitedHealthcare), and select state all-payer data sets, from 2005 to 2010. They identified patients who underwent lumbar spinal fusion with and without BMP. The ICD-9-CM code 84.52 was used to identify patients who underwent spinal fusion with BMP. ICD-9-CM diagnosis codes identified complications that occurred during the initial hospital stay. ICD-9-CM procedural codes were used to identify reoperations within 90 days of the index procedure. The relative risks (and 95% CIs) of BMP use compared with no BMP use (control) were calculated for the association of any complication with BMP use compared with the control. RESULTS Between 2005 and 2010, 460,773 patients who underwent lumbar spinal fusion were identified. BMP was used in 30.7% of these patients. The overall complication rate in the BMP group was 18.2% compared with 18.7% in the control group. The relative risk of BMP use compared with no BMP use was 0.976 (95% CI 0.963–0.989), which indicates a significantly lower overall complication rate in the BMP group (p < 0.001). In both treatment groups, patients older than 65 years had a statistically significant higher rate of postoperative complications than younger patients (p < 0.001). CONCLUSIONS In this large-scale institutionalized database study, BMP use did not seem to increase the overall risk of developing a postoperative complication after lumbar spinal fusion surgery.