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Incidental durotomies resulting in symptomatic postoperative cerebrospinal fluid (CSF) leaks can be treated with bedrest, subarachnoid lumbar drain, and surgical re-exploration. Another option is an epidural blood patch, which forms a clot over the dural tear in a minimally invasive manner. Our objective was to describe our center's outcomes and complications following epidural blood patches for symptomatic postoperative durotomies.Patients undergoing spine surgeries at one institution from 2012-2020 were included. Patient charts were reviewed for demographic information, surgical data, rate of dural tear, type of repair, and use of blood patches postoperatively.A total of 1392 patients (726 male, 666 female, average age: 56.3 ± 15.4 years), including 436 cervical and 956 posterior thoracolumbar/lumbar spine surgeries were screened. There were 6 (1.4%) cervical, 64 (6.7%) lumbar, and a total of 70 (5.0%) patients with incidental dural tears/blebs. Of these patients, we identified 2 cervical and 8 lumbar spine patients with persistent CSF leaks who received epidural blood patches postoperatively. Nine of 10 (90%) had resolution of symptoms. One lumbar patient failed both an initial blood patch and subsequent surgical re-exploration, but had successful relief after a second blood patch.The incidence of dural tears/blebs was 1.4% in cervical, 6.7% in lumbar, and 5.0% in all spine surgeries. Of the 10 patients with symptomatic CSF leaks, 9 were successfully treated with blood patches. Targeted epidural blood patch is effective in treating symptomatic CSF leaks and minimizes the morbidity of surgical re-exploration.

Orthopaedic surgery is the least diverse surgical subspecialty in medicine. However, to date, there is no literature that shows which medical schools have successfully contributed to improving orthopaedic surgeon diversity.The purpose of this study is to identify the top U.S. medical schools that have successfully matched black applicants into orthopaedic surgery residencies and juxtapose this ranking to the current top medical schools as ranked by the U.S. News and World Report (USNWR).The J. Robert Gladden Orthopaedic Society (JRGOS) database was queried for all orthopaedic surgeons, fellows, and residents who identified as black or multi-racial with black being one of the included races, yielding 938 physicians, of which 672 met our inclusion criteria. From this list, a ranking of the top 20 medical schools was generated.The top five medical schools ranked in the JRGOS database are Howard University College of Medicine (HUCOM), Meharry Medical College, Harvard Medical School (HMS), the University of Pennsylvania, and Morehouse School of Medicine (MSM). In addition, 10 (50%) of the medical schools ranked in the top 20 by the JRGOS database were also ranked by the USNWR. When ranking medical schools for black female applicants, HUCOM, MSM, HMS are the top three programs. Lastly, a ranking by region identified that the northeast contained the highest number of ranked medical schools.There are both historically black and non-historically black medical schools which have a proven track record of producing a significant number of future black orthopaedic surgery residents.

Retrospective analysis.This study aimed to identify the prevalence of concomitant thoracic spinal and sternal fractures and factors associated with concomitant fractures.The sternum has been implicated in stability of the upper thoracic spine, and both bony structures are included in the stable upper thoracic cage. High force trauma to the thorax can cause multiple fractures to different upper thoracic cage components.This is a retrospective analysis of electronic medical record data of patients treated at a Level 1 Trauma Center who underwent surgery for thoracic spinal fracture between 2008-2020. We recorded presence of concomitant sternal fracture, injury characteristics, hospital course data, and demographic information.107 patients with thoracic spinal fractures had a sternal fracture prevalence of 18.7%. The average age was 53.2 [15-90]. 72 (67.3%) were male and 35 (32.7%) were female, 92 (85.9%) were White, 10 (9.3%) were African American, 3 (2.8%) were Hispanic, and 2 (1.9%) were Asian. The average age of patients with sternal fractures was 48.7 years, compared to those without sternal fractures, 54.3 years (P = 0.251). Patients with T1-T7 fractures [14 of 48 (29.2%)] had a significantly higher rate of sternal fractures compared to patients with T8-T12 fractures [6 of 59 (10.2%)] (P = 0.012). Patients with additional rib (P0.001), scapula (P = 0.01), clavicle fractures (P = 0.01), and those with multiple other thoracic fractures (P = 0.01) had significantly higher rates of sternal fractures compared to patients without these. Patients with concomitant sternal fractures [10 of 20 (50.0%)] had a significantly higher rate of respiratory complication during their hospital course than patients without concomitant sternal fracture [40 of 87 (46.0%)] (P0.001). Sex, age, mechanism of injury, fracture morphology, estimated blood loss during surgery, intraoperative complications, post-surgical intubation status, and post-surgical intubation duration were not associated with sternal fractures.The prevalence of concomitant thoracic spinal fracture and sternal fracture in our series is 18.7%. T1-T7 fractures and presence of rib, scapula, and clavicle fractures were significantly associated with the presence of sternal fractures. Presence of concomitant sternal fracture was significantly associated with respiratory complication during hospital course.

Cross-sectional prospective study.To evaluate the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression domains in comparison to the Spine Oncology Study Group-Outcomes Questionnaire (SOSG-OQ) in patients with metastatic spine disease.While there remains a significant movement toward incorporating patient-reported outcome measures (PROMs) into clinical care, there are few validated PROMs for patients with metastatic spine disease. The SOSG-OQ was designed and validated for metastatic spine tumor patients. However, the use of general symptom-based PROMs, such as PROMIS domains, may reduce both patient and physician burden and improve interdisciplinary care if shown to be concurrently valid.Metastatic spine tumor patients from January 2017 to July 2021 at a single academic medical center were asked to complete PROMIS PF, PI, and Depression domains and the SOSG-OQ. Spearman correlation (p) coefficients were calculated.A total of 103 unique visits, representing 79 patients met our inclusion criteria. A majority were men (59; 57%) and Caucasian (93; 90%), and the average age was 64-years-old (range: 34-87). There were 13 different types of histologies reported, with multiple myeloma, breast cancer, and prostate cancer representing 28 (27%), 26 (25%), and 13 (13%), respectively. Additional cancers included renal cell carcinoma, lung cancer, colon cancer, thyroid cancer, large B-cell lymphoma, nonHodgkin lymphoma, esophageal cancer, plasmacytoma, metastatic paraganglioma, and metastatic spindle cell sarcoma. SOSG-OQ was strongly correlated with PROMIS PI (ρ = 0.78) and PROMIS PF (ρ = 0.71), and moderately correlated with PROMIS Depression (ρ = 0.58).PROMIS PF, PI, and Depression appear to capture similar clinical insight as the SOSG-OQ. Spine surgeons can consider using these PROMIS domains in lieu of the SOSG-OQ in metastatic spine tumor patients.Level of Evidence: NA.

Achieving fusion in spine surgery can be challenging because of patient factors such as smoking and diabetes. The consequences of pseudarthrosis can be severe, including pain, instability, and additional surgery. Autologous iliac crest bone graft is the historical standard for augmenting spine fusion, providing high rates of fusion throughout the cervical, thoracic, and lumbar spine. Harvest of autologous iliac crest bone can be associated with comorbidities and this has led to development of alternative biologic materials to enhance spine fusion. Substitutes include various forms of allograft products including decellularized allograft; demineralized bone matrix; synthetic materials including bioactive glass; and autologous and allograft mesenchymal stem cells. Bone morphogenetic proteins can be efficacious for fusion but have significant risks and are not suitable for all spine procedures. There is a wide variety of utilization of biologics for spine fusion that are influenced by spinal region, surgeon preference, surgical training, health system formulary, and cost.

The lack of diversity among orthopaedic health care providers is a pressing matter that must continue to be corrected at all levels. Improving diversity among orthopaedic physicians starts with improving diversity in residency training programs. This study brings light to the demographics and achievements of successful minority applicants, detailing what types of students are successfully matching into orthopaedic surgery. Between June and July 2020, the authors distributed a 12-question, anonymous survey to 53 URM students who successfully matched into orthopaedic surgery residencies for the 2020 application cycle. The survey inquiries about respondent demographics, academic accomplishments, and match process success as well as whether the presence of URM faculty, program director, and chairman influenced how they made their rank list. Overall, 37 students (71%) completed the entire survey. Most students indicated that the presence or absence of URM faculty influenced their rank list (n = 32, 88.9%) and that this distinction was meaningful to their orthopaedic candidacy (n = 28, 87.5%). Less than half of the respondents (n = 16; 44.4%) noted that the presence of a URM residency program director or department chairman influenced their rank list, while 20 (55.6%) noted that it did not. In conclusion, URM applicants with multiple academic achievements can be successful during the orthopaedic match process. Furthermore, the presence of URM faculty is an important factor that URM applicants consider. Residency directors must both identify the competitive URM applicants and strive to recruit more URM faculty when aiming to increase program diversity. Level of Evidence: Level IV.

Objective The American Medical Association and National Institutes of Health have recommended that patient education materials should be written at the sixth-grade reading level to maximize patient comprehension. The objective of the present study was to evaluate the readability of Internet information for the 9 most common spinal surgeries. Methods We reviewed 90 online patient educational materials regarding the 9 most common spinal surgeries as reported by the North American Spine Society. A Google search was performed on March 23, 2019 for each surgery, and the top 10 most visited websites for each surgery were assessed for reading level using the Flesch-Kincaid formula. Results Using the Flesch-Kincaid formula, the average grade reading level of the 90 websites included was 12.82, with a reading ease of 37.04 (“difficult college”). Only 6 websites relayed information to patients at or below the national average of an eighth-grade reading level. The websites for bone morphogenic protein had the highest average grade reading level at 15.88 ± 2.6. Lumbar microscopic discectomy had the lowest average grade reading level at 10.37 ± 2.89. All surgical options discussed had an average readability above the recommended sixth-grade reading level. Conclusions The most accessed online materials for common spinal surgeries, not only exceeded the readability limits recommended by both the American Medical Association and the National Institutes of Health, but they also exceeded the average reading ability of most adults in the United States. Patients, therefore, might not fully comprehend the information from commonly accessed websites regarding surgical spine treatment options.

Study design Retrospective, Observational Study. Objective The objective of this study is to evaluate the return on investment (ROI) of the Cervical Spine Research Society (CSRS), Scoliosis Research Society (SRS) and North America Spine Society (NASS) grants as quantified by the number of publications generated and federal grants obtained (National Institute of Health [NIH], Department of Defense [DOD]). Summary of background data The CSR, SRS and NASS, have awarded numerous research grants over the past three decades. Methods Through publicly available data we identified grants awarded by the Spine Societies. We collected the type of grant awarded, the Principal Investigator information, dollar amount of the grant, number of publications in PubMed from each grant, number of citations, and the publication journal. The NIH and DOD website were queried to determine which grantees subsequently received either NIH or DoD funding. Results From 1989 to 2016: 81 (CSRS), 126 (SRS), and 93 (NASS) grants were awarded. From these grants 206 publications acknowledged receiving financial support from the spine societies. The SRS funded 100 papers, NASS 62 papers and CSRS 44 papers. A total of 32 NIH grants and 4 DOD grants were subsequently awarded. The conversion rate to NIH grants was 15% (n = 12 CSRS), 7.9% (n = 10 SRS), and 11% (n = 10 NASS). The conversion rate to DOD grants was 3.7% (n = 3 CSRS), 0.8% (n = 1 SRS), and 0% (n = 0 NASS). ROI of spine society grant dollars per future NIH and DoD grants were the lowest for CSRS (Dollars Per NIH Grant: $207,434; Dollars Per DoD Grant: $829,734). Male investigators received 85% of CSRS grants, 75% of SRS grants and 83% of NASS grants. Conclusion CSRS grants appear to have the highest ROI of all spine society grants when evaluating subsequent NIH and DOD funding. However, the overall conversion rate to NIH and DOD grants remains low.Level of Evidence: 3.

Study design Retrospective cross-sectional analysis. Objective The aim of this study was to establish the strength of relationship between the Patient-reported Outcomes Measurement Information System (PROMIS) Adult Depression (AD), Physical Function (PF), and Pain Interference (PI) with the Swiss Spinal Stenosis Questionnaire (SSSQ) in assessing lumbar spinal stenosis (LSS). Summary of background data In 2009, there were >35,000 surgeries for LSS, which amounted to $1.65 billion in health care cost. By 2021, there will be >2.4 million people in the United States with symptomatic LSS. There is an increasing emphasis on patient-reported outcomes (PROs) to define value in medicine. Therefore, it would be beneficial to compare PROMIS, a universal PRO, against the SSSQ, the "criterion standard" for assessing LSS. Methods Eighty-two patients with LSS completing the PROMIS and SSSQ were enrolled. Per existing institutional protocol, PROMIS AD, PF, and PI were completed at every clinic visit. Linear regression analysis was then performed to evaluate how well the SSSQ and PROMIS scores correlated to each other. Results When linear regression was performed for pre-treatment values, the R2 value for the SSSQ PF versus PROMIS PF was 0.14 (P = 0.0008), whereas the R2 value for the SSSQ symptom severity versus PROMIS PI was 0.03 (P = 0.13). The R2 value for the combined SSSQ physical function and symptom severity versus PROMIS AD was 0.07 (P = 0.02). When post-treatment SSSQ satisfaction scores were correlated to postoperative PROMIS AD, PI, and PF scores, the R2 values for a good linear fit were 0.13, 0.25, and 0.18 respectively (P values: 0.01, 0.003, and 0.003). Conclusion Pre-treatment PROMIS scores do not adequately capture the disease-specific impact of spinal stenosis, but postoperative PROMIS scores better reflect outcomes after surgery for LSS. PROMIS scores should not be used in isolation to assess outcomes in patients with LSS.Level of Evidence: 4.

Impact factor, citation rate, and other traditional measures of scholarly impact do not account for the role that social media has in the dissemination of research. The Altmetric Attention Score (AAS) quantifies the active online presence of individual articles on various platforms (eg, Twitter, Facebook).We sought to better understand the factors associated with greater online attention and AAS in seven spine journals.Cross-sectional study.No patients were included in this study. We analyzed 380 articles in seven major spine journals.Extracted manuscript characteristics included AAS; number of Twitter, Facebook, and news outlet mentions; number of citations, references, academic institutions, and authors; and sample size, geographic region, subject of study, and level of evidence.All original scientific manuscripts published in the official January, February, and March 2017 issues of Spine, The Spine Journal, Spine Deformity, Journal of Neurosurgery-Spine, Clinical Spine Surgery, Global Spine Journal, and European Spine Journal were identified. The correlation of AAS and number of citations was determined by Spearman's Rho (ρ) correlation coefficient. Manuscript factors associated with AAS were determined by a multivariable linear regression analysis.A total of 380 manuscripts were included in the analysis. The average AAS across all seven journals was 4.9 (SD: 19.4; Range: 0-356), with the highest average AAS reported for The Spine Journal at 8.0 (SD: 13; Range: 0-60). There was a weak, positive correlation between AAS and number of citations (ρ = .32; p.05); this relationship was individually present for four out of the seven included journals. In addition, number of references was associated with higher average manuscript AAS (β: 0.16 [95% CI: 0.002-0.32]; p.05). No manuscript characteristics were associated with lower AAS.Our analysis of seven spine journals revealed a weak, positive correlation between AAS and number of citations. Number of references was associated with higher AAS. We believe these findings may be useful to authors seeking ways to maximize the impact of their research.

Systematic Review.To synthesize previous studies evaluating racial disparities in spine surgery.We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses guidelines and protocol. The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions, and length of stay.A total of 1753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Whites (Ws) and African Americans (AAs) groups; 14 studies reported adverse outcomes for AAs. When compared with Ws, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition, and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy, and were less likely to receive cervical disk arthroplasty compared with Ws for similar indications.This systematic review of spine literature found that when compared with W patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted.

Background: Calcium pyrophosphate dihydrate (CPPD) deposition, also known as pseudogout, in the cervical ligamentum flavum (CLF), is a rare disease which can cause spinal cord signaling changes leading to rapid deterioration in function. The natural history of cervical myelopathy as a result of CPPD deposition within the CLF is not well understood. Our objective is to describe the presentation, imaging findings, and treatment options of CPPD deposition or pseudogout of the cervical spine. Methods: Using PubMed, we analyzed studies published from 1978 to 2022. Key words used were “pseudogout,” “CPPD deposit disease,” “cervical yellow ligament,” “CLF,” and “cervical spine.” We excluded “crowned dense syndrome” and “ossification of ligament flavum.” Using a department database, we queried for patients treated for CPPD of the cervical spine. Results: Twenty clinical studies on CPPD of the cervical spine with 69 patients aged between 15 and 92 years (mean = 72) were identified. Neck pain and numbness of the hands were the most common symptoms. Diabetes mellitus and hypertension were the most common comorbidities. Males and females were affected at equal rates. C4-C5 and C5-C6 were the most affected segments. Earlier surgical treatment produced better outcomes. A laminectomy and fusion or laminoplasty were the most common procedures performed with most patients experiencing some return of neurologic function. Conclusion: Although rare, CPPD deposit disease in the CLF should be readily considered as a differential diagnosis due to the continuously aging population. CPPD’s progressively worsening nature makes an early diagnosis and treatment important in improving the patient’s overall quality of life.

BACKGROUND: Harrington instrumentation for adolescent idiopathic scoliosis (AIS) was revolutionary and allowed patients to mobilize faster as compared with patients treated with uninstrumented fusion. However, Harrington instrumentation provided correction of the deformity in 1 plane, resulting in limited sagittal plane control. Patients who received these 2 surgeries are aging, and to date, ultralong follow-up of these patients has not been reported. OBJECTIVE: The purpose of this study was to evaluate long-term patient-reported outcomes and radiographic parameters after Harrington nonsegmental distraction instrumentation vs uninstrumented fusion in the treatment of AIS. METHODS: Fourteen adult patients with AIS who were previously instrumented (n = 7) or uninstrumented (n = 7) were identified. Recent x-ray image measurements such as pelvic incidence (PI), sagittal vertical axis (SVA), pelvic tilt (PT), lumbar lordosis (LL), and pelvic incidence minus lumbar lordosis (PI-LL) were used to analyze deformities. Scoliosis Research Society-7 (SRS-7), Neck Disability Index (NDI), and Oswestry Disability Index (ODI) were used to evaluate patient-reported outcomes. Complications and rates of revision surgery were also evaluated. RESULTS: The mean age was 67.1 ± 5 years in the instrumented group and 64.1 ± 9 years in the uninstrumented group. There were no significant differences between instrumented and uninstrumented in SRS-7 (23.4 ± 2.9 vs 23.6 ± 2.6, P = 0.93), NDI (5.7 ± 4.5 vs 10.6 ± 4.5, P = 0.08), and ODI (9.7 ± 13.7 vs 9.4 ± 8.7, P = 0.99). Radiographic measurements of instrumented vs uninstrumented resulted in comparable PT (24.0 ± 7.9 vs 30.5 ± 4.7, P = 0.09), PI (61.3 ± 16.9 vs 67.2 ± 9.5, P = 0.47), LL (34.9 ± 14.4 vs 42.8 ± 11.0, P = 0.29), PI-LL (26.4 ± 25.1 vs 24.3 ± 10.4, P = 0.43), and SVA (38.1 ± 30.1 vs 52.3 ± 21.6, P = 0.37). There were 2 patients in the instrumented group who developed adjacent segment disease that required operative intervention compared with none in the uninstrumented group (P = 0.46). CONCLUSION: In long-term follow-up of instrumented and uninstrumented fusion, patients had similar patient-reported outcomes and radiographic parameters, although the instrumented cohort had higher rates of adjacent segment disease. LEVEL OF EVIDENCE: 4.

Introduction While epidural blood patch can be an effective management option in lumbar pseudomeningoceles in certain clinical settings, its utility in the cervical spine is unclear. The aim of this study was to evaluate the safety and effectiveness of percutaneous aspiration and autologous blood patch for post-operative durotomy related pseudomeningoceles within the cervical spine. Methods A single institution retrospective review detailing 3 patients with durotomy related pseudomeningocele following posterior cervical spine surgery was completed. Results In all three cases, aspiration with subsequent injection of autologous epidural blood patch successfully treated each pseudomeningocele. One patient required more than one intervention, while the other two were successfully treated after one procedure. All three patients improved clinically without need for additional surgery. Conclusion Percutaneous aspiration and epidural blood patch can be used to safely manage post-operative pseudomeningoceles within the posterior cervical spine.

Despite its importance for clinical decisions, the long-term consequences of posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS), particularly in the lower lumbar spine, remain unclear. This study evaluates the long-term health-related quality of life and the need for a further surgical procedure in patients treated with Harrington instrumentation from 1961 to 1977 according to the lowest instrumented vertebra (LIV) and in comparison with age-matched norms.A search was performed to identify and contact the 314 identified patients with AIS treated with PSIF by Dr. L.A. Goldstein. The assessment included identified subsequent spine surgery, the Oswestry Disability Index (ODI), Scoliosis Research Society-7 (SRS-7), EuroQol-5 Dimensions (EQ-5D), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). The health-related quality of life was compared with U.S. norms and, within the cohort, was compared by patient factors, LIV, and subsequent spine surgery.In this study, 134 patients (42.7%) were identified; 24 (7.6%) had died, 81 (25.8%) consented to participate in the study, and 29 (9.2%) declined participation. The mean follow-up was 45.4 years (range, 40 to 56 years). There were 81 patients who completed the surveys, 77 patients who completed the SRS-7, 77 patients who completed the ODI, and 76 patients who completed the PROMIS-29 and EQ-5D. There were 12.8% of patients with LIV L3 or proximal and 36.4% with LIV L4 or distal who had an additional surgical procedure (odds ratio, 3.98). Comparing the ODI of patients who had undergone an additional surgical procedure with those who had not showed 42% and 73% minimal disability, 53% and 23% moderate disability, and 5% and 2% severe disability. Of the patients who had not undergone an additional surgical procedure, those with LIV L3 or proximal had mean scores of 14.12 points for the ODI and 23.3 points for the SRS-7 and those with LIV L4 or distal had mean scores of 17.9 points for the ODI and 22.7 points for the SRS-7; these differences were not significant. The mean PROMIS-29 and EQ-5D scores were not different from normal U.S. age-based means.Patients with AIS treated with PSIF at a mean 45-year follow-up and LIV L4 or distal had a higher rate of undergoing an additional surgical procedure than those with LIV L3 or proximal. Patients undergoing an additional surgical procedure had lower health-related quality of life than those who did not. Despite this, there was no difference in health-related quality of life for patients with LIV L4 or distal compared with patients with LIV L3 or proximal. This cohort of patients with AIS treated with PSIF demonstrates normal self-reported health-related quality of life compared with the age-matched general population. These long-term outcomes of PSIF for AIS are encouraging.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

To our knowledge, metastasis to the site of congenital cervical fusion in Klippel-Feil syndrome (KFS) has not been described before and this report describes the management. The patient’s clinical presentation, imaging findings, and surgical treatment and outcomes are described. This is a case of a 47-year-old man with severe right C5 radicular symptoms with associated weakness as the first presentation of metastatic pancreatic cancer. The lesion involved the anterior and posterior elements of congenitally fused C4–C5 vertebrae with right foraminal involvement. The patient was managed with C2–T1 posterior spinal fusion and instrumentation with C4–C6 laminectomy and debulking of the lesion. The patient had resolution of his radicular symptoms. The cervical spine accounts for 8–15% of metastatic spine disease. KFS and congenital cervical fusion are uncommon. To our knowledge, this is the first description of a metastatic spine disease at a level of a congenital cervical fusion. The patient underwent successful surgical intervention consisting of posterior spinal fusion and laminectomy.

Study Design: Retrospective observational study. Objective: To establish occipital condyle dimensions (length, width, height), as well as the medialization angle necessary for safe occipital condyle screw placement in occipitocervical fixation. Methods: Between 1/2014-6/2014, patients who presented to a single level 1 academic trauma center emergency room and received computed tomography (CT) imaging of the cervical spine as part of routine clinical care were identified. After excluding patients with cervical fractures, neoplastic disease, or infection, 500 condyles representing 250 patients were analyzed. Condyle length, height, and width (all reported in millimeters [mm]) were evaluated on the sagittal, coronal, and axial series, respectively. Medialization angle (reported in degrees) was evaluated on the axial series of CT imaging. Measurements were compared by sex and age. Results: The average condyle length, width, and height were 18.6 millimeters (mm) (range, 14.5-23.0 mm), 10.5 mm (range, 7.4-13.8 mm), and 11.3 mm (7.1-15.3 mm), respectively. Additionally, the average occipital condyle medialization angle was 23° (range, 14-32°). Occipital condyles of men were significantly longer, wider, and taller (all comparisons, p < 0.05). The medialization angle was significantly steeper for women than men (p < 0.05). No measurement differences were appreciated by age. Conclusion: Our findings are similar to previous studies in the field; however, length appears slightly shorter. Further, measurement differences were appreciated by sex but not age. Thus, our measurement findings emphasize the importance of preoperative planning utilizing individual patient anatomy to ensure safe placement of occipital condyle screws for optimal outcomes.

Staphylococcus aureus and Streptococcus agalactiae (Group B Streptococcus, GBS) are common causes of deep musculoskeletal infections (MSKI) and result in significant patient morbidity and cost to the healthcare system. One of the major challenges with MSKI is the lack of faithful diagnostics to correctly identify the primary pathogen, as standard culture based assays are prone to false positives in the case of polymicrobial infections, and false negatives due to limitations in sample acquisition and antibiotic use prior to presentation. To improve upon our current diagnostic methods for MSKI, we developed a multiplex immunoassay for antigen specific IgGs in serum (Luminex), and medium enriched for newly synthesized antibodies (MENSA) for anti-S. aureus and GBS generated from cultured peripheral blood mononuclear cells (PBMCs) of orthopaedic infection patients undergoing surgical treatment. Samples were obtained from 110 MSKI patients: 80 diabetic foot ulcer, 21 periprosthetic joint infection, 5 septic arthritis, 2 spine, 1 hand, and 1 fracture related infection (FRI). Anti-S. aureus and anti-GBS antibody titers were compared to culture results to assess their concordance in identifying the pathogens. Immunoassay, particularly MENSA, showed high diagnostic potential for monomicrobial S. aureus and GBS orthopaedic infections (AUC > 0.95). MENSA also demonstrated diagnostic potential for GBS polymicrobial orthopaedic infection and for GBS DFU (AUC > 0.83 for both). Serum showed high diagnostic potential for S. aureus PJI (AUC > 0.95). Taken together, these findings support the development of species-specific immunoassays for the identification of causal pathogens in active MSKI, especially in conjunction with standard culture.

Structural bone allograft transplantation remains one of the common strategies for repair and reconstruction of large bone defects. Due to the loss of periosteum that covers the outer surface of the cortical bone, the healing and incorporation of allografts is extremely slow and limited. To enhance the biological performance of allografts, herein, we report a novel and simple approach for engineering a periosteum mimetic coating on the surface of structural bone allografts via polymer-mediated electrospray deposition. This approach enables the coating on allografts with precisely controlled composition and thickness. In addition, the periosteum mimetic coating can be tailored to achieve desired drug release profiles by making use of an appropriate biodegradable polymer or polymer blend. The efficacy study in a murine segmental femoral bone defect model demonstrates that the allograft coating composed of poly(lactic-co-glycolic acid) and bone morphogenetic protein-2 mimicking peptide significantly improves allograft healing as evidenced by decreased fibrotic tissue formation, increased periosteal bone formation, and enhanced osseointegration. Taken together, this study provides a platform technology for engineering a periosteum mimetic coating which can greatly promote bone allograft healing. This technology could eventually result in an off-the-shelf and multifunctional structural bone allograft for highly effective repair and reconstruction of large segmental bone defects. The technology can also be used to ameliorate the performance of other medical implants by modifying their surfaces.

The prevalence of C2 fractures has increased in recent years. The treatment of these fractures include halo-vest immobilization (HVI), rigid cervical collar, or spinal fusion. There is controversy regarding the management of these fractures with different institutions having their own protocols based on individualized experience. The volume-outcome relationship of HVI use for C2 fractures has not been studied. Evaluation of such relationships are important as they suggest that patients may benefit from referral to and treatment at high-volume institutions.To evaluate the volume-outcome relationship in HVI use for C2 fractures in New York State.Retrospective analysis of a statewide database.We queried the New York Statewide Planning and Research Cooperative System database for the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 805.02 (closed fracture of second cervical vertebra) and procedure code 029.4 (insertion or replacement of skull tongs or halo traction device) to identify all patients who received HVI for a fracture of the second cervical vertebra between the years 2001 and 2014. Those who had isolated C2 fractures were selected.Outcomes of interest included resource utilization characteristics (hospitalization charges and length of stay), perioperative complications, comorbidities, 30-day mortality, any readmission, and any future cervical fusion surgery.The 2001 to 2014 Statewide Planning and Research Cooperative System database was used to identify patients with C2 fractures who received HVI. Our key independent variable was institution volume modeled as high- (25 halos/year), medium-, (10-25 halos/year), or low-volume (10 halos/year) based on the total number of HVI procedures reported by hospitals during the study period. We compared outcomes with respect to hospital volume. We also compared patients by age groups:40, 40 to 60, 60 to 80, and80. Multivariate logistic regressions were performed for the binary variables any complication and any readmission while controlling for covariates hospital volume, age, sex, race, insurance status, and Elixhauser comorbidity mean. Statistical significance was set at a value of p.05 for all analyses.In all, 625 patients with C2 fractures managed with HVI were included. Most patients were male (53%) and Caucasian (76%) with a mean age of 57. Patients at high-volume hospitals were younger (52 vs. 59 and 60 for medium- and low-volume, respectively; p.01) and had fewer future readmissions (40% vs. 54% and 84% for medium- and low-volume, respectively; p.01). On multivariable analysis, those with private insurance and worker's compensation had lower likelihood of future readmission compared to Medicaid patients. Patients80 had higher rates of major in-hospital complications (52% vs. 40%, 18%, and 19% for groups 60-79, 40-59, and40, respectively; p.01), mortality (14% vs. 5%, 1%, and 1% for groups 60-79, 40-59, and40, respectively; p.01), and readmissions after the initial HVI (62% vs. 50%, 54%, and 37% for groups 60-79, 40-59, and40, respectively; p.01). The annual rate of HVI use for C2 fractures decreased significantly from 2001 to 2014 (0.32 to 0.06 HVI procedures per 100,000 people; p.01) with the rate of decline being less pronounced in high-volume institutions (70% decrease vs. 85% and 90% for medium- and low-volume, respectively).Halo vest utilization for C2 fractures in New York State has been declining over the past decade, with the decline being less pronounced in high-volume hospitals. Our hospital volume analysis suggests that HVI use in high-volume institutions is associated with a lower rate of future readmissions. This finding suggests that patients with C2 fractures may benefit from treatment at high-volume institutions. Further research to help improve referral of appropriate patients and increase access to such institutions is warranted.

BACKGROUND: There is a paucity of literature examining surgical trends and outcomes in both child and adult cerebral palsy (CP) patients. We aimed to evaluate surgical trends, complications, length of stay, and charges for spinal deformity surgery in CP patients. METHODS: Using the Nationwide Inpatient Sample (NIS) from 2001 to 2013, patients with CP scoliosis who underwent spinal fusion surgery were identified. Patient characteristics and comorbidities were recorded. Trends in spinal fusion approaches were grouped as anterior (ASF), posterior (PSF), or combined anterior-posterior (ASF/PSF). Complication rates, length of stay, and charges for each approach were analyzed. Bivariate analyses using adjusted Wald tests and multivariate analyses using linear (logarithmic transformation) and logistic regressions were performed. RESULTS: Of the 5191 adult CP patients who underwent spinal fusion the majority underwent PSF (86.5%), followed by the ASF/PSF approach (9.3%). The rate of PSF for cerebral palsy patients with spinal deformity increased significantly per 1 million people in the US population (0.90 to 1.30; P = .048). Complication rate, hospital length of stay, and charges were higher for patients undergoing ASF/PSF (P

BACKGROUND: Given the high volume of user traffic to YouTube, it is important that the medical information disseminated on this platform is of high quality. Unfortunately, previous studies have demonstrated this to not be the case. We aimed to evaluate the quality and educational content of YouTube videos concerning spine tumors using 2 previously validated assessment tools. METHODS: The first 50 videos returned by the keyword search “spine tumor” were included in the study. The JAMA benchmark criteria (range: 0–4) were used to assess video reliability, whereas the Global Quality Score (GQS) (range: 0–5) was used to determine educational quality and content. RESULTS: Videos were primarily authored by academic medical groups (80%), while content was primarily related to disease-specific information (44%) or the patient experience (24%). Surgical treatment options and nonsurgical management were discussed in 66% and 50% of all videos, respectively. Sixty percent of videos reported benefits of treatment, while 44% reported potential risks or complications. The average JAMA score and GQS were 3.1 ± 0.27 (range: 3–4) and 2.6 ± 1.3 (range: 1–5), respectively. Multivariate linear regression analyses revealed that video duration (β = 0.00697, P = 0.04) and number of views (β = 0.000018, P = 0.001) were positively associated with JAMA score. Video duration and number of dislikes were associated with higher GQS (β = 0.041, P = 0.025) and lower GQS (β = −0.189, P = 0.04), respectively. Lastly, number of days since upload was associated with lower Video Power Index (β = −0.003, P = 0.003). CONCLUSIONS: The reliability, quality, and educational content of YouTube videos were poor to suboptimal. Physicians should be wary of the education provided by YouTube on spine tumors and guide patients in seeking out additional sources of information. CLINICAL RELEVANCE: YouTube videos are commonly viewed by patients seeking health information on spine tumors. While certain videos may provide useful information, the absence of an editorial process allows videos with poor reliability and low quality to be uploaded. We believe these findings may be useful to physicians seeking ways to better guide their patients with the most appropriate educational tools throughout their disease management.

Background: Resection of intramedullary spinal cord tumors (IMSCTs) in pediatric patients results in a high incidence of spinal deformity (i.e., kyphoscoliosis often requiring fusion). Here, a 6-year-old male underwent a spinal fusion to correct postlaminectomy thoracic kyphosis following resection of an IMSCT. Case Description: A 6-year-old male initially underwent multilevel thoracic laminectomies for resection of an IMSCT. Six months later, he presented with the onset of kyphoscoliosis. During adolescence he became increasingly paraparetic due to a thoracic kyphosis that had now progressed to 118°. He underwent a 360 decompression/fusion that included a T1-T9 laminectomy, a T5 to T11 anterior interbody arthrodesis/rib autograft, and posterolateral T2-T12 fusion/iliac crest autograft with Harrington rods placed from T5 to T12. Postoperative radiographs showed the thoracic kyphosis improved to 62°. However, 4.5 years later, X-rays showed the thoracic kyphosis newly progressed to 90° (i.e., from T3 to T12). Thirty-four years after this corrective surgery, he remained neurologically intact with only mild complaints of balance changes, and bladder/bowel urgency while radiographs confirmed continued stability. Further, the thoracic magnetic resonance imaging showed only chronic thoracic spine/cord changes. Conclusion: A 6-year-old child originally underwent a thoracic laminectomy for an IMSCT. As an adolescent, due to progressive postlaminectomy kyphosis, he underwent a successful secondary thoracic 360° decompression/ fusion. Notably, 34 years later, he did not require any surgical revision.

Klippel-Feil syndrome (KFS) is a rare multisystem constellation of findings with congenital cervical fusion as the hallmark. The etiology is not fully understood.Recent studies have indicated that KFS is more prevalent than previously described.Hypermobility in the nonfused segments may lead to adjacent segment disease and potential disc herniation and myelopathy after minor trauma.Most patients with KFS are asymptomatic and can be managed nonoperatively. Surgical treatment is reserved for patients presenting with pain refractory to medical management, instability, myelopathy or radiculopathy, or severe adjacent segment disease.Patients with craniocervical abnormalities and upper cervical instability should avoid contact sports as they are at increased risk for spinal cord injury after minor trauma.

Introduction: Division chiefs (DCs) play an integral role within the department, making critical decisions and helping shape the future of both the division and the department. This study aimed to investigate the demographic characteristics and scholarly work of DCs in academic orthopaedic sports medicine division in the United States. Methods: Orthopaedic residency programs at academic centers were identified using the Association of American Medical Colleges' Electronic Residency Application Service. DCs were identified using the program's respective websites where data points such as sex, race/ethnicity, fellowship training institution, time since graduating fellowship, academic rank, number of degrees, and additional leadership titles were collected. Scopus database was used to determine h-indices. Results: From the 191 programs identified, 100 had a DC for the sports medicine subspecialty division, and 66 programs offered a sports medicine fellowship. Most DCs (96%) were men. The racial/ethnic demographics of the DCs were mostly White (86%), followed by Asian (11%), African American (1%), Hispanic/Latino (1%), and mixed ethnicity (1%). On average, the DCs were 19.6 years past their fellowship completion. The average h-index was 21.2. Many (48%) had an academic rank of professor, 28% associate professor, and 12% assistant professor. Four held additional graduate degrees. The fellowship programs that trained the most DCs were Hospital for Special Surgery (11), Kerlan Jobe Orthopaedic Clinic (8), University of Pittsburgh (7), American Sports Medicine Institution (5), Cleveland Clinic (5), Cincinnati Sports Medicine (4), Massachusetts General Hospital (4), and Steadman Hawkins Clinic (4). Discussion: DCs in academic orthopaedic surgery plays a crucial role in the department and is a topic that is understudied. A lack of diversity exists among DCs in academic Sports Medicine in orthopaedics. The position is held predominately by White men with a rank of either full or associate professor and extensive leadership experience. More efforts are needed to increase the diversity of sports medicine leadership within academic orthopaedic programs in the United States.

The double crush hypothesis originally proposed that compression of a peripheral nerve at a proximal site increases its susceptibility to additional distal lesions.The etiology of double crush syndrome is likely multifactorial as mechanical, systemic, pharmacologic, or environmental factors may increase a patient's susceptibility to this syndrome.To date, there remains no standardized definition of double crush syndrome, and there is no consensus on its exact pathophysiology or diagnostic criteria.Patients with double crush syndrome should be counseled that surgical repair may produce inferior outcomes compared with those who are treated for isolated entrapment neuropathies.

STUDY DESIGN Retrospective review. OBJECTIVE Assess measures of spinal-pelvic balance in predicting functional outcome in patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis (AIS) at minimum 40-year follow-up. SUMMARY OF BACKGROUND DATA Back pain and long-term function are considered when choosing levels for surgery in AIS patients. Three hundred and fourteen patients underwent fusion for AIS between 1961 and 1977. One hundred and thirty-four patients were located for potential long-term follow-up. METHODS With IRB approval, medical records and public resources were used to locate patients. Patients completed health related quality of life instruments, and returned for assessment including full radiographs. Radiographs were analyzed for scoliosis measures, and recognized spinal-pelvic measures including the lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI) and pelvic tilt (PT). Bivariate and multivariable analyses were performed to assess the association between spinal-pelvic measures and patient-reported outcomes (PROs). RESULTS Thirty-five of 134 patients agreed to return for complete health related quality of life (HRQoL) and radiographic follow-up. There were no differences at baseline between those agreeing and declining participation. The cohort was 94% female, had an average age of 60.5 years, and average follow-up of 46 years. In bivariate analysis, PI-LL was the only spinal-pelvic parameter which statistically discriminated between patients doing well and not, as assessed by the Oswestry Disability Index and the PROMIS Pain Interference and Fatigue instruments. In multivariable analysis, (PI-LL > 9°) was associated with worse scores in PROMIS-Pain Interference, Physical Function, Depression, Fatigue, Social Function as well as the total Oswestry score. An SVA > 50 mm was associated with worse scores in the SRS-7. CONCLUSIONS In a cohort of 35 patients with average follow-up of 46 years after posterior spinal instrumentation with Harrington rods (PSIF) for adolescent idiopathic scoliosis, spinal-pelvic mismatch as identified by (PI-LL > 9°) was associated with inferior HRQoL outcomes. Other spinal-pelvic measures (SVA and PT) were not reliably associated with inferior HRQol.Level of Evidence: 4.