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BACKGROUND: Intraoperative neurological monitoring (IONM) is commonly used in spine surgery. However, the utility of IONM in anterior cervical decompression and fusion (ACDF) remains a topic of debate. The purpose of the study was to investigate the utility and cost of IONM (both Somatosensory evoked potentials (SSEPs) and Motor Evoked Potentials (Tc-MEPs)) in reducing postoperative neurological deficits in myelopathic and non-myelopathic patients undergoing ACDF. METHODS: Retrospective chart review was performed to include only patients with cervical radiculopathy or myelopathy undergoing one or two level ACDF over a 7-year period at a busy academic center. SSEP and Tc-MEP tracings were reviewed for all monitored patients and significant changes and inconsistencies were noted. IONM billing codes (SSEP/Tc-MEP) were reviewed and summed to evaluate the average procedural cost. Medical records were reviewed for preoperative physical exam and for new postoperative neurological deficits on postoperative day one and again at six weeks and matched to the monitored tracings. RESULTS: There were 249 total patients (48 Non-monitored, 201 monitored). There was no difference in gender, age, or BMI between monitored and non-monitored groups. There was no difference in new neurological deficits in monitored compared with non-monitored patients with radiculopathy (p=0.1935) or myelopathy (p=0.1977). However, when radiculopathy and myelopathy patients were combined, there was an increased incidence of new neurologic deficits in monitored patients (8.0%) versus non-monitored patients (0%) (p=0.0830). All new neurological deficits occurred in patients with normal IONM tracings. There were no new neurologic deficits in the non-monitored radiculopathy or myelopathy groups. The average IONM procedure charge was $6500. CONCLUSION: Our results indicate that intraoperative spinal cord monitoring did not reduce new neurological deficits in our cohort of patients. The higher incidence in new neurological deficits despite no IONM changes in our monitored group suggests a lack of utility of IONM in ACDF. Furthermore, at an average of $6500 per IONM procedure, the present study underlines the importance of prudence when choosing to use IONM in the era of cost containment. Level of Evidence: III

Objective Determine patient and injury characteristics predictive of vascular injury (VAI) in blunt cervical spine (BCS) trauma to identify high-risk patients and propose an alternative screening protocol. Methods Patients presenting between 2014-2018 with BCS injury and cervical spine CT imaging were included. Demographics and injury characteristics of BCS injuries were collected. Univariate and multivariate analyses to determine risk factors for VAI were performed. Once factors associated with greater odds of VAI were identified, this information was used to create an alternative protocol for indicating CTA in patients who sustained BCS injury. Results A total of 475 patients were included. CTA of the neck was performed in 55.5% patients. In patients who received CTA, 18.2% had a contraindication to receiving anti-platelet therapy, and 25% were already receiving anti-coagulation therapy as an outpatient medication. VAI was found in 13.2% patients. In patients with VAI, 48.5% were already receiving anti-coagulation as outpatient medication. Acute kidney injury was found in 10.5% patients who had received CTA. Factors associated with greater odds of having VAI included transverse foramen involvement(p=0.0001), subluxation/displacement/dislocation of fracture(p=0.03), high energy mechanism(p=0.02), SLIC score >4(p=0.04), and concomitant lumbar spine injury(p=0.03). Using Modified Hawkeye Protocol, 40.2% of patients were indicated to receive a CTA, and 17 VAI were identified. Compared to Denver Criteria, CTAs were performed in 73 less patients(p=0.04). Conclusions Updated protocols utilizing evidence-based clinical parameters to predict chance of VAI may avoid unnecessary advanced imaging and contrast load to patients in the setting of BCS trauma.

BACKGROUND CONTEXT Computed topography angiography (CTA) is routinely used in evaluation for vascular injury in patients that have sustained blunt cervical spine trauma. Current screening criteria often leads to over utilization of imaging in patients who are already receiving antithrombic therapy or have clear contraindications due to concomitant injuries. PURPOSE This study sought to identify patient and injury characteristics predictive of vascular injury (VAI) in blunt cervical spine trauma in order to identify high-risk patients and propose alternative screening criteria. STUDY DESIGN/SETTING This was a retrospective cohort study collected from patients presenting for blunt cervical spine injury between 2014-2018 at a level I trauma tertiary care center. PATIENT SAMPLE A total of 475 patients over the age of 18 who sustained blunt cervical spine trauma and had available cervical spine CT were included in analysis. OUTCOME MEASURES 1) Incidence of vertebral artery injuries (VAI) in blunt cervical spine injury. 2) In patients with VAI, percentage of patients with contraindication to anti-platelet therapy OR receiving anti-platelet therapy prior to injury. 3) In patients with VAI, percentage of patients that developed acute kidney injury. 4) Injury and patient characteristics associated with higher risk of sustaining VAI. METHODS This was a retrospective cohort study collected from patients presenting for blunt cervical spine injury between 2014-2018. Patients were included who sustained a cervical spine injury and cervical spine CT was available. Demographics including age, gender, outpatient aspirin use, presence of kidney disease was recorded. Injury characteristics including mechanism of action, level of cervical spine injury, type of injury, concomitant thoracic and/or lumbar spine injury, if CTA was obtained, presence of VAI, operative interventions, and subaxial-cervical spine injury classification (SLIC) was collected. Data was evaluated using univariate and multivariate analyses to determine risk factors for VAI. RESULTS A total of 475 patients were included, average age 60.2 years. Motor vehicle accident was the most common cause of injury in 225 (47.4%) patients. CTA of the neck was performed in 264 (55.5%) patients. In patients who received CTA, 48 (18.2%) had a contraindication to receiving anti-platelet therapy and 66 (25%) were already receiving anti-platelet therapy as an outpatient medication. 26 (5.5%) patients were found to have VAI, and in patients with VAI, 4 (14.3%) patents were already receiving ASA as an outpatient medication, and no patients required secondary vascular interventions. Acute kidney injury was found in 28 (10.5%) patients who had received CTA. Factors associated with greater odds of having VAI included transverse foramen involvement (OR4.27, CI 2.05-8.89, p=0.0001), multilevel cervical spine fractures (OR2.09, CI 0.97-4.99), subluxation/displacement/dislocation of fracture (OR2.23, CI 1.08-4.59,p=0.03), high energy mechanism (OR2.38, CI 1.14-4.96), SLIC score >4 (OR2.65, CI 1.07-6.55,p=0.04), and concomitant lumbar spine injury (OR4.37, CI 1.13-16.9,p=0.03). CONCLUSIONS Updated protocols utilizing evidence-based clinical parameters to predict chance of VAI may avoid unnecessary advanced imaging and contrast load to patients in the setting of blunt cervical spine trauma. Further prospective studies are needed to determine if identified risk factors could be used as specific screening criteria to identify high-risk patients who would benefit most from further advanced imaging. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Computed tomography–guided spine biopsy is a routine procedure in diagnosing vertebral infection or tumor. Following a thoracic intervertebral disc biopsy for presumed osteodiscitis, a patient immediately presented with flaccid paralysis and loss of temperature and pinprick sensation below biopsy level, followed rapidly by complete sensation loss. There was no evidence of direct injury during the biopsy, and emergent post-biopsy magnetic resonance imaging revealed no cord signal abnormality or compression. Later magnetic resonance imaging demonstrated corresponding-level cord edema, presumed secondary to transient cord ischemia during the procedures. Despite frequent utility, authors recommend caution in utilization of computed tomography–guided spine biopsy.

Study Design In vitro biomechanical testing was performed using a simulated vertebral body bone graft instrumented with strain gauges. Strains were recorded from various locations on the graft during axial compressive loading. Comparisons were made of the strain patterns recorded before and after application of two different anterior plates. Objectives To quantify the changes in axial compression experienced by the strut graft in the presence of an anterior plate. Summary of Background Data The use of anterior instrumentation to augment anterior thoracolumbar grafting offers the potential advantage of saving additional motion segments while being performed in a single-stage surgery. Several biomechanical studies have compared the anteriorly grafted and instrumented spine to the compressive axial stiffness and torsional rigidity of the intact spine. No previous study has addressed the loading patterns experienced by the graft before and after plating. Methods Anterior spinal plates of two designs (Amset ALPS Anterior Locking Plate System; AMS, Hayward, California; Anterior Thoracolumbar Locking Plate System; Synthes Spine, Paoli, Pennsylvania) were evaluated to determine the axial compressive forces experienced by the bone graft before and after application of the plates. Bovine spines harvested from 8- to 12-week-old calves were used for testing. All plates were tested in axial compression to 500 N. Simultaneous recordings were made of the axial strains on the simulated bone graft and the load applied to the construct. Comparisons were made of the strain through the graft without any instrumentation (graft alone, or baseline), with the plate applied, and after removal of the caudal screws (dynamization). Results With the application of the ALPS plate, the compressive strain through the graft adjacent to the plate averaged 77% of the graft alone construct (range, 39% to 158%). After application of the Synthes plate, the compressive strain through the graft adjacent to the plate averaged 34% of the graft alone construct (range, -14% to 97%). Once the caudal screws were removed, the dynamized construct allowed near-baseline compression through the graft. Conclusions Although the literature indicates that the anteriorly instrumented spine may restore the overall spinal structure to near-normal resistance to rotation and flexion forces, the current study demonstrates that a significant amount of compression through the graft is lost by its application. This decreased axial loading further supports the concept of device-related osteopenia observed clinically with such devices.

Neuropathic joints can arise secondary to multiple etiologies. Charcot, in 1868, 1 described neuropathic joints due to tabes dorsalis. Later, Morvan 2 noted a series of cases with neuropathic joints and compromised sensation. Most of these patients had syringomyelia. Jordan, in 1936, 3 first recognized the presence of neuropathic joints in diabetic patients. Diabetes mellitus is now recognized as the most common cause of neuropathic arthropathy. Estimates state that one of every 680 diabetic patients develops Charcot arthropathy at some site. 4 The incidence of spinal involvement has ranged from 6% to 21% in reported cases of Charcot arthropathy. 5,6 Mitchell, reporting in 1831, 7 noted a relationship between spinal cord lesions and arthropathies. In 1884, Kronig 8 reported the first case of neuropathic spinal arthropathy. The reported causes of neuropathic spinal arthropathy include tabes dorsalis, 5,9-14 syringomyelia, 15.16 spinal cord tumors, 16-18 traumatic spinal cord injury, 18-22 acute transverse myelitis, 17 and diabetes mellitus. 4,23,24 Congenital insensitivity to pain is a very rare cause of neuropathic arthropathy. In 1932, Dearborn 25 reported a case of congenital general pure analgesia. The report described a carnival worker calling himself the Human Pin Cushion. Since that time, various authors have proposed theories to explain the cause of this disorder. To date, however, no single anatomic, physiologic, or pathologic entity has been identified as the cause of congenital insensitivity to pain. 26-32 In 1953, Petrie 33 described the orthopedic manifestations of congenital insensitivity to pain. Piazza et al, in 1988, 34 reported a case of neuropathic spinal arthropathy in congenital insensitivity to pain. A 28-year-old woman with destruction at the L1-L2 interspace developed kyphosis and instability. She remained neurologically intact and was fused successfully with staged anterior and posterior procedures. 34 Heggeness 35 recently reported the case of a 17-year-old girl who developed truncal asymmetry during pregnancy. A dense paraparesis developed 10 days after delivery. She had developed a Charcot spine at L3 and L4 with significant canal compromise. She underwent anterior decompression and stabilization of the spine after which she made a complete neurologic recovery. Two other cases of spinal arthropathy with congenital insensitivity to pain have appeared in literature. 33,36 We report the case of a 12-year-old girl with congenital insensitivity to pain and a neuropathic spine who suffered a progressive neurologic compromise secondary to her L4-5 lesion.

A 5-year retrospective review of 83 patients with 98 metacarpal fractures was performed. Fractures of the thumb metacarpal were excluded. Ninety-six closed metacarpal fractures were reduced closed and fixed with flexible intramedullary fixation, using multiple 0.8-mm prebent rods. Two open metacarpal fractures were also fixed with this technique. Fractures amenable to flexible intramedullary fixation include short oblique and transverse fractures. Contraindications include long oblique and bicortical comminuted fractures. The average follow-up time was 9 months (range, 2 to 34 months) with 15 patients lost to follow-up examination. All fractures went on to heal. Three complications occurred: backing out of a rod in one case and bending of the rods after repeat trauma in two. There were no infections. Flexible intramedullary nailing of specific metacarpal fractures affords excellent results with a low complication rate. Proper selection of fractures and good surgical technique are necessary to avoid complications.

This study involves an evaluation of specific radiologic patterns of various cervical spine injuries on plain radiographs in order to determine a rational approach for further radiologic investigation and resultant treatment. We retrospectively reviewed 236 patients with 319 cervical spine injuries. Fractures included 50 of the dens, 21 hangman, 4 Jefferson, 29 burst, 24 compression, 32 corner/teardrop, 65 facet, 24 lamina, and nine pedicle. Dislocations included one occipitoatlantal, two atlantoaxial rotatory, and 28 facet. Pleuridirectional tomography performed in 137 cases and computerized tomography was performed in 26. The cases were divided into three groups according to the significance of their radiographic findings: Group I: no additional information was added by the additional radiographic studies compared to the plain radiographs. Group II: the additional radiographic studies changed the extent or type of injuries seen on the plain radiographs. Group III: plain radiographs were negative. The abnormalities were only found on the additional radiographic studies. Results of 137 patients undergoing tomography: 62 were in group I, 64 were in group II, and 11 were in group III. Of the 26 patients undergoing computerized tomography, 13 were in group I, 13 were in group II, and no patients were in group III. Specific fracture types were reviewed according to the distribution of the three groups. We concluded that pleuridirectional tomography appears to be particularly advantageous in patients with injuries involving the facets. Computerized tomography appears to add the most additional information in patients with laminar and posterior element fractures and C1 fractures. We feel that timely and accurate diagnosis of cervical spine injuries is essential.(ABSTRACT TRUNCATED AT 250 WORDS)