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Study Design: Retrospective large database study. Objective: To determine the impact of cirrhosis on perioperative outcomes and resource utilization in elective spinal fusion surgery. Methods: Elective spinal fusion hospitalizations in patients with and without cirrhosis were identified using ICD-9-CM codes between the years of 2009 and 2011 using the Nationwide Inpatient Sample database. Main outcome measures were in-hospital neurologic, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, wound-related complications, and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients with and without cirrhosis undergoing spinal fusion. Results: A total of 1 214 694 patients underwent elective spinal fusions from 2009 to 2011. Oh these, 6739 were cirrhotic. Cirrhosis was a significant independent predictor for respiratory (odds ratio [OR] = 1.43, confidence interval [CI] 1.29-1.58; P < .001), gastrointestinal (OR = 1.72, CI 1.48-2.00; P < .001), urinary and renal (OR = 1.90, CI 1.70-2.12; P < 0.001), wound (OR = 1.36, CI 1.17-1.58; P < 0.001), and overall inpatient postoperative complications (OR = 1.43, CI 1.33-1.53; P < .001). Cirrhosis was also independently associated with significantly greater inpatient mortality (OR = 2.32, CI 1.72-3.14; P < .001). Cirrhotic patients also had significantly longer lengths of stay (5.35 vs 3.35 days; P < .001) and inpatient costs ($36 738 vs $29 068; P < .001). Conclusions: Cirrhosis is associated with increased risk of perioperative complications, mortality and greater resource utilization. Cirrhotic patients undergoing spinal fusion surgeries should be counseled on these increased risks. Current strategies for perioperative management of cirrhotic patients undergoing spinal fusion surgery need improvement.

Study Design: Retrospective database study. Objective: To investigate the impact obstructive sleep apnea (OSA) has on perioperative complications, inpatient mortality, and costs in patients undergoing spinal fusions. Methods: Hospitalizations for spinal fusion surgery between the years 2009 and 2011 were identified using the Nationwide Inpatient Sample and grouped into patients with and without OSA. Patient demographic data, comorbidities, hospital characteristics, hospitalization outcomes, and costs were extracted and compared. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing spinal fusion with and without OSA. Results: A total of 107 451 (7.7%) OSA patients who underwent spinal fusions were identified from 2009 to 2011. Compared with patients without OSA, OSA patients were significantly older, more likely to be male, and have significantly greater comorbidity burden. Multivariable regression analysis demonstrated that OSA had a significant independent association with slightly increased respiratory (odds ratio [OR] = 1.13, confidence interval [CI] = 1.09-1.16; P < .001), urinary and renal (OR = 1.11, CI = 1.07-1.16; P < .001) or overall inpatient complications (OR = 1.05, CI = 1.02-1.05; P < .001). OSA was also independently associated with significantly lower inpatient mortality (OR = 0.39, CI = 0.33-0.45; P < .001). Conclusions: While OSA confers greater comorbidity burden and is associated with slightly higher inpatient complication rates following spinal fusions, diagnosed OSA was not an independent predictor of inpatient mortality. A cautious interpretation of this finding is that on a national level, the current methods of preoperative medical optimization and inpatient management of OSA are satisfactory.

Study Design: Retrospective chart review. Objectives: To evaluate the efficacy of tobramycin and vancomycin powder in reducing surgical site infections in posterior lumbar instrumented fusion. Methods: A multicenter, electronic database search was conducted for all patients who underwent posterior instrumented lumbar fusions. Results: The addition of vancomycin powder decreased postoperative infections from an incidence of 5.7% down to a rate of 2.0%. This difference was statistically significant (P = .018). The addition of tobramycin powder to the wound in addition to vancomycin further decreased the infection rate down to 1.8%. The postoperative infection rate was statistically significant (P = .041) when compared with the no-powder group. However, the difference was not statistically significant (P = 1.00) when compared with vancomycin alone. There was also a trend toward gram-negative organisms with the addition of more antibiotic powder. In the control group, for example, the organisms cultured were 66% methicillin-sensitive Staphylococcus aureus and 33% gram-negative organisms. In the vancomycin group, 30% of the organisms cultured were Staphylococcus aureus and 60% gram-negative organisms. In the vancomycin and tobramycin powder group, 100% of the organisms cultured were gram-negative. Conclusions: There is a reduction in surgical site infections with addition of antibiotic powder to the wound prior to closure. However, the reduction in the infection rate was not as great with the addition of tobramycin powder to vancomycin alone and there was a noticeable change in the spectrum of organism cultured with this addition. Clinicians should consider the risk-to-benefit ratio in each case when deciding to use antibiotic powder.

Background: As a growing number of patients seek consultations for increasingly complex and costly spinal surgery, it is of both clinical and economic value to investigate the role for second opinions (SOs). Here, we summarized and focused on the shortcomings of 14 studies regarding the role and value of SOs before proceeding with spine surgery. Methods: Utilizing PubMed, Google Scholar, and Scopus, we identified 14 studies that met the inclusion criteria that included: English, primary articles, and studies published in the past 20 years. Results: We identified the following findings regarding SO for spine surgery: (1) about 40.6% of spine consultations are SO cases; (2) 61.3% of those received a discordant SO; (3) 75% of discordant SOs recommended conservative management; and (4) SO discordance applied to a variety of procedures. Conclusion: The 14 studies reviewed regarding SOs in spine surgery showed that half of the SOs differed from those given in the initial consultation and that SOs in spine surgery can have a substantial impact on patient care. Absent are prospective studies investigating the impact of following a first versus second opinion. These studies are needed to inform the potential benefit of universal implementation of SOs before major spine operations to potentially reduce the frequency and type/extent of surgery.

STUDY DESIGN A retrospective study. OBJECTIVE To determine the impact of sickle cell anemia on perioperative outcomes and resource utilization in elective spinal fusion surgery. SUMMARY OF BACKGROUND DATA Sickle cell anemia has been identified as an important surgical risk factor in otolaryngology, cardiothoracic surgery, general surgery, and total joint arthroplasty. However, the impact of sickle cell anemia on elective spine surgery is unknown. METHODS Hospitalizations for elective spinal fusion surgery between the years of 2001-2014 from the US National Inpatient Sample were identified using ICD-9-CM codes and patients were grouped into those with and without sickle cell anemia. The main outcome measures were in-hospital neurological, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, and wound-related complications and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing elective spinal fusion with or without sickle cell anemia. RESULTS From a total of 4,542,719 patients undergoing elective spinal fusions from 2001 to 2014, 456 sickle cell disease patients were identified. Sickle cell anemia is a significant independent predictor for pulmonary embolism [odds ratio (OR)=7.37; confidence interval (CI), 4.27-12.71; P

BACKGROUND CONTEXT Bone graft extenders are being used more in spine surgery as a substitute for iliac crest bone graft, but potential conflict of interest could impact how the fusion rates are reported. PURPOSE To evaluate if the reported fusion rates are significantly greater in studies where there are potential conflicts of interest versus studies where there are no conflicts of interest. STUDY DESIGN/SETTING Meta-analysis PATIENT SAMPLE Comparison between studies where there were no reported conflicts of interest versus studies where there were reported conflicts of interest. OUTCOME MEASURES Reported fusion rates in the studies. METHODS PubMed was searched for studies evaluating fusion rates when bone graft extenders including demineralized bone matrix and hydroxyapatite and tricalcium sulfate are used as bone graft extenders with laminectomy bone. Studies were screened for one- or two-level fusions and for degenerative spinal conditions. RESULTS A total of 1,928 studies were evaluated with 86 studies included in the study. The fusion rates varied from 4% to 100%. There were 24 studies where there was a potential conflict of interest and 62 studies where there was no conflict of interest. There were 1,308 total patients in the studies where there was a potential conflict of interest and 3,696 patients in studies without conflict of interest. The fusion rates of all the studies combined was 84.63%. The fusion rates of those studies where there was a conflict of interest was 80.93% versus 86.06% when there was no conflict of interest, this was not statistically significant (p>0.07). The fusion rates with CT was 79.79% vs 87.94% when there was no CT. The fusion rates when there was an independent reviewer was 82.61% vs 85.63% when there was no independent reviewer. CONCLUSIONS There is a great variability in the reported fusion rates of bone graft extenders. The reported fusion rates were actually lower in the studies where there was a potential conflict of interest. This is counter to what would be expected. The use of CT scans and an independent reviewer seem to account for the lower reported fusion rates. The use of CT scans and independent reviewers may be a means of negating the potential conflicts of interest in fusion studies. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

We conducted a study to determine the common characteristics of patients who developed radiculopathy symptoms and corresponding heterotopic ossification (HO) from transforaminal lumbar interbody fusions (TLIF) using recombinant human bone morphogenetic protein 2 (rhBMP-2). HO can arise from a disk space with rhBMP-2 use in TLIF. Formation of bone around nerve roots or the thecal sac can cause a radiculopathy with a consistent pattern of symptoms. We identified 38 patients (26 males, 12 females) with a mean (SD) age of 50.8 (7.5) years who developed radiculopathy symptoms and corresponding HO from TLIF with rhBMP-2 in the disk space between 2002 and 2015. To document this complication and improve its recognition, we recorded common patterns of symptom development and radiologic findings: specifically, time from implantation of rhBMP-2 to symptom development, consistency with side of TLIF placement, and radiologic findings. Radicular pain generally developed a mean (SD) of 3.8 (1.0) months after TLIF with rhBMP-2. Development of radiculopathy symptoms corresponded to consistent "pseudo-pedicle"-like HO. In all 38 patients, HO arising from the annulotomy site showed a distinct pseudo-pedicle pattern encompassing nerve roots and the thecal sac. In addition, development of radiculopathy symptoms and corresponding HO appear to be independent of amount of rhBMP-2. HO resulting from TLIF with rhBMP-2 in the disk space is a pain generator and a recognizable complication that can be diagnosed by assessment of symptoms and computed tomography characteristics.

Introduction Return-to-work (RTW) outcomes following spine surgery are critical information for patients aspiring to return to employment following surgical correction. Among patients receiving workers' compensation (WC), spinal surgery has been repeatedly linked to poor RTW rates. However, among patients not receiving WC, the percentage of patients who return to employment is unclear. Methods We conducted a retrospective cohort study of 326 non-WC patients who underwent spinal surgery at two institutions. We determined RTW status and analyzed potential predictors of RTW status. Results Preoperative work status was the only markedly positive predictor of RTW status; patients who were working prior to their surgery were more likely to return to work after surgery. Patients with at least one comorbidity were less likely to return to employment. All other sociodemographic, surgery-related, and complication variables did not reach statistical significance. However, smoking status, short fusion, and cervical fusion were clinically relevant predictors of a negative RTW status. Discussion Among non-WC patients, employment before surgery was a positive predictor for RTW status. For patients with a positive comorbidity status, a lower likelihood of returning to employment is predicted. Randomized trials are needed to fully explore the effect of predictor variables on RTW status among non-WC patients. Conclusions Patients not receiving WC who underwent spinal surgery had a high chance of returning to employment within 1 year if they had been working at least 3 months before the date of surgery.

The practice of contemporary pain medicine is laced with a number of significant ethical challenges. Considerable difficulties include the overutilization of interventional procedures, the application of under-evidenced treatment modalities, and potentially superfluous opioid prescribing. As with many other fields in medicine, including orthopedic surgery, relationships with industry are both common and pervasive, and influence our medical practice through education, publications, and research. This article highlights these ethical challenges and broaches several physician-driven solutions: The Association for Medical Ethics, the Physicians Payment Sunshine inspired by it, and other non-legislative reforms are discussed.

What information must patients receive to give truly informed consent for device implantation? Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

H.L. Mencken wrote that ‘‘When somebody says it’s not about money. It’s about the money.’’ Once again, the issue is about the money. Five years ago, I founded the Association for Medical Ethics (AME), calling for full disclosure of all money paid to researchers by manufacturers. Over those past 5 years, I have often heard ‘‘It’s the principle, not the money,’’ from defensive clinical researchers and industry folks. Would any reasonable person believe what I write when my article is about a product whose manufacturer is paying me? Well, if it is a little money say for implant expenses for testing you will probably have more confidence than if it is millions of dollarsdwith large sum comes large doubts. In those cases, you will probably reserve judgment on using the product and first perform the necessary due diligence to confirm the findings independently. This scenario may be a big problem for industries with marginal products who have a low expectation that initial company data will stand up to independent surveillance and analysis. Conversely, companies with substantial confidence in product performance have little to fear if surgeons choose conservative ‘‘wait and see’’ attitudes and do not jump right in there using the new product. Most prudent doctors will ‘‘wait and see’’ when they detect the influence of something other than independent unbiased literature from a historically trusted source in medicine. ‘‘Wait and see’’ can be very bad for launching new products because as industry folks say, ‘‘what ruins all those good papers is follow-up.’’ Unless practice patterns have already been changed to adopt the product in the absence of independent data, if complications and bad results surface in articles with generalized use, the battle to launch a new product with efficacy or safety problems is lost. It should not be surprising then that the solution for some company executives to prevent hindering profit making is to sweep these problems (complications) under the rug

Cell interactions in the nervous system are frequently mediated by surface proteins that are attached to the membrane by a glycosyl phosphatidylinositol (GPI) anchor. In this study, we have characterized the expression of such proteins on glial cells. We have detected a major GPI-anchored protein on astrocytes and Schwann cells, with a molecular weight of 140 kD. When Schwann cells were treated with forskolin to promote a myelinating phenotype, expression of this 140-kD protein dramatically decreased, whereas another GPI-anchored protein of 80 kD was strongly induced; expression of other integral membrane proteins were likewise dramatically altered. The size and pattern of expression of the 140-kD protein suggested that it might correspond to the Ran-2 antigen, a glial lineage marker. This notion was confirmed by immunoprecipitating this 140-kD protein with the Ran-2 monoclonal antibody. The Ran-2 antigen is expressed over the entire Schwann cell surface in a punctate fashion; it is removed by phosphatidylinositol phospholipase C treatment, thereby confirming that it is GPI-anchored. When Schwann cells are cocultured with neurons, the Ran-2 antigen initially concentrates at sites of Schwann cell contact with neurons, suggesting that it may play a role in early Schwann cell-neuron interactions; it is then downregulated. Protein sequencing of the Ran-2 antigen immunopurified from rat brain membranes showed complete identity over two extended segments with the copper binding protein ceruloplasmin. These findings indicate that astrocytes and Schwann cells express a novel GPI-anchored form of ceruloplasmin and suggest that this GPI form plays a role in axonal-glial interactions.

Surgical treatment for degenerative conditions of the hip, knee, and spine has an impact on overall healthcare spending. Surgical rates have increased dramatically and considerable regional variation has been observed. The reasons behind these increasing rates and variation across regions have not been well elucidated. We therefore identified demographic (D), social structure (SS), health belief (HB), personal (PR) and community resources (CR), and medical need (MN) factors that drive rates of hip, knee, and spine surgery. We conducted a systematic review to include all observational, population-based studies that compared surgical rates with potential drivers (D, SS, HB, PR, CR, MN). We searched PubMed combining key words focusing on (1) disease and procedure; (2) study methodology; and (3) explanatory models. Independent investigators selected potentially eligible studies from abstract review and abstracted methodological and outcome data. From an initial search of 256 articles, we found 37 to be potentially eligible (kappa 0.86) but only 28 met all our inclusion criteria. Age, nonminority, insurance coverage, and surgeon enthusiasm all increased surgical rates. Rates of arthroplasty were higher for females with higher education, income, obesity, rurality, willingness to consider surgery, and prevalence of disease, whereas spinal rates increased with male gender, lower income, and the availability of advanced imaging. Regional variation in these procedures exists because they are examples of preference-sensitive care. With strategies that may affect change in factors that are potentially modifiable by behavior or resources, extreme variation in rates may be reduced.

Dual-photon absorptiometry characterized bone loss in males aged less than 40 years after complete traumatic paraplegic and quadriplegic spinal cord injury. Total bone mass of various regions and bone mineral density (BMD) of the knee were measured in 55 subjects. Three different populations were partitioned into four groups: 10 controls (healthy, age matched); 25 acutely injured (114 days after injury), with 12 reexamined 16 months after injury; and 20 chronic (greater than 5 years after injury). Significant differences (p less than 0.0001) in bone mass mineral between groups at the arms, pelvis, legs, distal femur, and proximal tibia were found, with no differences for the head or trunk. Post hoc analyses indicated no differences between the acutely injured at 16 months and the chronically injured. Paraplegic and quadriplegic subjects were significantly different only at the arms and trunk, but were highly similar at the pelvis and below. In the acutely injured, a slight but statistically insignificant rebound was noted above the pelvis. Regression techniques demonstrated early, rapid, linear (p less than 0.0001) decline of bone below the pelvis. Bone mineral loss occurs throughout the entire skeleton, except the skull. Most bone loss occurs rapidly and below the pelvis. Homeostasis is reached by 16 months at two thirds of original bone mass, near fracture threshold.

The Charité III (DePuy Spine, Inc, Raynham, Massachusetts) and ProDisc II (Synthes Spine, West Chester, Pennsylvania) artificial disk replacements were approved for use by the United States Food and Drug Administration in October 2004 and January 2006, respectively. The purpose of this study was to retrospectively review 29 patients receiving either disk replacement who presented with complications to the University of California Irvine Spine Center. Specifically, patient outcome data from the Oswestry Disability Index (ODI) and the SF-36 were analyzed. The probable sources of pain were determined based on diagnostic facet and nerve root injections, single photon emission computed tomography bone scans, computed tomography scans, magnetic resonance imaging scans, flexion extension radiographs, patient history, and physical examination and direct surgical observation when possible. Results suggested that the main source of pain is facet degeneration and fractures in this area due to flawed biomechanics of disk replacement design. Oswestry Disability Index and SF-36 scores exhibited marked disability with a large improvement in all scores after revision surgery. This difference was statistically significant for the ODI and the SF-36 MCS (mental), but not for the SF-36 PCS (physical). A successful outcome in the revised patients was achieved completely in the majority, and only partially in some, by a solid fusion after meticulous and complete facet excision and correction of the segmental deformity.

The Charite III artificial disc replacement was approved for use in the United States in October of 2004 by the FDA. Another similarly designed lumbar disc replacement called the ProDisc II was also approved by the FDA a year later in January of 2006. The purpose of this study was to retrospectively review 29 patients with either the Charite III or the Prodisc II disc replacement surgery and complications.Copyright © 2009 by ASME

Dual-photon absorptiometry (DPA) is now widely used to determine bone mineral density of the lumbar spine and hips. Because the resulting images are often not of sufficient resolution to identify many bone or soft tissue abnormalities that may influence results, clinical and radiographic correlation is necessary. Presented are two cases in which results of DPA of the hips were elevated because of the presence of heterotopic ossification.

Since its initial description about a century ago, spinal fusion has become a common surgical intervention in the treatment of various debilitating spinal disorders. However, given the complexities and demands of the procedure, patient selection remains a key component in the success of the operation. In this article, we will review the various indications for spinal fusion, the current advances in fusion techniques, as well as the potential complications associated with the procedure.

One main question in spinal kinematics is the determination of the spine's apparent axial center of rotation. Previous research on this topic has yielded contradictory results. The objective of this study was to determine the apparent axial center of rotation for seven lumbar and six thoracic spinal segments by developing and validating a new method. A custom six-degree-of-freedom device, allowing full range of motion, was used with motion recording and analysis software. This system tracked a grid of markers on a specimen when rotational torque was applied in both clockwise and counterclock wise directions at 3.53 Nm, 7.05 Nm, 10.58 Nm, and 14.10 Nm. The area encompassing the apparent axial center of rotation was determined by identifying the five markers with the least amount of motion. The marker angular displacement was calculated as the angle between a virtual line drawn between two points in the initial and final torque conditions. Rotation in both directions was averaged. The lumbar and thoracic spinal segments averaged an apparent axial center of rotation at the posterior border of the vertebral endplates and the anterior border of the spinal canal, with average clockwise to counterclockwise angular displacement ratios of 0.87 and 0.97, respectively.

This study compared 50 patients with lumbar facet fractures and continued pain after lumbar laminectomy with a postlaminectomy control group without facet fractures. Computed tomographic analysis compared variables including direct measurements of bone resection. Average follow-up between surgery and postsurgical computed tomographic examination was 3.2 years. In the fracture group, more than one half of the bone immediately above the flare of the inferior articular process at the level of the laminectomy, measured in a medial to lateral direction, had been resected. No one in the control group had more than one quarter of this bone removed (P = .0001). Lumbar facet fractures may be one cause of late postlaminectomy pain. Caution in resection of a particular area of bone may avoid this problem.

The remarkable recuperative power of the human body after prolonged periods of marked systematized undernourishment is illustrated by careful physical examination of 121 American soldiers released three weeks previously from 18 different prisoner of war camps in Germany. Only one of these prisoners showed moderate undernourishment and vitamin deficiency. More than 53% showed no evidence of any vitamin deficiency clinically, and the others showed minimal evidence (one-plus) of vitamin de ficiencies to varying extents. Analysis shows that the supplementary rations furnished in the Red Cross Packages were the most important single factor in preventing serious nutritional failure in these prisoners of war.

Forty patients were studied retrospectively to evaluate the effect of epidural steroid injections on low back pain and sciatica characteristic of spinal stenosis or a herniated lumbar disc. All but one of these patients had radicular symptoms. The average age was 55 years, and the average follow-up time was eight months. All patients were injected by the same anesthesiologist with 2 cc of Depomedrol-40. Thirty-six patients received either one, two, or three injections. Four patients received either four or five injections. The overall results were poor, with about 60% of patients reporting varying degrees of relief from leg and back pain immediately after injection. However, at follow-up examination, only 24% were asymptomatic; 40% reported no change in preinjection numbness, weakness, or pain; and approximately 35% had varying degrees of relief with no consistent pattern. Of those who had complete relief, there was no correlation between relief of pain, age, or number of injections. From this study, it appears that approximately 50% of patients with radicular symptoms may receive temporary relief with steroid injection. However, long-term relief occurs in less than 25% of patients.